scholarly journals Completeness of filling medical record documents on inpatient ward, Ungaran General Hospital-Semarang, Central Java -Indonesia

2020 ◽  
Vol 12 (1) ◽  
pp. 145-155
Author(s):  
Lestari Wiji ◽  
Astuti Retno ◽  
Isworo Slamet
Keyword(s):  
General Hospital ◽  
Medical Record ◽  
Inpatient Ward ◽  
Central Java

scholarly journals The Assessment of Medical Recording Resources in Asembling Units with Workload Staffing Needs (WISN) Methods in Bendan General Hospital, Pekalongan

2020 ◽  
pp. 18-31
Author(s):  
Nisa Bela Aryana ◽  
Maulana Tomy Abiyasa ◽  
Hery Kurniawan ◽  
Slamet Isworo
Keyword(s):  
General Hospital ◽  
Medical Record ◽  
Medical Records ◽  
District General Hospital ◽  
City Government ◽  
Records Management ◽  
General Description ◽  
Inpatient Ward ◽  
Ongoing Training ◽  
Staffing Needs

Objective: Bendan district general hospital is a type C hospital owned by the Pekalongan City Government which is demanded to have good service performance. The assembling unit in the Medical Records department at the Hospital is a unit that influences the overall service process because in this unit all medical records management for patients from all wards is managed. Research Purposes:  This study aims to find a general description of the workload and the needs of assembling officers in the medical records department. Method: This research was conducted by assembling officers, from February to March 2020, with the type of descriptive research using the interview method based on the Workload Indicator Staffing Needs (WISN) Formula. The Results: The results of the study were based on the calculation of the WISN method so that the officers' needs were 2 people for 7 hours / day and with 6 working days / week. The effective working day in 1 year is 227 days with a standard workload of assembling medical record documents on the inpatient ward of 14887 documents and inputting data in a computer with a standard workload of 23820 documents. Conclusion: that the workload of the assembling officer in the medical record department is not appropriate, there is still a buildup of medical records in the assembling section. Suggestion: It is necessary to add assembling officers to the medical record unit and to provide ongoing training so that the performance of officers is compatible in performing their work.

scholarly journals Accuracy of STRONGKids to Identify Risk of Children Malnutrition in Sanjiwani General Hospital Gianyar, Bali

2021 ◽  
Vol 6 (1) ◽  
pp. 1-6
Author(s):  
Dewa Ngakan Putu Yogi Astika Yogi Astika
Keyword(s):  
General Hospital ◽  
Medical Record ◽  
Pediatric Patients ◽  
Healing Process ◽  
High Sensitivity ◽  
Test Method ◽  
Screening Tools ◽  
Chi Square ◽  
Cross Sectional ◽  
Hospital Malnutrition

Malnutrition in the hospital is a condition that needs to be watched out for because it affects the length of stay and healing process of hospitalized patients. Until now, the prevalence of malnutrition in the hospital is still high in both adult and pediatric patients. Malnutrition screening is required while the patient will be hospitalized. It is necessary to research the accuracy of STRONGKids (Screening tools for risk on nutritional status and growth) as a malnutrition screening in pediatric patients in hospitals, especially at Sanjiwani General Hospital Gianyar percentage of malnutrition in hospitals at Sanjiwani Gianyar Hospital so that they receive early treatment. The purpose of this study was to determine the accuracy of STRONGKids as a screening test for malnutrition in the hospital for children at Sanjiwani General Hospital Gianyar. This research uses a design cross-sectional by the diagnostic test method. Data taken from medical records. Data collection method with consecutive sampling. The number of samples is 40 subjects. The inclusion criteria were children aged one month - 18 years and hospitalized at Sanjiwani Gianyar Hospital. The exclusion criteria were incomplete medical record data, and subjects were categorized as obese or obese on the medical record. The data analysis technique used the SPSS computer program. STRONGKids data are presented in 2 x 2 table form Chi-square. The results obtained were the percentage of hospital malnutrition of 9.8%. STRONGKids with a cutoff value of 1 had a sensitivity of 100% and a specificity of 35.1%. So, the STRONGKids score has fairly high sensitivity, so that the use of the STRONGKids score in combination with anthropometric measurements can be used to detect malnutrition in hospitals. Keywords: sensitivity, STRONGKids, child malnutrition

scholarly journals Prevalensi periodontitis pada pasien diabetes mellitus (Studi observasional di poliklinik penyakit dalam RSUP Dr. Sardjito)

