scholarly journals Sistem Informasi Rekam Medis Di Klinik Gigi Rumah Sakit Paru dr. Ario Wirawan Salatiga

2021 ◽  
Vol 3 (2) ◽  
pp. 110-116
Author(s):  
Heribertus Ary Setyadi ◽  
Doddy Satrya Perbawa
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Current System ◽  
Visual Basic ◽  
Dental Clinic ◽  
X Ray ◽  
Patient Registration ◽  
Input Design ◽  
Patient Will ◽  
Flow Diagrams

Abstrak  - Saat ini  pelayanan di klinik gigi Rumah Sakit Paru dr. Ario Wirawan (RSPAW) masih menggunakan cara konvensional atau offline. Proses pendaftaran pasien dapat dilakukan dengan datang ke klinik untuk mengambil nomor antrian. Untuk pasien baru wajib mengisi form pasien baru. Setelah itu pasien akan diperiksa oleh dokter, jika pasien yang sudah pernah periksa maka dokter akan melihat blangko yang berisi rekam medis pasien. Selesai proses pengerjaan dokter menulis terapi yang sudah diberikan di blangko rekam medis pasien. Tahap analisis yang dilakukan adalah menganalisis permasalahan sistem yang sedang berjalan dan analisis kebutuhan sistem yang dikembangkan. Langkah perancangan dari sistem yang dikembangkan dalam penelitian ini adalah membuat bagan alir sistem yang dikembangkan, diagram arus data, desain input, desain output dan desain basis data. Sistem dibuat menggunakan visual basic dan Ms.Acces. Sistem yang dikembangkan dalam penelitian ini meliputi pengolahan data pasien, data diagnosa, data tindakan data obat, data dokter. Fasilitas pemeriksaan pasien yang ada dalam sistem antara lain riwayat penyakit dan namnesa, diagnosa pasien, tindakan pemerisaan pasien, obat yang diberikan dan poto ronsen. Sistem dapat menghasilkan daftar pasien, daftar dokter, daftar obat, daftar diagnosa, daftar tindakan, laporan rekam medis, laporan penjualan obat dan laporan pemasukan.Kata Kunci: Rekam Medis, Klinik Gigi, Visual BasicAbstract  - Currently the service at the dental clinic at the Lung Hospital, dr. Ario Wirawan (RSPAW) still uses conventional or offline methods. The patient registration process can be done by coming to the clinic to take a queue number. New patients are required to fill out a new patient form. After that the patient will be examined by the doctor, if the patient has been examined, the doctor will see a blank containing the patient's medical record. After completing the process, the doctor writes the therapy that has been given on the patient's medical record blank. The analysis phase carried out is analyzing the problems of the current system and analyzing the needs of the system being developed. The design step of the system developed in this research is to make a flow chart of the system developed, data flow diagrams, input design, output design and database design. The system is made using visual basic and Ms. Access. The system developed in this study includes patient data processing, diagnostic data, drug data action data, doctor data. Patient examination facilities that exist in the system include medical history and name, patient diagnosis, patient examination procedures, drugs given and X-ray photos. The system can generate patient lists, doctor lists, drug lists, diagnostic lists, action lists, medical record reports, drug sales reports and income reports.Keywords : Medical Records, Dental Clinic , Visual Basic

ANALISIS PELAKSANAAN REKAM MEDIS DI RUMAH SAKIT IBU DAN ANAK (RSIA ) WIDIYANTI

2018 ◽  
Vol 11 (1) ◽  
Author(s):  
Fera Siska
Keyword(s):  
Qualitative Research ◽  
Data Analysis ◽  
Data Collection ◽  
Human Resources ◽  
Medical Record ◽  
Medical Records ◽  
Depth Information ◽  
Operational Procedure ◽  
Patient Registration ◽  
Qualitative Research Design

ABSTRACTBackground : Medical record is one of the most important pillars that can not be considered trivial in a hospital, with the development of medical scienceCommon Purpose : To find in-depth information about the implementation of medical records at the hospital Widiyanti PalembangResearch Method : Qualitative research design with data collection techniques are conducted in triangulation, The data analysis is inductive, and the results of the study are emphasized more at the meaning than the generalization. The Research Results : the Implementation of medical records have been running but there is no medical record organization, the implementation of medical record activities done by rolling. Human Resources (HR) medical records should be placed specifically in the medical record along with clear tasks. Method of organizing medical record has been run although the result is not optimal, because Standard Operational Procedure (SOP) that made not socialized. Facilities and infrastructure that support the implementation of the medical record is good, marked by the existence of a special records archive medical records. Facilities and infrastructure such as chairs, desks, computers, patient registration books and outpatient registration and inpatient services are available, do not have budget funds for medical record implementation, especially by sending medical recruiter for trainingConclusion : Implementation of medical records have been running but not optimal.

