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 QUANTITATIVE EVALUATION OF MEDICAL RECORD DOCUMENTATION IN IMAM REZA HOSPITAL, MASHHAD, IRAN

2017 ◽  
Vol 1 (4) ◽  
pp. 98-99
Author(s):  
Zahra Mazloum khorasani ◽  
Mahmood Tara ◽  
Kobra Etminani ◽  
Zohre Moosavi ◽  
Zahra Ebnehoseini
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Qualitative Evaluation ◽  
Cross Sectional Study ◽  
Diabetic Patients ◽  
Cross Sectional ◽  
Accurate Treatment ◽  
Diabetes Center ◽  
Data Elements ◽  
Medical Record Documentation

Introduction: Diabetes is the most common endocrine disease. Given the importance of medical record documentation for diabetic patients and its significant impact on accurate treatment process, as well as early diagnosis and treatment of acute and chronic complications, this study aimed to qualitatively evaluate medical record documentation of diabetic patients. Methods: This descriptive and cross-sectional study was conducted on all medical records of diabetic patients (1200 cases) in the comprehensive Diabetes Center of Imam Reza Hospital. A checklist was prepared according to the main sectors and their sub-data elements to conduct a qualitative evaluation on documentation of medical records of diabetic patients.  Descriptive statistics were used to report the results. Results: In this study, 1200 (710 women and 490 men) cases were evaluated. Mean documentation of main sectors of diabetic patients’ records were as follows: 49% demographic characteristics, 14% patient referral, 4% diagnosis, 50% lab tests, 25% diabetes medications,13% nephropathy screening test, 10% diabetic neuropathy, 41% specialty and subspecialty consultations and internal medicine physicians visits did not complete for all the patients. Conclusion: According to the results of this study, qualitative evaluation of medical record documentation of diabetic patients Showed poor documentation in this regard. It is suggested that results of this study be accessible to physicians of healthcare centers to take a positive step toward improved documentation of medical records. In addition, it seems necessary to modify diabetic medical records.

scholarly journals Medical record keeping practices in a tertiary level hospital

2021 ◽  
Vol 6 (4) ◽  
pp. 723-730
Author(s):  
Priti Kana Barua ◽  
Ashees Kumar Saha ◽  
Jay Priya Borua ◽  
Shampa Barua ◽  
Nasima Akhter ◽  
...  
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Cross Sectional Study ◽  
Systematic Sampling ◽  
Future Health ◽  
College Hospital ◽  
Record System ◽  
Cross Sectional ◽  
Record Keeping ◽  
The Government

Medical record is the most important document in the medical field. This cross sectional study was conducted at Chittagong Medical College hospital from January to December, 2017 with the aim to assess the existing medical record keeping practices. Around 214 patients’ record files were selected by systematic sampling method and 30 record keeping personnel were also interviewed. Data were collected by review of records by observational checklist and semi-structured questionnaire were administered to medical record keeping personnel. This study showed that, out of 44 items of patient record file among them 33 items were recorded in 100%. Majority of the medical records (89.7%) were satisfactorily completed. All of the respondents mentioned that they had no training regarding medical record keeping practices. All the respondents stated that some problem faced during keeping the medical record and (90.0%) respondents stated that computerized medical record system could solve the problem they faced. This study showed that, the medical recording status is good in majority areas but keeping practice was not organized at all. There were important defects in keeping the medical records. It seems that there are multiple factors contributing to the problem, such as lack of manpower, insufficient record room and they had no training about medical record keeping practice. It is necessary for the government to develop policies and strategies to improve medical record keeping practice for patient safety, to reduce error, repetition of investigations, protect the medico legal issues and future health care advancement. Asian J. Med. Biol. Res. December 2020, 6(4): 723-730

scholarly journals Frequency, comprehension and attitudes of physicians towards abbreviations in the medical record

2018 ◽  
Vol 94 (1111) ◽  
pp. 254-258
Author(s):  
Uri Hamiel ◽  
Idan Hecht ◽  
Achia Nemet ◽  
Liron Pe’er ◽  
Vitaly Man ◽  
...  
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Online Teaching ◽  
Tertiary Hospital ◽  
Physician Education ◽  
Cross Sectional Survey ◽  
Cross Sectional ◽  
Inappropriate Use ◽  
Online Lecture ◽  
Impact Patient Care