2017 ◽  
Vol 3 (2) ◽  
pp. 98 ◽  
Author(s):  
Rezmelia Sari ◽  
Dahlia Herawati ◽  
Rizky Nurcahyanti ◽  
Pramudita Kusuma Wardani
Keyword(s):  
Internal Medicine ◽  
Diabetes Mellitus ◽  
Informed Consent ◽  
Observational Study ◽  
General Hospital ◽  
Oral Hygiene ◽  
Periodontal Diseases ◽  
Central Java ◽  
Patients With Diabetes ◽  
Tissue Attachment

Prevalence of periodontal diseases in patients with  diabetes mellitus (An observational study     at internal medicine polyclinic in  Dr.  Sardjito General Hospital). Diabetes Mellitus (DM) is a  chronic disease    with an increasing prevalence and causes complications. The most frequent complication found in the oral cavity of patients with diabetes mellitus is periodontal diseases is characterized by the loss of tissue attachment. There have been numerous studies on the association of DM with periodontal diseases but there has not been any data on the prevalence of periodontal diseases in diabetic group, especially in Yogyakarta and Central Java. Dr. Sardjito General Hospital is a referral hospital in DIY and Central Java, so this study is expected to provide a picture regarding the level of periodontal tissue health among people in Yogyakarta and Central Java. This research was an observational study, involving 36 patients with DM according to criteria of the subjects: suffering from type 2 diabetes, being cooperative  and willing to sign an informed consent. The controlled variables: being 40 – 60 years of age, having good oral hygiene (OHI) according to Green and Vermillion, taking neither antibiotics nor anti-inammatory drugs in the last 3 months, not having a history of other systemic diseases. Oral hygiene exams were carried out, followed by examination using probe WHO to determine if there is CAL. The data were presented descriptively. The results showed that the prevalence of periodontal diseases in patients with DM at Internal Medicine Polyclinic in Dr. Sardjito General Hospital is 88.24% with a mean of CAL distance of 4.6 mm. The conclusion of this study is that the prevalence of periodontal diseases in patients with DM is high although the oral hygiene status is good. ABSTRAKDiabetes Mellitus (DM) adalah penyakit kronis menahun dengan prevalensi yang semakin meningkat dan menimbulkan komplikasi. Komplikasi yang paling sering terjadi di rongga mulut pasien DM adalah periodontitis yang ditandai dengan kehilangan perlekatan jaringan. Penelitian tentang hubungan DM dengan periodontitis banyak dilakukan namun belum ditemukan data mengenai prevalensi periodontitis pada kelompok  DM  khususnya di DIY dan  Jawa Tengah.  RSUP Dr. Sardjito merupakan rumah sakit rujukan DIY dan Jawa Tengah sehingga penelitian ini diharapkan dapat memberi gambaran mengenai tingkat kesehatan jaringan periodontal di masyarakat DIY dan Jawa Tengah. Jenis penelitian ini adalah observasional dengan melibatkan 36 orang pasien DM sesuai kriteria subjek yaitu menderita DM tipe II, kooperatif dan bersedia menandatangani informed consent. Variabel terkendali yaitu usia 40 – 60 tahun, kebersihan mulut (OHI) menurut Green and Vermillion dalam kriteria baik, tidak menggunakan antibiotik dan antiinamasi dalam 3 bulan terakhir dan tidak memiliki riwayat penyakit sistemik lain. Dilakukan pemeriksaan kebersihan mulut dilanjutkan dengan pemeriksaan menggunakan probe WHO untuk menentukan ada tidaknya CAL. Data disajikan secara deskriptif. Hasil penelitian menunjukkan bahwa prevalensi periodontitis pada pasien DM di Poli Klinik Penyakit Dalam RSUP Dr. Sardjito adalah 88,24% dengan rata-rata jarak CAL adalah 4,6 mm. Kesimpulan penelitian ini adalah prevalensi periodontitis pada pasien DM tinggi walaupun status kebersihan mulut tergolong dalam kriteria baik.