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.

Penyelenggaraan rekam medik balai pengobatan rumah sakit gigi dan mulut program studi kedokteran gigi fakultas kedokteran universitas sam ratulangi manado

e-GIGI ◽  
2014 ◽  
Vol 2 (1) ◽  
Author(s):  
Edwin N Kalara
Keyword(s):  
Quality Of Care ◽  
Medical Record ◽  
General Condition ◽  
Medical Records ◽  
Check List ◽  
Study Program ◽  
Critical Data ◽  
Patient Registration ◽  
Forensic Case

Abstract: Completemedical recordcanprovidelegal protection forphysicians, dentists andmedical personnelin the event ofcertain cases. Dental medical records have critical data that needs to be recorded, summarized in the dental medical record sheet so that it serves as a check list for patients. Such as the identity of the patient, the patient's general condition, odontogram, Dental care data and the name of the treating dentist, so the medical record is crucial in analyzing a forensic case and as a primary proof of accurate, also in terms of improving quality of care. The purpose of this study was to determine the organization of medical records on BP-RSGM Dentistry Study Program Faculty of Medicine, University of  Sam Ratulangi Manado . The population  in this study were medical records in BP - RSGM University of Sam Ratulangi from a period of 3 weeks in a row on the 27th August to 14th September 2012 . The results showed that the procedure for the implementation of medical records at the BP-RSGM University of Sam Ratulangi begin receiving patient registration, medical records filling up on pengarsipannya is already pretty good. It was referring to the organization of the medical record that the guidelines issued by the Ministry of Health in 2006. Keywords: medical records Abstrak: Rekam medis yang lengkap dan jelas dapat memberikan perlindungan hukum bagi dokter, dokter gigi dan tenaga medis ketika terjadi kasus-kasus tertentu. Rekam medis gigi memiliki data-data penting yang perlu dicatat  dan dirangkum dalam lembar rekam medis gigi sehingga berfungsi sebagai check list untuk pasien. Seperti identitas pasien, keadaan umum pasien, odontogram, data perawatan Kedokteran Gigi dan nama dokter gigi yang merawat, sehingga rekam  medis merupakan hal yang sangat menentukan dalam menganalisa suatu kasus forensik dan sebagai alat bukti utama yang akurat, juga dalam hal peningkatan mutu pelayanan. Tujuan penelitian ini adalah untuk mengetahui penyelenggaraan rekam medis pada BP RSGM Program Studi Kedokteran Gigi Fakultas Kedokteran Universitas Sam Ratulangi Manado. Populasi dalam penelitian ini adalah rekam medis di BP-RSGM Universitas Sam Ratulangi Manado dari kurun waktu 3 minggu berturut turut pada tanggal 27 Agustus sampai 14 September 2012. Hasil penelitian menunjukkan bahwa tatacara penyelenggaraan rekam medis di BP RSGM Universitas Sam Ratulangi mulai pendaftaran penerimaan pasien, pengisian rekam medis sampai pada pengarsipannya adalah sudah cukup baik. Hal tersebut sudah mengacu pada pedoman penyelengaraan rekam medis yang dikeluarkan oleh Departemen Kesehatan RI tahun 2006.Kata kunci : rekam medis

scholarly journals Sistem Informasi Rekam Medis Puskesmas Kotaratu Berbasis Desktop

2021 ◽  
Vol 5 (2) ◽  
pp. 306-314
Author(s):  
Aprilia Ningsi ◽  
◽  
Kristina Sara ◽  
Anastasia Mude ◽  
◽  
...  
Keyword(s):  
Information System ◽  
Health Center ◽  
Medical Record ◽  
Medical Records ◽  
Visual Basic ◽  
Medical Record Data ◽  
Administrative Process ◽  
Record Data ◽  
Develop Software ◽  
Long Time

The administrative process at Kotaratu health center still uses manual means. So, it takes a long time in handling patient visits and making reports. The goal of the study was to build a desktop-based medical record information system using the Microsoft Visual Basic. Net Programming Language and MySQL as its database. Data collection techniques through interviews, observations and literature studies. Meanwhile, to develop software (system) with waterfall method, while testing uses blackbox-testing. Our findings are in the form of a desktop-based information system at Kotaratu health center. Furthermore, Blackbox-testing results show that all components in this system are running well, and all medical record data is stored in the database to provide a convenience in managing patient data, searching for medical records, managing medical records and making reports periodically.