AimsAbbreviations are common in the medical record. Their inappropriate use may ultimately lead to patient harm, yet little is known regarding the extent of their use and their comprehension. Our aim was to assess the extent of their use, their comprehension and physicians’ attitudes towards them, using ophthalmology consults in a tertiary hospital as a model.MethodsWe first mapped the frequency with which English abbreviations were used in the departments’ computerised databases. We then used the most frequently used abbreviations as part of a cross-sectional survey designed to assess the attitudes of non-ophthalmologist physicians towards the abbreviations and their comprehension of them. Finally, we tested whether an online lecture would improve comprehension.Results4375 records were screened, and 235 physicians responded to the survey. Only 42.5% knew at least 10% of the abbreviations, and no one knew them all. Ninety-two per cent of respondents admitted to searching online for the meanings of abbreviations, and 59.1% believe abbreviations should be prohibited in medical records. A short online lecture improved the number of respondents answering correctly at least 50% of the time from 1.2% to 42% (P<0.001).ConclusionsAbbreviations are common in medical records and are frequently misinterpreted. Online teaching is a valuable tool for physician education. The majority of respondents believed that misinterpreting abbreviations could negatively impact patient care, and that the use of abbreviations should be prohibited in medical records. Due to low rates of comprehension and negative attitudes towards abbreviations in medical communications, we believe their use should be discouraged.

scholarly journals FAKTOR-FAKTOR PENYEBAB KETERLAMBATAN PENGKLAIMAN BPJS RAWAT INAP DI RUMAH SAKIT UMUM IMELDA PEKERJA INDONESIA (RSU IPI) MEDAN TAHUN 2020

2020 ◽  
Vol 5 (2) ◽  
pp. 166-180
Author(s):  
Erlindai Purba
Keyword(s):  
Social Security ◽  
Medical Record ◽  
Medical Records ◽  
Quantitative Research ◽  
Chi Square ◽  
Cross Sectional ◽  
Quantitative Research Methods ◽  
Test Application ◽  
Initial Survey ◽  
Questionnaire Method

The Social Security Organizing Agency (BPJS) is an institution formed to organize a Social Security Program in Indonesia based on Law Number 40 of 2004 and Law Number 24 of 2011. Indonesian General Imelda Worker Hospital is a private hospital in the city of Medan who have collaborated with BPJS Based on the initial survey of researchers on 30 medical records documents 13 files (43%) are in accordance with claim requirements and 17 files (56%) are incomplete. Data collection in this study is a questionnaire method. This research was conducted using quantitative research methods with cross sectional approach. The population used in this study were all medical record officers in the medical record unit in the IPI General Hospital Medan as many as 31 officers. Based on the results of a statistical test research conducted using the Chi Square (X2) computer test application with a significance of 95% (p <0.05) it can be concluded that the Hospital conducts an evaluation for medical records officers so that the performance of officers is as expected. Increase evaluation for the completeness of medical record documents used in BPJS claims.

scholarly journals ELECTRONIC MEDICAL RECORD AT RSIGM SULTAN AGUNG SEMARANG REVIEWED FROM THE COMPLETENESS AND THE SAFETY FORMAT SYSTEM

Jurnal Medali ◽  
2021 ◽  
Vol 3 (1) ◽  
pp. 20
Author(s):  
Adam Reza Pahlevi ◽  
Erdianto Setya Wardhana ◽  
Erna Dwi Agustin
Keyword(s):  
Medical Record ◽  
Electronic Medical Record ◽  
Electronic Medical Records ◽  
Medical Records ◽  
Inclusion Criteria ◽  
Health Ministry ◽  
Cross Sectional ◽  
Electronic Signature ◽  
Informed Consent Form ◽  
The Subject

