scholarly journals SOSIALISASI PELAKSANAAN SISTEM PENGGUNAAN TRACER SEBAGAI PELACAK BERKAS REKAM MEDIS PADA RUMAH SAKIT NAILI DBS PADANG

2019 ◽  
Vol 3 (2) ◽  
pp. 172
Author(s):  
Yastori Yastori
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Fast Time ◽  
Length Of Service ◽  
File Storage ◽  
Quality Of Health Services ◽  
Health Services Needs ◽  
Frequent Problem ◽  
Record Section

Peningkatan mutu layanan kesehatan perlu dilakukan terutama bagi rumah sakit. Rekam medis yang hilang, salah letak, missfile sulit ditemukan dalam waktu yang cepat menjadi permasalahan yang sering terjadi dan mempengaruhi kualitas pelayanan dan menjadi pemicu permasalahan terjadinya berkas rekam medis ganda sehingga mempersulit pengembalian berkas rekam medis sesuai urutan dan mengakibatkan lamanya pelayanan terhadap pasien. Berdasarkan survei pendahuluan, rumah sakit Naili DBS belum menggunakan tracer untuk menandai berkas keluar. Metode yang digunakan adalah observasi dengan wawancara dan diskusi mengenai permasalahan dibagian rekam medis terutama bagian penyimpanan dan pelacakan berkas rekam medis. Pendidikan diberikan melalui sosialisasi pentingnya penggunaan tracer, sistem penggunaan dan tahapan dalam mempersiapkan tracer. Kegiatan ini bertujuan untuk menciptakan budaya  pemanfaatan tracer sebagai kartu pelacak berkas rekam medis keluar dari rak penyimpanan berkas, dilaksanakan pada 11 April 2019 dan berjalan lancar. Hasil yang diperoleh yaitu bahwa di rumah sakit Naili DBS belum menggunakan tracer dan cara pelacakan berkas rekam medis dengan melihat nomor rekam medis pada saat pasein melakukan pendaftaran sehingga membutuhkan waktu yang lebih lama jika dibandingkan dengana adanya tracer. Setelah diadakan sosialisasi ini, bagian rekam medis di rumah sakit Naili DBS memahami akan pentingnya tracer pada bagian rekam medis di rumah sakit.  Kata kunci : Tracer, Rekam Medis, Missfile ABSTRACT Improving the quality of health services needs to be done especially for hospitals. Missing medical records, misplaced, missfiles are difficult to find in a fast time that is a frequent problem that affects the quality of service and triggers problems with the occurrence of multiple medical record files, making it difficult to return the medical record files in order and result in length of service to patients. Based on preliminary surveys, the Naili DBS hospital has not used tracers to mark outgoing files. The method used is observation with interviews and discussions about problems in the medical records section, especially the storage and tracking of medical record files. Education is given through the socialization of the importance of using tracers, usage systems and stages in preparing tracers. This activity aims to create a culture of utilizing tracers as tracking cards for medical record files off the file storage shelves, held on April 11, 2019 and running smoothly. The results obtained are that the Naili DBS hospital has not used tracer and how to track medical record files by looking at the medical record number at the time of registration so that it takes longer than the tracer. After this socialization, the medical records section at Naili DBS Hospital understood the importance of tracers in the medical record section at the hospital. Keywords: Tracer, Medical Record, Missfile

scholarly journals Tinjauan Pelaksanaan Review Berkas Rekam Medis Sesuai Standar Manajemen Informasi Dan Rekam Medik (MIRM 13.4) Di Rumah Sakit Imelda Pekerja Indonesia Tahun 2020

2021 ◽  
Vol 6 (1) ◽  
pp. 7-13
Author(s):  
Esraida Simanjuntak ◽  
Mustamil Alwi Dasopang
Keyword(s):  
Medical Record ◽  
Information Management ◽  
Medical Records ◽  
Research Method ◽  
Medical Personnel ◽  
Education Assessment ◽  
Management Standards ◽  
Hospital Worker ◽  
Quality Of Health Services

