The Use of Medical Record Information in the 2011 Version of the Accreditation Standards for a Level 3 General Hospital

2014 ◽  
Vol 2 (8) ◽  
pp. 337-339
Author(s):  
Yansheng Hu ◽  
Yao Liu ◽  
Jinfeng Liang
Keyword(s):  
General Hospital ◽  
Medical Record ◽  
Accreditation Standards ◽  
Level 3

Referral Rate of Admitted Cardiovascular Patients Eligible for Cardiac Rehabilitation in a Private Level 3 General Hospital: A Three-Year Retrospective Study

2019 ◽  
Vol 03 (05) ◽  
Author(s):  
Joseph Marc S. Seguban ◽  
Karen G. Amoloza-De Leon ◽  
Marie A. Barrientos-Regala ◽  
Michelle Q. Pipo ◽  
Noemi S. Pestano ◽  
...  
Keyword(s):  
Retrospective Study ◽  
Cardiac Rehabilitation ◽  
General Hospital ◽  
Referral Rate ◽  
Cardiovascular Patients ◽  
Level 3

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

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 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.

scholarly journals Gambaran Derajat Merokok Pada Penderita PPOK di Bagian Paru RSUP Dr. M. Djamil

2016 ◽  
Vol 5 (2) ◽  
Author(s):  
Fadhil El Naser ◽  
Irvan Medison ◽  
Erly Erly
Keyword(s):  
Chronic Obstructive Pulmonary Disease ◽  
General Hospital ◽  
Pulmonary Disease ◽  
Medical Record ◽  
Significant Relationship ◽  
Strong Correlation ◽  
Chronic Obstructive ◽  
Medical Record Data ◽  
Obstructive Pulmonary Disease ◽  
Record Data

AbstrakPenyakit Paru Obstuktif Kronik (PPOK) adalah penyakit dengan karakteristik keterbatasan saluran napas yang tidak sepenuhnya reversibel dan dapat dicegah. Indonesia merupakan salah satu negara berkembang yang memiliki jumlah perokok aktif yang tinggi. Tujuan penelitian ini adalah untuk mengetahui gambaran derajat merokok pada penderita PPOK di Bagian Paru Rumah Sakit Umum Pusat Dr. M. Djamil Padang. Ini adalah penelitian deskriptif retrospektif dengan menggunakan data rekam medik penderita merokok dengan yang dirawat di Bagian Paru Rumah Sakit Umum Pusat Dr. M. Djamil. Data sekunder diambil dari rekam medik penderita Penyakit Paru Obstruktif Kronik (PPOK) yang dirawat di Bagian Paru Rumah Sakit Umum Pusat dari  1 Januari 2013 sampai 31 Desember 2013. Data diolah secara manual dan disajikan dalam bentuk tabel distribusi frekuensi. Sebanyak 20 subjek didapatkan nilai indeks brinkman berat sebanyak 15 orang. Setelah dilakukan uji statistik didapatkan hubungan yang signifikan antara derajat merokok dengan derajat keparahan PPOK (p = 0,033) dan korelasi yang kuat antara keduanya (r  = 0,577). Terdapat hubungan yang signifikan dan korelasi yang kuat antara derajat merokok dengan derajat keparahan PPOK.Kata kunci: merokok. indeks Brinkman, PPOK AbstractCOPD is a disease with airway limitation characteristic. That is not fully reversible and can be prevented. Smoking is the leading cause of COPD. Indonesia is one of the developing countries that have a high number of active smokers. The increase in prevalence is also occurred in the province of West Sumatra, which increased from 30.2% in 2007 to 38.4% in 2010. The objective of this study was to describe the degree of smoking in patients with COPD in Pulmonary Section General Hospital Dr. M. Djamil. This study used a retrospective descriptive design using medical record data of smoker patients with Chronic Obstructive Pulmonary Disease (COPD) who were treated in the Pulmonary Section General Hospital Dr. M. Djamil. The data was taken from the secondary status of patients with Chronic Obstructive Pulmonary Disease (COPD) who were treated in Pulmonary Section General Hospital from January 1, 2013 to December 31, 2013 that recorded in the medical record. Data processed manually from the status of COPD patients and were presented in the form of frequency distribution table. From 20 subjects obtained that 15 samples were classified to severe Brinkman index.  Statistical tests found a significant relationship between the degree of smoking with COPD severity (p = 0.033) and a strong correlation between the two (r  = 0.577). There is a significant relationship and strong correlation between the degree of smoking with COPD severity.Keywords: smoking, Brinkman Index, COPD

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