Background: An electronic medical record is a medical system that can be used to store information about the track of a patient`s health. The completeness format of Electronic Medical Record used the format of Electronic Medical Record Guidance from Health Ministry Year 2015. The safety of electronic medical records has 6 aspects as follows privacy, integrity, authenticity, availability, access, control, non-rapadiatum.Method: This research aimed to know the description of the completeness format and the safety of The Electronic Medical Record at RSIGM Sultan Agung Semarang. This research used descriptive observational using a cross-sectional method. The subject of this study was Electronic Medical Records in March 2020. The samples were selected according to the inclusion criteria obtained from RSIGM Sultan Agung SemarangResult: The result of this research was used to know the description of the completeness of Electronic Medical Record Format and the safety of Electronic Medical Record at RSIGM Sultan Agung Semarang.Conclusion: The conclusion of this research showed Electronic Medical Record had been applied at RSIGM Sultan Agung Semarang but there are still lack in the informed consent form and the informed refusal, the safety of the electronic medical record was still lack in the electronic signature format.

Reducing visual analog scale (VAS) in circumcision patient by the additional of topical anesthesia agent in local anesthesia procedures

2021 ◽  
Vol 2 (2) ◽  
Author(s):  
M. Fadel Dikaprio ◽  
Muhammad Fadhol Romdhoni ◽  
Refni Riyanto Riyanto ◽  
Susiyadi
Keyword(s):  
Local Anesthesia ◽  
Visual Analog Scale ◽  
Medical Records ◽  
Cross Sectional Study ◽  
Topical Anesthesia ◽  
Sectional Study ◽  
Pain Sensation ◽  
Analog Scale ◽  
Cross Sectional ◽  
Central Java

Circumcision could be painful before, during, and after the surgery. The local anesthesia is often used in medical practice in order to reduce pain during circumcision. Topical anesthesia works by eliminating pain sensation after direct application on skin. This study aimed to investigate the effect of additional of topical anesthesia agent for circumcision on the visual analog scale (VAS). It was a cross sectional study using the data of medical records from a Circumcision Clinic (Rumah Sunatan) in Purwokerto, Central Java conducted from July 2019 to March 2020. As a result, there were 127 subjects (70.6%) belong to Mild Category VAS, while 26 subjects (14.4%) got Moderate, and 27 subjects (15.0%) fall under Severe Category. The application of topical anesthesia for circumcision could reduce the VAS value by 70.6 %.

scholarly journals Medical students’ experience with accessing medical records in Saudi Arabia: a descriptive study

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Jwaher A. Almulhem
Keyword(s):  
Saudi Arabia ◽  
Medical Students ◽  
Medical Record ◽  
Medical Records ◽  
Medical Curriculum ◽  
National Guard ◽  
Cross Sectional Study ◽  
General Information ◽  
Record System ◽  
Cross Sectional

Abstract Background Medical students can enhance their knowledge by accessing patients’ medical records and documenting patient care. This study assessed medical students’ access to paper medical records and electronic health records (EHRs) in Saudi Arabia and compared students’ experience of accessing paper medical records and EHR from their perspective. Methods This cross-sectional study enrolled second-year to intern medical students randomly from different medical colleges in Saudi Arabia. A self-developed survey was administered to them. It comprised 28 items in three sections: general information about medical students and their level of accessing medical records, their experience with the medical record system used in hospitals, and their preference for the medical record type. Results 62.8% of participants had access to medical records, with 66.1% of them having access to EHRs and 83.27% had read-only access. The EHR group and paper group mostly liked being able to reach medical records effortlessly (70.1% and 67.1%, respectively). The EHR group had a better experience compared to the paper group with U = 5200, Mean Rank = 122.73, P = .04. Students who trained in University – owned and National Guard hospitals had better experiences compared to students who trained in other hospitals with Mean Ranks =122.35, and 147.99, respectively. Conclusion Incorporating EHR access into the medical curriculum is essential for creating new educational opportunities that are not otherwise available to medical students.

scholarly journals Analisis Pengimplementasian Pendistribusian Berkas Rekam Medis Pasien Rawat Jalan Di Rumah Sakit X Bandung