  One of the parameters for determining the quality of health services in the hospital is data or information from good and complete medical records. Medical records are an important part of helping the implementation of service delivery to patients at the hospital. Standards relating to medical records in SNARS Edition 1 are in the group of hospital management standards, namely Medical Record Information Management (MIRM) regarding medical record document processing including provision, filling of medical records and reviewing medical records. This research method is descriptive with the method of observation. When this research was conducted in July 2020 at the Imelda Hospital Worker Indonesia Medan. The population taken was 705 medical record documents while the sample in this study was 87 medical record documents. Based on the results of the study, in the review the accuracy of returning medical record documents was 57.4% and 42.5% were incorrect. Readability review of ER assessment as much as 63.2%, assessment of Inpatient as much as 56.3%, CPPT as much as 60.9%, approval for action as much as 77%, reports of anesthesia as much as 68.9%. 3 forms of completeness review are complete, namely Education Assessment, rejection and education form (100%). Suggestions in this study are that review officers must be more assertive to remind every doctor or other medical personnel to pay attention to the accuracy of the restoration, the legibility of medical record files and the completeness of medical record documents. As well as regularly socializing the elements of the MIRM 13.4 assessment.

scholarly journals The influence of knowledge and perceptions of doctors on the quality of medical records

2021 ◽  
Vol 10 (2) ◽  
Author(s):  
Nining Dwi Suti Ismawati ◽  
Stefanus Supriyanto ◽  
Setya Haksama ◽  
Cholicul Hadi
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Cross Sectional Study ◽  
Inpatient Service ◽  
Sectional Study ◽  
Academic Hospital ◽  
Cross Sectional ◽  
Quality Of Health Services ◽  
Ethical Clearance

Background: Medical record reflects the quality of health services provided, which is influenced by existing resources, such as the doctors in charge. This study aims to determine whether doctors' knowledge and perceptions affect the quality of the medical record.Design and Methods: This is a quantitative and cross-sectional study carried out at Dr. Soetomo's general and academic hospital Surabaya, Indonesia, in September and October 2020. Data were purposively obtained from a total of 45 doctors working at the hospital's inpatient service surgery ward using the questionnaire and checklist medical record quality. Furthermore, ethical clearance and doctors’ informed consent were obtained, with the data statistically processed and analyzed by multiple linear regressions.Results: The results and conclusion showed that doctors' knowledge and perceptions of the quality of medical records were influence to medical record quality (p<0.05).Conclusions: Hospital management needs to regularly increase doctors' knowledge and perceptions by socializing and monitoring medical records.

scholarly journals THE USE OF OUTGUIDE IN UNIT MEDICAL RECORD OUTPATIENT ARJAWINANGUN DISTRICTHOSPITALS CIREBON

2020 ◽  
Vol 7 (2) ◽  
pp. 43-45
Author(s):  
Chynditian ◽  
Riantina Luxiarti ◽  
Bayu Ajie Pradiptya
Keyword(s):  
Medical Record ◽  
District Hospital ◽  
Storage System ◽  
Storage And Retrieval ◽  
File Storage ◽  
Speed Up ◽  
The Subject ◽  
Quality Of Health Services ◽  
Descriptive Method

Provision of medical records files quickly and precisely will greatly help the quality of health services provided to patients. If the medical record file storage system that is used is not good, problems will occur that can interfere with the availability of medical record files. Therefore the existence of an outguide in the medical record file storage can help speed up the provision of medical record files and minimize errors in the storage of medical record files. The purpose of this study was to determine the use of outguides in the outpatient medical record unit at Arjawinangun District Hospital Cirebon. This type of research is a descriptive method The subject of this study was the outpatient medical record file storage officer at Arjawinangun District Hospital Cirebon with a total of 4 special officers in the storage and retrieval of medical record files. The instrument used in this study used checklist sheets. The results showed that 100% the use of outguide was not used in the process of searching medical record files because outguide availability was very limited. So when outguide not used properly, it can be errors in the storage of patient's medical record files.For this reason, the medical record unit must use the outguide properly in order to minimize the occurrence of misplacement of the patient's medical record file and speed up the time for the provision of the medical record file.

scholarly journals Study Literature Review On Returning Medical Record Documents Using HOT-FIT Method

2021 ◽  
Vol 1 (1) ◽  
pp. 61-65
Author(s):  
Deni Maisa Putra ◽  
Oktamianiza Oktamianiza ◽  
Mega Yuniar ◽  
Washi Fadhila
Keyword(s):  
Literature Review ◽  
Medical Record ◽  
Medical Records ◽  
Descriptive Analysis ◽  
Net Benefit ◽  
Literature Study ◽  
Return Policy ◽  
Record Section ◽  
Doctors And Nurses

