Aspek Hukum  Rekam Medis  atau Rekam Medis Elektronik  sebagai Alat Bukti  Dalam  Transaksi Teurapetik

This study aims to obtain information on: first, the obligation to create and conceal Electronic Medical Record and its juridical consequences; Secondly, due to the law of absence or error in the manufacture of Electronic Medical Records and the position of Electronic Medical Record as a tool in the theoretical transactions.The research method used is normative juridical approach method, analytical descriptive research specification, research phase is done through literature study to examine primary law material, secondary law material, and tertiary law material. Data collection techniques are conducted through document studies, conducted by reviewing documents on positive law. Furthermore, the method of data analysis is done through normative qualitative.The results of the study indicate: Legal aspects of Medical Record or Electronic Medical Record in Teurapetik Transactions related to: first, the obligation of health workers in coaching and health services to make Medical Record or Electronic Medical Record correctly and responsible for secrecy because it is the opening of Medical Record or Electronic Medical Record without With the permission of the patient having the consequences of criminal law. The absence or misuse of the Medical Record or Electronic Medical Record means that health workers may be subject to criminal, civil and administrative sanctions. Second, the position of Medical Record or Electronic Medical Record is evidence in the form of a letter (if given outside the court), and expert information (if delivered in court).

Download Full-text

PENGARUH KELENGKAPAN PENGISIAN FORMULIR TRANSFER PASIEN INTERNAL TERHADAP MUTU REKAM MEDIS

Jurnal Ilmiah Kesehatan Media Husada ◽

10.33475/jikmh.v10i2.267 ◽

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

Download Full-text

Criminal Liability for Misuse of Electronic Medical Records in Health Services

SOEPRA ◽

10.24167/shk.v5i2.2431 ◽

2020 ◽

Vol 5 (2) ◽

pp. 215

Author(s):

Prilian Cahyani ◽

Astutik Astutik

Keyword(s):

Health Services ◽

Medical Record ◽

Electronic Medical Record ◽

Electronic Medical Records ◽

Medical Practice ◽

Medical Records ◽

Health Workers ◽

Criminal Liability ◽

Medical Personnel ◽

Conceptual Approach

Electronic medical records (RME) have been used in hospitals as a substitute for or complementary to medical records in the form of paper. The obligation to make medical records is the responsibility of every doctor or dentist in carrying out the medical practice. However, the use of electronic-based medical records does not rule out the possibility of raising problems in the field of law, if some abuse it. This will raise the issue of who has the obligation to take responsibility. The problem is the background of the author to write in an article with the title "Accountability for the Misuse of Electronic Medical Record Abuse in Health Services". The formulation of the problem in this article is: 1) Setting an electronic medical record; 2) Criminal liability for the misuse of electronic medical records. The research method used is normative legal research with a statutory approach and a conceptual approach. From the discussion, it can be seen that in Indonesia the obligation to make medical records is specifically regulated in the Medical Practice Law. Furthermore, in the Ministry of Health No. 269 / MENKES / PER / III / 2008 especially Article 2 paragraph 2 states that medical records can be made electronically. However, to date, no specific regulations are governing electronic medical records. The use of electronic systems in medical records makes it necessary to heed the provisions of Law No. 11 of 2008 concerning Electronic Information and Transactions. The party who has the responsibility for the misuse of the Electronic Medical Record covers people who in this case are medical personnel or certain health workers. Hospitals can also be held responsible for the misuse of electronic medical records.

Download Full-text

Analisis Kelengkapan Penulisan Soap, KIE, dan ICD X pada Rekam Medis di Poli Umum dan KIA-KB Puskesmas X Surabaya

Jurnal Administrasi Kesehatan Indonesia ◽

10.20473/jaki.v5i2.2017.139-144 ◽

2018 ◽

Vol 5 (2) ◽

pp. 139

Author(s):

Ayunda Zilul Gosanti ◽

Ernawaty Ernawaty

Keyword(s):