2021 ◽  
Vol 6 (2) ◽  
pp. 174-182
Author(s):  
Alya Nurul Maulani ◽  
Aura Nurzilal Ridwan ◽  
Meira Hidayati ◽  
Aris Susanto
Keyword(s):  
Public Health ◽  
Qualitative Research ◽  
Medical Record ◽  
Research Methods ◽  
Operating Procedure ◽  
Medical Records ◽  
Standard Operating Procedure ◽  
Application System ◽  
Standard Operating ◽  
Patient Health

Medical records are an important part of the treatment of patient health, one form of service in each public health facilities is the distribution of medical record files. Based on research conducted at Hospital X Bandung, in the distribution of medical records the system used has not fully used electronic, the data entered into the application will then be searched manually by the officer for further medical record files distributed to each polyclinic concerned. The purpose of this study is to find out how the distribution of outpatient medical records at Hospital X Bandung using descriptive qualitative research methods that are research that aims to explain and describe the on distributing outpatient medical record documents with subjects in this study is an outpatient medical record document at Hospital X Bandung while the object in this study is the medical record officer in the distribution and filing. Thus, it can be concluded that the implementation of the distribution of medical record files has been quite effective and in accordance with the standard of time that has been set and Standard Operating Procedure that has been made despite some problems and constraints that always occur at the time of distribution of medical records, one of them is the application system used errors or buffering, the code on each polyclinic is sometimes confused with each other, but the officers can solve the problem.

scholarly journals Analisis Kelengkapan Pengisian Rekam Medis Pada Poliklinik Rawat Jalan Bedah Di Rs Pertamina Bintang Amin

2021 ◽  
Vol 3 (2) ◽  
pp. 146-154
Author(s):  
Dwi Robbiardy Eksa ◽  
Neno Fitriyani Hasbie ◽  
Achmad Farich ◽  
Dinda Ayu Pratiwi
Keyword(s):  
Medical Record ◽  
Frequency Distribution ◽  
Medical Records ◽  
Management Plan ◽  
Cross Sectional ◽  
Post Surgery ◽  
Progress Notes ◽  
Distribution Of Components ◽  
Short Time ◽  
Surgical Clinic