A Retrieval System for a Library of Pathology Reports, Slides and Kodachromes

1972 ◽  
Vol 11 (03) ◽  
pp. 152-162 ◽  
Author(s):  
P. GAYNON ◽  
R. L. WONG
Keyword(s):  
Medical Records ◽  
Operative Procedure ◽  
Clinical Findings ◽  
Free Text ◽  
X Ray ◽  
Inverted File ◽  
Natural Language Parsing ◽  
On Line ◽  
Pathology Reports ◽  
Frequency Counts

With the objective of providing easier access to pathology specimens, slides and kodachromes with linkage to x-ray and the remainder of the patient’s medical records, an automated natural language parsing routine, based on dictionary look-up, was written for Surgical Pathology document-pairs, each consisting of a Request for Examination (authored by clinicians) and its corresponding report (authored by pathologists). These documents were input to the system in free-text English without manual editing or coding.Two types of indices were prepared. The first was an »inverted« file, available for on-line retrieval, for display of the content of the document-pairs, frequency counts of cases or listing of cases in table format. Retrievable items are patient’s and specimen’s identification data, date of operation, name of clinician and pathologist, etc. The English content of the operative procedure, clinical findings and pathologic diagnoses can be retrieved through logical combination of key words. The second type of index was a catalog. Three catalog files — »operation«, »clinical«, and »pathology« — were prepared by alphabetization of lines formed by the rotation of phrases, headed by keywords. These keywords were automatically selected and standardized by the parsing routine and the phrases were extracted from each sentence of each input document. Over 2,500 document-pairs have been entered and are currently being utilized for purpose of medical education.

Perencanaan Arsitektur Sistem Informasi Rekam Medis dan Monitoring Gizi Buruk Berbasis Cloud Computing (Studi Kasus: Dinas Kesehatan Propinsi Jawa Barat)

2017 ◽  
Vol 8 (3) ◽  
Author(s):  
Ova Nurisma Putra
Keyword(s):  
Cloud Computing ◽  
Information System ◽  
Medical Record ◽  
Medical Records ◽  
Monitoring And Evaluation ◽  
Open Group ◽  
Development Method ◽  
Information System Architecture ◽  
Architecture Framework ◽  
Architecture Development

Abstract. West Java Provincial Health Office still faces difficulties in managing information, especially in medical records. Recording and reporting of malnutrition are still done in some stages starting from collecting data from village midwives, puskesmas, Regency/City Health Office then Provincial Health Office and forwarded to the the central office. It is necessary to manage information through service system by utilizing Cloud Computing based on information technology. This research uses The Open Group Architecture Framework (TOGAF) approach in Architecture Development Method (ADM), from Architecture Capability Iteration to  Architecture Development Iteration. Monitoring and Evaluation (M & E) are two integrated activities in the context of controlling a program. The results of this research are planning a medical record information system architecture and monitoring malnutrition based on Cloud Computing with the name of M2Rec (Medical Record and Monitoring) in the form of integrated recommendation and development between current information system and proposed information system architecture.Keywords: togaf adm, medical record and monitoring, cloud computing Abstrak. Perencanaan Arsitektur Sistem Informasi Rekam Medis dan Monitoring Gizi Buruk Berbasis Cloud Computing. Dinas Kesehatan Propinsi Jawa Barat masih mengalami kesulitan dalam pengelolaan informasi yang baik, terutama pada proses rekam medis, pencatatan dan pelaporan gizi buruk masih dilakukan secara bertingkat mulai pengumpulan data dari bidan desa, puskesmas, Dinas Kesehatan Kabupaten/Kota kemudian Dinas Kesehatan Propinsi dan diteruskan ke pusat. Sehingga perlu diupayakan pengelolaan informasi melalui sistem pelayanan dengan memanfaatkan teknologi informasi berbasis Cloud Computing. Penelitian ini menggunakan pendekatan framework The Open Group Architecture Framework (TOGAF) Architecture Development Method (ADM), yaitu iterasi ke satu pada Architecture Capability Iteration daniterasi ke dua pada Architecture Development Iteration. Monitoring dan Evaluasi (M&E) merupakan dua kegiatan terpadu dalam rangka pengendalian suatu program. Hasil dari penelitian ini adalah perencanaan arsitektur sistem informasi rekam medis dan monitoring gizi buruk berbasis Cloud Computing dengan nama M2Rec (Medical Record and Monitoring) yang berupa rekomendasi integrasi dan pengembangan antara sistem informasi berjalan saat ini dengan arsitektur sistem informasi yang diusulkan.Kata kunci: togaf adm, medical record and monitoring, cloud computing.