Public Health ◽

Family Planning ◽

Health Center ◽

Medical Record ◽

Medical Records ◽

Random Sampling ◽

Health Workers ◽

Public Health Center ◽

Descriptive Research ◽

Mother And Child

Based on the standart that Public Health Center “X” completeness of SOAP, KIE, and ICD X must be 100%. The aim of research was to analyze how the completeness of writing SOAP, KIE, and ICD X inGeneral Poly and Health of Mother and Child Family Planning Public Health Center “X”. This study was descriptive research with 500 medical records that consist of 260 for January and 240 for February as sample and they taken by random sampling. The result showed that completeness of SOAP, KIE, and ICD X on January in General Poly were 48% and decrease on February became 45,8%.While Health Mother and Child Family Planning Poly showed that completeness on January were 97,8% and increase on February became 98,6%. The incompleteness of medical records can be influenced by several factors is compliance the health workers who responsible in filling the medical records and they have multi job in Public Health Center “X” also the patient was increase. To minimize the incompleteness of SOAP, KIE, and ICD X, medical staff needs to expose by socialization of medical record to remember their responsibilty of their job description.Keywords : Completeness, medical record, Public Health Center

Download Full-text

KAJIAN NORMATIF KEBERADAAN TOKO MODERN DI KOTA SEMARANG

Hukum dan Masyarakat Madani ◽

10.26623/humani.v5i3.946 ◽

2015 ◽

Vol 5 (3) ◽

pp. 50

Author(s):

Efi Yulistyowati ◽

Endah Pujiastuti

Keyword(s):

Data Analysis ◽

Data Collection ◽

Research Data ◽

Analysis Method ◽

Literature Study ◽

Normative Study ◽

Descriptive Research ◽

Approach Method ◽

The City ◽

Collection Methods

ABSTRAKArtikel hasil penelitian tentang kajian normatif keberadaan toko modern di Kota Semarang akan mengkaji mengenai keberadaan toko modern di Kota Semarang apakah sudah memenuhi ketentuan dalam Peraturan Presiden Nomor 112 Tahun 2007. Untuk membahas permasalahan tersebut, metode pendekatan yang dipakai adalah yuridis normatif, dengan spesifikasi penelitian deskriptif analitis, metode pengumpulan datanya : studi dokumentasi dan studi kepustakaan, sedangkan metode analisis data yang dipergunakan adalah analisis kualitatif.Hasil dari penelitian menunjukkan bahwa keberadaan toko modern di Kota Semarang sudah memenuhi beberapa ketentuan yang ada dalam Peraturan Presiden Nomor 112 Tahun 2007, yang belum terpenuhi adalah : ketentuan Pasal 13 & Pasal 15 Peraturan Presiden Nomor 112 Tahun 2007.Articles of research on the normative study of the existence of modern stores in the city of Semarang will examine the existence of modern stores in the city of Semarang whether they have fulfilled the provisions in Presidential Regulation No. 112 of 2007. To discuss these problems, the approach method used is normative juridical, with the specifications of analytical descriptive research, data collection methods: documentation and literature study, while the data analysis method used is qualitative analysis. The results of the study show that the existence of a modern shop in Semarang City has fulfilled several provisions in the Presidential Regulation Number 112 of 2007, which has not been fulfilled are:provisions in Article 13 and provisions Article 15 of the Presidential Regulation Number 112 of 2007.Keywords: Study, Normative, Modern Shop, Semarang City.

Download Full-text

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

International Journal of Engineering, Science and Information Technology ◽

10.52088/ijesty.v1i1.102 ◽

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.

Download Full-text

Improvement of patient safety through implementation of electronic medical records

Medical Technologies Journal ◽

10.26415/2572-004x-vol1iss4p111-112 ◽

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.

Download Full-text

Review Of Returning Medical Records In Outpatient Medical Record

KESANS : International Journal of Health and Science ◽

10.54543/kesans.v1i1.3 ◽

2021 ◽

Vol 1 (1) ◽

pp. 6-12

Author(s):

Raden Minda Kusumah ◽

Jessica Putri Meyliyan

Keyword(s):

Data Collection ◽

Health Center ◽

Medical Record ◽

Medical Records ◽

Reporting System ◽

Standard Operating Procedures ◽

Literature Study ◽

Standard Operating ◽

Descriptive Approach

In returning the outpatient medical record file to thesection of the Medical Record Unit, Assembling there was a delay. This is because the return of medical record files has not been carried out according to Standard Operating Procedures, as a result, causing delays in the reporting system. The method used is qualitative using a descriptive approach. Data collection techniques by observation, interviews and literature study. This study aims to determine the return of former medical records of outpatients at Dayeuhkolot Health Center. The results of the study prove that the delay in returning outpatient medical record files at the Dayeuhkolot Health Center with presentations during the 1 week study amounted to 63 or 22% of 285 medical record files. Efforts have been made to disseminate information to all officers related to the efforts made by the person in charge of COVID-19 patients in returning medical record files on time.