Application of the Weed System to Psychiatric Records

1972 ◽  
Vol 3 (2) ◽  
pp. 119-129 ◽  
Author(s):  
Richard L. Grant ◽  
Barry M. Maletzky
Keyword(s):  
Medical Education ◽  
Patient Care ◽  
General Hospital ◽  
Medical Record ◽  
Medical Schools ◽  
Medical Chart ◽  
Chart Audit ◽  
Record Keeping ◽  
Teaching Research ◽  
Practicing Physicians

The medical record is being called upon to play an increasingly important role in medical education and effective patient care. The Weed system of “problem-oriented” medical record-keeping can enhance the effectiveness of the medical chart for these purposes and also for the various goals of chart audit. There has been increasing acceptance and application of this system both in medical schools and by practicing physicians. The psychiatric record has been particularly lacking in consistent organization, clarity, accuracy and readability. We have combined, in our approach to psychiatric records in a general hospital, a strongly behavioral and social psychiatric perspective with the Weed system to provide a psychiatric record that is a usable and practical document for teaching, research, effective continued patient care, and medical and fiscal audit.

scholarly journals TINJAUAN PELAKSANAAN PENGODEAN DIAGNOSIS PENYAKIT PADA PASIEN RAWAT JALAN DI RSUD TUGUREJO PROVINSI JAWA TENGAH

2019 ◽  
Vol 6 (2) ◽  
pp. 139-147
Author(s):  
Qisthi Qurrota A’yuni ◽  
Kori Puspita Ningsih
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Standard Operating Procedure ◽  
Disease Diagnosis ◽  
Cross Sectional ◽  
Accreditation Standard ◽  
Central Java ◽  
Procedure Guidelines ◽  
Five Elements ◽  
Diagnosis Coding

Background: The implementation of diagnosis coding in the Medical Record Unit at a health institution plays an important role in the administration of medical records at the hospital because it describes the quality management of medical records. In order to maintain the quality, it is crucial to accomplish the accreditation standard, especially at ICM. 13 related coding. Objective: This study aimed to understand the procedures of implementation, compliance disease diagnosis code execution in an outpatient based on accreditation standards KARS 2012, the percentage and the resistance of diagnosis coding implementation in outpatients. Methods: This research was a descriptive qualitative approach with cross sectional design. The subjects were medical records staff with Diploma 3 medical record education background, outpatients coding officer, reporting coordinator, the head of clinic space and a clinic nurse. The data collectin techniques used were observation, documentation and interview studies. Testing the validity of the data use triangulate of source and triangulate of techniq. Results: The coding was done by the medical records staffs and nurses, coding reference were in the form of policies, guidelines and standard operating procedure, guidelines used by nurses in coding was assistive book. Tugurejo Hospital Accreditation in Central Java province had fulfilled the five elements of ICM. 13 and passed the accreditation of type B-level plenary meeting. The percentage of outpatient coding implementation reached 78.6%, consisting of JKN amounted to 75.4% and 3.2% were non JKN. The barriers of coding implementation consists of five elements such as man, method, material, machine and money. Conclusion: In general the implementation of the coding in JKN outpatient has already done optimally, but for non JKN has not been optimal because of the inhibiting factors such as man, method, material, machine and money. Keywords: Coding, disease diagnosis, outpatient

scholarly journals Completeness criteria and filling of medical records in dental clinic of Cianjur General Hospital (January - April 2011)

2012 ◽  
Vol 24 (2) ◽  
Author(s):  
Annisa Rosalina ◽  
Netty Suryanti ◽  
Riana Wardani
Keyword(s):  
General Hospital ◽  
Medical Record ◽  
Medical Records ◽  
Random Sampling ◽  
Sampling Technique ◽  
Patient Treatment ◽  
Dental Clinic ◽  
The Republic ◽  
Descriptive Method ◽  
Medical Record Documentation

Introduction: The medical record documentation of patient treatment Provides the which in turn, must be maintained Clearly, concisely, comprehensively and accurately. Medical record and its filling criteria must be based on the regulation of the Minister of Health of The Republic of Indonesia No. 269/Menkes/Per/III / 2008 regarding to the medical record. The research was Aimed to unveil the completeness of both criteria and filling on medical records at the General Hospital’s Dental Polyclinic of Cianjur District. Methods: Survey-based descriptive method was applied within the research. Its Data was acquired through the examination on medical records and interviews. Random sampling was conducted to run the sampling technique. 89 pieces of outpatient’s medical records were embodied as samples. Results: Based on the research results, it is discovered that 6 out of 12 criteria (50%) are not listed within the medical record. Thus, the filling on medical records of 100% is found incomplete. Conclusion: Medical records Dental Clinic Regional General Hospital Cianjur according to standards Permenkes No. 269/2008 not inlude on complete criteria according to standards Permenkes No. 269/2008.

scholarly journals Proteinuria pada Penderita Gagal Ginjal Kronik di Rumah Sakit Martha Friska Multatuli Medan Tahun 2015-2016