The return of medical record files is a system that is quite important in medical records, because the return of medical records starts from the file in the inpatient room until it returns to the medical record section in accordance with the return policy, which is 2x24 hours. The method used is a literature study with descriptive analysis which is done by describing the facts that exist then being analyzed, described, looking for similarities, views, and summaries of several studies. The results of the literature study show that humans are not responsible for returning medical record files, the organization lacks supervision from the management of returning files, technology (technology) with technology can assist in returning medical record files. So it is necessary to pay attention to the 3 components, so that it can produce a benefit (Net Benefit) from returning the medical record document. Based on the results of the study, it can be concluded that the factors that influence the return of medical record documents are in terms of the HOT-FIT method, (human) where the officers lack a sense of responsibility for medical record documents, and doctors and nurses do not pay attention to the form of filling out record documents medical records, so that it becomes an obstacle in returning medical record documents. It's good to have good supervision from the management.

Study of Incompleteness Medical Records of Inpatient in Appendicitis Cases at Dr. Reksodiwiryo Hospital Padang

2022 ◽  
Vol 2 (1) ◽  
pp. 39-44
Author(s):  
Nurhasanah Nasution
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Research Method ◽  
Digestive Surgery ◽  
Diagnostic Codes ◽  
Diagnosis Codes ◽  
Service Information ◽  
Incomplete Filling ◽  
Existing Data

Background: Incomplete filling of medical record files for inpatients at Dr. Reksodiwiryo hospital medical records will be describe health services and the quality of medical record services. Medical record quality services include the completeness of medical record files, accuracy in providing diagnosis and diagnosis codes, as well as speed in providing service information. The requirements for quality medical records must be accurate, complete, reliable, valid, timely, usable, common, comparable, guaranteed, and easy.Methods: This research method is a descriptive with a retrospective approach or looking at existing data. This study was carried out in September 2021. The population was 70 files cases of inpatient digestive surgery. Samples were taken from 27 files of inpatients with appendicitis cases.Results: From the research that has been done, the highest percentage of incomplete identification components is found on the gender item about 81.48%, the highest percentage of incomplete important report components is obtained on the medical resume and informed consent items about 11.1%. The highest percentage of incomplete authentication components was obtained in the nursing degree about 96.3%. The highest percentage of the components of the recording method was obtained by 59.3%, there are several blank sections about 16 files. The percentage of incomplete diagnostic codes and procedures is 100%  Conclusions: the researcher suggested that the hospital can have an Operational Standart on filling out the completeness of medical records files

scholarly journals Improvement of patient safety through implementation of electronic medical records

2017 ◽  
Vol 1 (4) ◽  
pp. 111-112
Author(s):  
Elahe Gozali ◽  
Marjan Ghazisaiedi ◽  
Malihe Sadeghi ◽  
Reza Safdari
Keyword(s):  
Patient Safety ◽  
Medical Record ◽  
Electronic Medical Record ◽  
Electronic Medical Records ◽  
Medical Records ◽  
Access To Health Care ◽  
Clinical Care ◽  
Drug Management ◽  
Bar Code

Introduction: Today, with the complexity of the process of conducting activities, the increase in diversity and the number of hospital services, and the increase in the expectations of clients - consistent with the fast technological advances - most of the hospitals in Iran have turned to mechanized systems to organize their daily activities and to register the patients' information and the care provided. One of these technologies is electronic medical records, which is known as a valuable system to evaluate patients' information in hospitals. The purpose of this paper was to examine the advantages of running electronic medical records in patient safety. Methods: This study is a review paper based on a structured review of papers published in the Google Scholar, SID, Magiran, Pubmed, and Science Direct databases (from 2007 to 2015) and the books on the benefits of implementing electronic medical records in patient safety and the related keywords. Results: Clinical information systems can have a significant effect on the quality of the outputs and patient safety. Various studies have indicated that the physicians with access to clinical guidelines and features such as computer reminders, doctors who did not have these features, presented more appropriate preventive care. Studies show that electronic medical records play a crucial role in improving the quality of patient health and safety services. Moreover, electronic medical record system is usually in connection with other technological tools: electronic drug management records,  electronic record of time and date of drug management are usually associated with bar code technology. Among the benefits of this system is the possibility to record clinical care by the treatment team, which would be especially beneficial for patient's bedside record. If the treatment personnel forgets to ask the patient a particular question, system reminds him/her. Furthermore, electronic medical record is able to remind the nurses of the patient's allergic reactions and medical history without the need for the patient to remind, which improves patient safety. Conclusion: Implementation of electronic medical records boosts up the quality of health services, patient safety, people's access to health care services, and the speed of patients treatment, leading to lower healthcare costs. Thus, considering the benefits mentioned and some other benefits of this kind, one can use this technology in clinical care provided to patients to come up with a safe and effective clinical care.