Download Full-text

KAJIAN LITERATUR: FAKTOR-FAKTOR YANG MEMENGARUHI KEJADIAN HIPERTENSI PADA LANSIA [LITERATURE REVIEW: FACTORS THAT AFFECT THE INCIDENCE OF HYPERTENSION IN ELDERLY]

Nursing Current Jurnal Keperawatan ◽

10.19166/nc.v8i1.2711 ◽

2020 ◽

Vol 8 (1) ◽

pp. 1

Author(s):

Lia Jeremia Rumahorbo ◽

Rieke Suzana Fanggidae ◽

Martina Pakpahan ◽

Dora Irene Purimahua

Keyword(s):

Literature Review ◽

Critical Appraisal ◽

Health Workers ◽

Health Centre ◽

The Elderly ◽

Literature Study ◽

Simplified Approach ◽

Approach Method ◽

Flow Diagrams

Hypertension takes the first place as a health problem for the elderly. Hypertension in the elderly comes as a part of aging where blood vessels become stiff and fragile. The purpose of this research was to identify factors that can not be modified and factors that can be modified that affect the incidence of hypertension in the elderly. Literature review used articles from Indonesia OneSearch, Google Shoolar and PubMed databases was then selected using PRISMA Flow Diagrams to produce eight articles according to the inclusion and exclusion criteria. Critical appraisal was done to see the feasibility and quality of the article. Data analysis in this literature review used a simplified approach method. The results of the literature study found that factors that can not be modified that affect the incidence of hypertension in elderly including; family history, race and age. While the factors that can be modified that affect the incidence of hypertension in elderly among others; obesity, physical activity, stress and nutrition. Health workers with family and the elderly can make effort to prevent hypertension against factors that can be changed by routinely checking blood pressure, controlling body weight, exercising regularly, regulating diet, good stress management and optimizing the function of Posbindu (service post of Community Health Centre for the elderly) preventing and managing hypertension in the elderly in the community. Future studies can examine the correlation of each risk factor that influences the incidence of hypertension in the elderly.BAHASA INDONESIA ABSTRAK: Hipertensi menempati urutan pertama sebagai masalah kesehatan yang diderita lansia. Hipertensi pada lansia muncul sebagai bagian dari penuaan dimana pembuluh darah menjadi kaku dan rapuh. Tujuan Penelitian untuk mengidentifikasi faktor-faktor yang tidak dapat dimodifikasi dan faktor-faktor yang dapat dimodifikasi yang memengaruhi kejadian hipertensi pada lansia. Kajian literatur menggunakan artikel yang berasal dari database Indonesia OneSearch, Google Shoolar dan PubMed kemudian diseleksi dengan menggunakan Flow Diagram PRISMA sehingga menghasilkan delapan artikel sesuai dengan kriteria inklusi dan eksklusi. Dilakukan critical appraisal untuk menganalisis artikel. Analisa data dalam penelitian ini menggunakan simplified approach method. Hasil penelitian didapatkan bahwa faktor-faktor yang tidak dapat dimodifikasi yang memengaruhi kejadian hipertensi pada lansia yaitu; riwayat keluarga, ras dan usia. Faktor-faktor yang dapat dimodifikasi yang memengaruhi kejadian hipertensi pada lansia yaitu; obesitas, aktivitas fisik, stres dan nutrisi. Petugas kesehatan bersama keluarga dan lansia dapat melakukan upaya pencegahan Hipertensi terhadap faktor-faktor yang dapat diubah dengan rutin melakukan pemeriksaan tekanan darah, mengontrol berat badan, berolahraga teratur, mengatur diet, manajemen stress yang baik serta optimalisasi fungsi Posbindu dalam pencegahan dan penanganan Hipertensi pada lansia dikomunitas. Penelitian selanjutnya dapat meneliti hubungan tiap faktor risiko yang memengaruhi dengan kejadian hipertensi pada lansia.