Analisis Unsur Manajemen dalam Pengolahan Rekam Medis di Rumah Sakit TNI AU Lanud Roesmin Nurjadin

2018 ◽  
Vol 1 (1) ◽  
pp. 20-25
Author(s):  
Henny Maria Ulfa
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Processing Method ◽  
Qualitative Approach ◽  
Check List ◽  
Training Material ◽  
Patient Medical Record ◽  
Qualitative Descriptive ◽  
Material Element ◽  
Descriptive Method

Hospitals must conduct a medical record activities according to Permenkes NO.269 / MENKES / PER / III / 2008 about Medical Record, to achieve the purpose of medical record processing required 5 management elements are: man, money, material, machine, and method. The medical record processing that has been implemented at the Hospital TNI AU LANUD Roesmin Nurjadin that is coding, coding only done for BPJS patients whose conducted by the officer with education background of D3 nursing, it be impacted to the storage part is wrong save and cannot found patient medical record file because are not returned. The purpose of this research is to know the element of management in the processing of medical records at the Hospital TNI AU LANUD Roesmin Nurjadin. This research is done by Qualitative descriptive method, Qualitative approach, instrument of data collection of interview guidance, observation guidance, check list register, and stationery, number of informant 6 people with inductive way data analysis. The result of this research found that Mans elements only amounts to 2 people so that officers work concurrently and have never attended training, material element and machines elements of medical record processing not yet use SIMRS and tracer, while processing method elements follow existing habits and follow the policy of hospital that is POP organization. Keywords: Management elements, medical record processing

scholarly journals Automatic Placement of Genomic Research Results in Medical Records: Do Researchers Have a Duty? Should Participants Have a Choice?

2015 ◽  
Vol 43 (4) ◽  
pp. 827-842
Author(s):  
Anya E.R. Prince ◽  
John M. Conley ◽  
Arlene M. Davis ◽  
Gabriel Lázaro-Muñoz ◽  
R. Jean Cadigan
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Genomic Research ◽  
Research Results ◽  
Research Participants ◽  
Difficult Question ◽  
Automatic Placement ◽  
Study Participants ◽  
Research Studies

The growing practice of returning individual results to research participants has revealed a variety of interpretations of the multiple and sometimes conflicting duties that researchers may owe to participants. One particularly difficult question is the nature and extent of a researcher’s duty to facilitate a participant’s follow-up clinical care by placing research results in the participant’s medical record. The question is especially difficult in the context of genomic research. Some recent genomic research studies — enrolling patients as participants — boldly address the question with protocols dictating that researchers place research results directly into study participants’ existing medical records, without participant consent. Such privileging of researcher judgment over participant choice may be motivated by a desire to discharge a duty that researchers perceive themselves as owing to participants. However, the underlying ethical, professional, legal, and regulatory duties that would compel or justify this action have not been fully explored.

CHEST X RAY SCORE AND CLINICAL SEVERITY IN COVID-19 PATIENTS

2021 ◽  
pp. 31-32
Author(s):  
Sheeba Rana ◽  
Vicky Bakshi ◽  
Yavini Rawat ◽  
Zaid Bin Afroz
Keyword(s):  
Retrospective Study ◽  
Medical Records ◽  
Scoring Systems ◽  
Clinical Severity ◽  
X Rays ◽  
Antigen Test ◽  
X Ray ◽  
Classi Cation ◽  
Chest X Ray ◽  
Male Subjects

INTRODUCTION: Various chest X-ray scoring systems have been discovered and are employed to correlate with clinical severity, outcome and progression of diseases. With, the coronavirus outbreak, few chest radiograph classication were formulated, like the BSTI classication and the Brixia chest X-ray score. Brixia CXR scoring is used for assessing the clinical severity and outcome of COVID-19. This study aims to compare the Brixia CXR score with clinical severity of COVID-19 patients. MATERIAL& METHODS:This was a retrospective study in which medical records of patients aged 18 years or above, who tested for RTPCR or st st Rapid Antigen Test (RAT) for COVID positive from 1 February 2021 to 31 July 2021 (6 months) were taken. These subjects were stratied into mild, moderate and severe patients according to the ICMR guidelines. Chest X Rays were obtained and lesions were classied according to Brixia scoring system. RESULTS: Out of these 375 patients, 123 (32.8%) were female and 252 (67.2%) were male subjects. The average brixia score was 11.12. Average Brixia CXR score for mild, moderate and severe diseased subjects were 5.23, 11.20, and 14.43 respectively. DISCUSSION:The extent of chest x-ray involvement is proportional to the clinical severity of the patient. Although, a perplexing nding was that the average Brixia score of the female subjects were slightly higher than their male counterparts in the same clinical groups. CONCLUSION: Brixia CXR score correlates well with the clinical severity of the COVID-19.

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