scholarly journals The efficient of beds used based on graphic Barber Johnson at Semen Padang Hospital in 2017

2019 ◽  
Vol 6 (12) ◽  
pp. 5071
Author(s):  
Sayati Mandia
Keyword(s):  
Statistical Analysis ◽  
Length Of Stay ◽  
Medical Record ◽  
Medical Records ◽  
Average Length ◽  
Sampling Technique ◽  
Occupancy Rate ◽  
Bed Occupancy ◽  
Average Length Of Stay

Background: Quality of hospital services can be seen from the bed usage. Statistical analysis of efficiency bed usage can be mesured based on inpatient medical records. To determine the efficiency requires four parameters namely bed occupancy rate (BOR), average length of stay (ALoS), turnover interval (TI), and bed turnover (BTR). parameters can be presented using Graphic Barber Johnson. This study aims to determine the efficiency of bed usage at Semen Padang Hospital in 2017.Methods: This research was conducted at Semen Padang Hospital, West Sumatera, Indonesia from January to December 2017. The study used a descriptive method with a qualitative approach. The data was collected from medical records department. The population is all abstraction data of in-patient medical record in 2017, 9796 medical record used total sampling technique. Data analysis was performed by calculating the values of ALoS, BOR, BTR, and TI. Data will be presented based on graphic Barber Johnson. Excel 2010 and graphic Barber Johnson method were applied for data analysis.Results: Number of daily inpatient censuses in 2017 are 31227 and number of service days are 31362. Number of beds 144. Statistical analysis results obtained total BOR 60%, BTR 67 times, TI 2 days and ALoS 3 days. The highest value of bed occupancy rate is 66% on August.Conclusions: Based on statistical, value of bed occupancy rate (60%) and turnover interval (2 days) are efficient at Semen Padang Hospital in 2017. Average length of stay (3 days) and bed turnover rate (67 times) are not efficient.

scholarly journals Description Of Completeness Of Sheeting Assessment Sheet In Hospital Sumber Kasih Cirebon City

2021 ◽  
Vol 8 (1) ◽  
pp. 36-39
Author(s):  
Agista Putri Miranti ◽  
Sri Nurcahyati ◽  
Thia Oktiany
Keyword(s):  
Health Service ◽  
Health Services ◽  
Medical Record ◽  
Pain Assessment ◽  
City Hospital ◽  
Research Instrument ◽  
Assessment Sheet ◽  
Quality Of Health Services ◽  
Quantitative Descriptive

Incompleteness in filling out the inpatient pain assessment sheet will have an impact on the discontinuity of information and will affect the quality of health service facilities. The purpose of this study was conducted to determine the completeness of the Inpatient Pain Assessment Sheet at Sumber Kasih Hospital, Cirebon City.This type of research is quantitative descriptive. The population is the entire medical record document from January to March in 2020 with a sample of 99 medical record documents. This research instrument uses observation sheets. The results of this study indicate that there are 1 (1%) medical record documents that are completely filled and 98 (99%) incomplete medical record documents on the pain assessment sheet form. As for the conclusion in this research the completeness of the study sheet of pain in Sumber Kasih Cirebon City Hospital 1 while the incomplete study sheet of 99. And also the advice in this research is advice for hospitals should be evaluated to maintain the quality of health services improve the performance of medical record officers in the Sumber Kasih Cirebon City Hospital.

scholarly journals Tinjauan Pelaksanaan Sistem Penyimpanan Rekam Medis Berdasarkan Standar Akreditasi Di UPTD Puskesmas Kotanopan Mandailing Natal

2021 ◽  
Vol 6 (1) ◽  
pp. 14-22
Author(s):  
Zulham Andi Ritonga ◽  
Hasran Ependi Lubis
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Storage System ◽  
Patient Medical Record ◽  
Biological Damage ◽  
Descriptive Research ◽  
Accreditation Standards ◽  
File Storage ◽  
Speed Up ◽  
Storage Racks