Download Full-text

P232 Assessing effectiveness and patient perceptions of a novel electronic medical record for the management of inflammatory bowel disease

Journal of Crohn s and Colitis ◽

10.1093/ecco-jcc/jjab076.358 ◽

2021 ◽

Vol 15 (Supplement_1) ◽

pp. S281-S281

Author(s):

P Kaazan ◽

T Li ◽

W Seow ◽

J Bednarz ◽

J Pipicella ◽

...

Keyword(s):

Inflammatory Bowel Disease ◽

Chronic Disease ◽

Medical Record ◽

Electronic Medical Record ◽

Medical Records ◽

Data Capture ◽

Patient Portal ◽

Specific Data ◽

Qualitative Feedback ◽

Inflammatory Bowel

Abstract Background There is an increasing prevalence of chronic disease worldwide, resulting in multiple management challenges. Inflammatory bowel disease (IBD) is an exemplar chronic disease requiring optimal longitudinal coordinated care. We propose that Crohn’s Colitis Care (CCCare), a novel IBD-specific electronic medical record intended to improve IBD care is effective and acceptable to patients. We aimed to assess both the effectiveness of CCCare for data capture and patients’ acceptability of CCCare. Methods Methods: The study was conducted at two tertiary Australian hospitals with dedicated IBD services: Royal Adelaide Hospital and Liverpool Hospital. The effectiveness of CCCare was examined by comparing IBD-specific data completeness between pre-existing medical records and CCCare. Acceptability was assessed with quantitative and qualitative feedback through the CCCare patient portal and with standardized paper-based questionnaires administered to a convenience sample of IBD clinic patients in two unmatched pre-CCCare and post-CCCare exposure cohorts. Descriptive statistics and multivariable regression models were applied to specifically examine overall ratings of CCCare acceptability using a 10-point numeric scale; factors associated with acceptability before exposure to the system and whether exposure or security concerns influenced its acceptability. Results In all 73 cases reviewed, there was data gain when using structured CCCare fields compared to IBD documentation in usual medical records. Acceptability assessment through the patient portal feedback of 287 patients showed that the majority were very likely to recommend it to others (score, 8.56 ± 2.2 on a scale of 0–10). Common themes of concern among the 22 respondents with qualitative feedback were related to the novelty and limited experience of CCCare. Study questionnaires indicated that the overall acceptability in the combined cohort (n=310) was very high (8.4 ± 2.1; scale of zero to ten) with more than three-quarters of patients rating acceptability as at least 8 out of 10. Self-reported information technology (IT) literacy was positively associated with acceptability. Exposure had a small positive affect on acceptability while the level security concerns had little impact on acceptability. Conclusion The IBD-specific electronic medical record CCCare is effective in facilitating enhanced completeness of IBD-specific data capture in comparison to pre-existing medical records. It is highly acceptable to patients, especially those with reasonable IT literacy. Patient concerns about privacy and security of EMRs did not significantly influence acceptability.

Download Full-text

Diabetes Risk Data Mining Method Based on Electronic Medical Record Analysis

Journal of Healthcare Engineering ◽

10.1155/2021/6678526 ◽

2021 ◽

Vol 2021 ◽

pp. 1-11

Author(s):

Yang Liu ◽

Zhaoxiang Yu ◽

Yunlong Yang

Keyword(s):

Data Mining ◽

Medical Record ◽

Electronic Medical Record ◽

Electronic Medical Records ◽

Medical Records ◽

Diabetes Risk ◽

Mining Method ◽

Training Set ◽

Medical Field ◽

Data Mining Method

In today’s society, the development of information technology is very rapid, and the transmission and sharing of information has become a development trend. The results of data analysis and research are gradually applied to various fields of social development, structured analysis, and research. Data mining of electronic medical records in the medical field is gradually valued by researchers and has become a major work in the medical field. In the course of clinical treatment, electronic medical records are edited, including all personal health and treatment information. This paper mainly introduces the research of diabetes risk data mining method based on electronic medical record analysis and intends to provide some ideas and directions for the research of diabetes risk data mining method. This paper proposes a research strategy of diabetes risk data mining method based on electronic medical record analysis, including data mining and classification rule mining based on electronic medical record analysis, which are used in the research experiment of diabetes risk data mining method based on electronic medical record analysis. The experimental results in this paper show that the average prediction accuracy of the decision tree is 91.21%, and the results of the training set and the test set are similar, indicating that there is no overfitting of the training set.

Download Full-text