ABSTRACT: ANALYSIS OF COMPLETENESS OF MEDICAL RECORDING IN THE POLYCLINIC OF SURGICAL AT THE PERTAMINA BINTANG AMIN Backrgound: Medical records contain all information about patients, illness, medications and records in it recording to the order of service / care. There are still some an inadequate medical records. This happens because of the short time factor, the levels of doctor’s knowledge, and human resources.Purpose: this study was to determine the frequency distribution of completing medical record filling in outpatient surgical polyclinics at Pertamina Bintang Amin Hospital in 2019.Method: This type of research is a descriptive study with a cross sectional approach. Regarding the analysis of the completeness of filling in medical records, the research subject was an outpatients surgical polyclinic at Pertamina Bintang Amin Hospital in 2019. The research time was August-October 2020 with a sample of 400 medical records.Result: It was found that 73,5% outpatient surgical medical records were completely filled, 9,5% less complete and 17% incomplete. The frequency distribution of the components of completing medical record filling consisted of 98,75% complete and 1,25% incomplete identify, complete date and time 90% and 1% incomplete, history 94,25% complete and 5,75% incomplete, the result of physical and supporting examinations 87,5% complete and 12,5% incomplete, diagnosis 97,5% complete and 2,5% incomplete, treatment or action 94,74% complete and 5,26% incomplete, other services provided to patients 83,5% are complete and 16,5% incomplete, consent to action if necessary 88,75% complete and 11,25% incomplete. Ant the frequency distribution of components that are considered less complete is the filling of the management plan 76,26%, all anesthesia during pre and post surgery 79,5%, all surgery reports (pathology and postoperative progress notes) 79,75%, all reports of recorvery room 66,75%. The frequency distribution of completing medical record filling in outpatient surgical polyclinics at Pertamina Bintang Amin Hospital is 73,5% completely filled, 9,5% less complete, and 17% complete.Conslusion: This shows that the result of completingthe filling of medical records at the outpatient surgical clinic at Bintang Amin Hospital are still less complete. Keywords: Completeness, Medical Record, Surgical Polyclinic    INTISARI: ANALISIS KELENGKAPAN PENGISIAN REKAM MEDIS PADA POLIKLINIK RAWAT JALAN BEDAH DI RUMAH SAKIT PERTAMINA BINTANG AMIN Pendahuluan: Rekam medis berisi semua informasi mengenai pasien, penyakit, pengobatan dan rekaman yang didalamnya sesuai dengan urutan pelayanan/perawatan. Masih ditemukan beberapa rekam medis yang tidak memenuhi syarat. Hal tersebut terjadi karena beberapa faktor  waktu yang singkat, tingkat pengetahuan dokter dan sumber  daya manusia.Tujuan: penelitian ini bertujuan untuk mengetahui distribusi frekuensi kelengkapan pengisian rekam medis pada poliklinik rawat jalan bedah di Rumah Sakit Pertamina Bintang Amin Tahun 2019.Metode: Jenis penelitian ini adalah penelitian deskriptif dengan pendekatan cross sectional. Mengenai analisis kelengkapan pengisian rekam medis, dengan subjek penelitian adalah poliklinik rawat jalan bedah di Rumah Sakit Pertamina Bintang Amin Tahun 2019 dengan jumlah sampel rekam medis sebanyak 400. Hasil: Didapatkan kelengkapan rekam medis poliklinik rawat jalan bedah sebanyak 73,5% terisi lengkap, 9,5% kurang lengkap dan 17% tidak lengkap. Distribusi frekuensi kelengkapan pengisian rekam medis poliklinik rawat jalan bedah di Rumah Sakit Pertamina Bintang Amin tahun 2019 tertinggi terdapat pada komponen tanggal dan waktu yaitu 99% lengkap dan komponen terendah terdapat pada semua laporan ruang pemulihan (recovery room) yaitu 66,75%. Distribusi frekuensi kelengkapan rekam medis poliklinik rawat jalan bedah di Rumah Sakit Pertamina Bintang Amin sebanyak 73,5% terisi lengkap, 9,5% kurang lengkap dan 17% tidak terisi lengkap.Kesimpulan: Hal ini menunjukkan hasil kelengkapan pengisian rekam medis pada poliklinik rawat jalan bedah Rumah Sakit Bintang Amin masih kurang lengkap. Kata Kunci : Kelengkapan, Rekam Medis, Rawat Jalan Bedah

scholarly journals Diagnosis Code Accuracy Analysis Of Acute Gastroenteritis Disease Based on Medical Record Document in Balung Hospital Jember

1970 ◽  
Vol 2 (2) ◽  
pp. 12
Author(s):  
Rinda Nurul Karimah ◽  
Dony Setiawan ◽  
Puput Septining Nurmalia
Keyword(s):  
Medical Record ◽  
Acute Gastroenteritis ◽  
Medical Records ◽  
Disease Diagnosis ◽  
Accuracy Analysis ◽  
Diagnosis Code ◽  
Diagnosis Codes ◽  
Icd 10

Accuracy analysis of replenishment diagnosis codes on the document medical records is very important because if the diagnosis code is not right or not in accordance with the ICD-10, it can cause a decline in the quality of care in hospitals as well as the influence of data, information reporting, and accuracy rates of INA-CBG's that are currently used as a method of payment for patient care. The purpose of this study was to analyze the accuracy of diagnosis codes acute gastroenteritis disease in hospitalized patients by medical record documents in the first quarter of 2015 in the Balung Hospital Jember. This research used qualitative data. Acquisition of data from this study through interviews and observations. Results obtained from the observation of medical record documents at the inpatient unit in the first quarter 2015 in Balung Hospital Jember, there are some numbers determining the accuracy of disease diagnosis codes as many as 17 medical record documents with acute gastroenteritis illness and the determination of improper diagnosis codes as many as 63 medical records document acute gastroenteritis illness. After analyzing, the cause of the problem is the accuracy of the diagnosis that affects the accuracy of writing code, beside it has never been disseminated to physicians and medical records personnel related to the management of medical records. Therefore, it is necessary to carry out activities that can improve the accuracy of disease diagnosis code and quality of human resources, among others, include doctors and medical records personnel in training and socialization related to the management of medical records. Key Words : Diagnosis codes , medical record, acute gastroenteritis

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