Storage of medical records is one of the assessments in puskesmas accreditation standards. The medical record file storage system is very important to do in health care institutions, because the storage system can make it easier for medical record files to be stored in storage racks, speed up the recovery or retrieval of medical record files stored on storage racks, easy to return, and protect record files. from theft, physical, chemical and biological damage. The purpose of this study was to determine how the implementation of a medical record storage system based on puskesmas accreditation standards, which was carried out in August 2020. The research method used was descriptive research with a qualitative approach. The number of research informants was 4 people. Storage of medical records had not used tracers and expedition book as a means of replacing medical record files and notes in and out of borrowed medical record files. Meanwhile, tracer and expedition books can assist officers in searching for missing / out of place medical record files. This can hamper the provision of patient medical record files that are needed. It is hoped that the UPTD Puskesmas Kotanopan will provide regular training or debriefing to medical record officers

scholarly journals PENGARUH KELENGKAPAN PENGISIAN FORMULIR TRANSFER PASIEN INTERNAL TERHADAP MUTU REKAM MEDIS

2021 ◽  
Vol 10 (2) ◽  
pp. 124-131
Author(s):  
Indar Farwanti Wahyuni
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Random Sampling ◽  
Health Workers ◽  
Sampling Technique ◽  
Simple Random Sampling ◽  
Patient Transfer ◽  
Literature Study ◽  
Number Of Patients

Abstract Internal patient transfer is the process of transferring patients from one room to another in a hospital while still being oriented towards quality and patient safety. The results of the observations showed that the filling of the internal patient transfer form was not optimal so that there were still incomplete forms due to the large number of patients and the weak coordination between health workers. To determine the effect of the completeness of filling out the internal patient transfer form on the quality of medical records. The research method used is quantitative with a descriptive approach. Data collection techniques used are observation, questionnaires and literature study. The sampling technique was simple random sampling technique so as to obtain a sample of 91 internal patient transfer forms. From the results of observations, 22% of the internal patient transfer forms were found that were not completely filled in, especially in the signature and clear name. The two variables have a strong relationship. The effect of the variable completeness of the internal patient transfer form on the medical record quality variable is 90.1% and the remaining 9.9% is influenced by other factors. Based on these studies, it can be concluded that the lack of accuracy and coordination of nurses, doctors and other officers in filling out internal patient transfer forms so that this affects the quality of medical records in the aspect of accuracy. Keyword : Completeness, Internal Patient Transfer Form, Medical Record Quality   Abstrak Transfer pasien internal merupakan proses pemindahan pasien dari satu ruangan ke ruangan yang lain di dalam satu rumah sakit dengan tetap berorientasi pada mutu dan keselamatan pasien. Hasil observasi menunjukkan bahwa belum optimalnya pengisian formulir transfer pasien internal sehingga masih terdapat formulir yang tidak lengkap disebabkan oleh faktor dari banyaknya pasien dan lemahnya koordinasi antara tenaga kesehatan. Untuk mengetahui pengaruh kelengkapan pengisian formulir transfer pasien internal terhadap mutu rekam medis. Metode penelitian yang digunakan yaitu kuantitatif dengan pendekatan deskriptif. Teknik pengumpulan data yang digunakan adalah observasi, kuesioner dan studi pustaka. Teknik pengambilan sampel adalah teknik simple random sampling sehingga memperoleh sampel sebanyak  91 formulir transfer pasien internal. Dari hasil observasi ditemukannya formulir transfer pasien internal yang belum terisi lengkap sebanyak 22% terutama pada tandatangan dan nama jelas. Kedua variabel memiliki hubungan yang kuat. Pengaruh variabel kelengkapan formulir transfer pasien internal terhadap variabel mutu rekam  medis sebesar 90,1% dan sisanya 9,9% dipengaruhi oleh faktor lain. Berdasarkan penelitian tersebut dapat disimpulkan bahwa kurangnya ketelitian dan koordinasi perawat, dokter dan petugas lain dalam pengisian formulir transfer pasien internal sehingga hal ini mempengaruhi mutu rekam medis pada aspek keakuratan. Kata kunci: Kelengkapan, Formulir Transfer Pasien Internal, Mutu Rekam Medis

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