2019 ◽  
Vol 1 (2) ◽  
pp. 77-80
Author(s):  
Juliana Ruminta Sijabat ◽  
Sartini Sartini ◽  
Abdul Karim
Keyword(s):  
Renal Failure ◽  
Chronic Renal Failure ◽  
General Hospital ◽  
Medical Record ◽  
Kidney Failure ◽  
Chronic Kidney Failure ◽  
Urine Samples ◽  
Medical Record Data ◽  
Record Data ◽  
Male Patients

This study aims to determine the presence or absence of protein in urine in patients with chronic renal failure. From the results of the study it was found that patients with chronic kidney failure in Martha Friska Multatuli General Hospital Medan from the 80 most patients in positive +++. Many patients with chronic kidney failure are male patients (62.5%) compared to female patients (37.5%) and the results of the examination based on age increase with age, ie at the age of 45 years and above. This type of research is descriptive analytic. Data is taken by recording medical record data of patients with chronic kidney failure based on age, sex and year. The study was conducted from January 2015 to December 2016. The place for conducting the research was conducted at Martha Friska Multatuli General Hospital (RSU) Medan. The study sample was urine samples from all patients with chronic renal failure. It can be concluded that the picture of protein in urine in patients with chronic kidney failure increases every year.

scholarly journals LAMA RAWAT PADA PASIEN DENGAN CEDERA KEPALA RINGAN

2019 ◽  
Vol 13 (2) ◽  
pp. 136-142
Author(s):  
Amila Amila ◽  
Sariani Sariani
Keyword(s):  
Head Injury ◽  
Length Of Stay ◽  
General Hospital ◽  
Medical Record ◽  
Mild Head Injury ◽  
Spearman Correlation ◽  
Early Management ◽  
Consecutive Sampling ◽  
Injury Patient

ABSTRACT : LENGTH OF STAY MILD HEAD INJURY IN SARI MUTIARA GENERAL HOSPITAL Background : Early management of  head injury patient in hospital will affect the outcome and length of stay mild head injury patient in the hospital.Purpose : The purpose of this study were to identify the correlation among age, GCS  and hyperglycemia with length of stay in the hospital.Methods :The data obtained was analyzed by correlational analytic with retrospective approach. The sample of this study was recruited with consecutive sampling as 117 people. Data collected by observation from medical record on the mild head injury patients who come to hospital from March 2014 until March 2015 at Sari Mutiara General Hospital Medan. The data was analyzed by pearson and spearman correlation  with significance α <0.05.Results : The study showed that  70.1%  Hyperglicemia, mean of age, GCS and length of stay were 32.09; 13,99 and 3.68 in mild head injury.There was no significantly correlation between age with length of stay (r = 0.163; p > 0.05). Whereas there was significant correlation between GCS and hyperglycemia with length of stay (r=-0.735; r = 0.610 ; p < 0.05)Conclusion : Based on the study, we concluded that the more hyperglycemia, the more severe length of stay in patient with mild head injury.  Keywords: Mild head injury; GCS; Hyperglycemia; Length of stayPendahuluan: Penanganan awal pasien cedera kepala pada saat datang ke rumah sakit akan mempengaruhi outcome serta Length of Stay (LOS) pasien di rumah sakitTujuan : Penelitian ini bertujuan untuk mengetahui hubungan umur, GCS dan hiperglikemia dengan LOS pasien cedera kepala ringan di RSU Sari Mutiara Medan.Metode : Metode penelitian dilakukan secara analitik korelasional dengan pendekatan retrospektif. Teknik sampling dalam penelitian ini menggunakan consecutive sampling dengan jumlah sampel sebanyak 117 orang  yang diambil dari data sekunder yaitu observasi pada catatan medis pasien cedera kepala ringan yang dirawat di RSU Sari Mutiara Medan dalam periode satu tahun (Maret 2014 s.d Maret 2015). Data dianalisis menggunakan uji korelasi Pearson dan Spearman dengan signifikan α <0.05.Hasil Penelitian: Hasil uji menunjukkan 70.1% pasien hiperglikemia, rata-rata umur pasien  adalah 32.09 tahun, rata-rata GCS dan lama rawat pasien cedera kepala ringan adalah 13,99 dan 3.68 hari. Hasil uji menunjukkan tidak ada hubungan antara umur dengan LOS pasien cedera kepala ringan dengan nilai p=0,080 dengan kekuatan korelasi r = 0,163. Hasil uji didapatkan hubungan yang signifikan antara GCS dan hiperglikemia dengan LOS pasien cedera kepala ringan (p=0,000) dengan kekuatan korelasi (r=-0.735; r= 0,610).Simpulan : Hal ini menunjukkan bahwa semakin tinggi hiperglikemia, maka semakin tinggi LOS pasien cedera kepala.

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