scholarly journals Studi Deskriptif Kelengkapan Dokumen Rekam Medis

2020 ◽  
Vol 3 (1) ◽  
pp. 36-39
Author(s):  
Ika Setya Purwanti ◽  
Diah Prihatiningsih ◽  
Ni Luh Putu Devhy

Medical records are files that contain records and patient identify documents, the results of examination treatments, action, and services that have been provided. The completeness of filling in the medical record file can make it easier for other health workers to provide patient action or treatment, and can be used as a useful source of information for hospital management in determining the evaluation and development of health services. The purpose of this research was to study the complete picture of medical record documents at Sanjiwani General Hospital, Gianyar. This research is a quantitative study using the checklist in accordance with Permenkes RI No. 269/Menkes/Per/III/2008. The method used in this study was observation using cross sectional and restrospective data collection. The results of this study indicate that the completeness of the medical record from the patients identity, the identity of the doctor, the identity of the nurse shows a completeness of 100% and the completeness of the information was 64,1%. Analysis of data from this research used descriptive methods. So that it is expcted from the results of this study to maintain the awareness and discipline of the officers responsible for filling out medical record in accordance with predetermined procedures.AbstrakRekam medis adalah berkas yang berisi catatan dan dokumen identitas pasien, hasil pemeriksaan, pengobatan, tindakan dan pelayanan yang telah diberikan. Kelengkapan pengisian berkas rekam medis dapat memudahkan tenaga kesehatan lain dalam memberikan tindakan atau pengobatan pasien, dan dapat dijadikan sebagai sumber informasi yang berguna bagi manajemen rumah sakit dalam menentukan evaluasi dan pengembangan pelayanan kesehatan. Tujuan penelitian ini adalah untuk mengetahui gambaran kelengkapan  rekam medis di RSUD Sanjiwani, Gianyar. Penelitian ini merupakan penelitian kuantitatif dengan menggunakan Check list sesuai dengan Permenkes RI No. 269/Menkes/Per/III/2008. Metode yang digunakan dalam penelitian ini adalah observasi dengan pendekatan cross sectional dan pengambilan datanya secara retrospektif. Hasil dari penelitian ini menunjukkan bahwa kelengkapan rekam medis dari kelengkapan identitas pasien, kelengkapan identitas dokter, kelengkapan identitas perawat menunjukkan kelengkapan rekam medis sebesar 100% sedangkan kelengkapan inform concern sebanyak 64,1%. Analisis data dalam penelitian ini menggunakan metode deskriptif. Dari hasil penelitian ini diharapkan agar rumah sakit dapat mempertahankan kesadaran dan kedisiplinan petugas yang bertanggung jawab dalam pengisian rekam medis sehingga sesuai dengan prosedur yang telah ditetapkan.

Author(s):  
Vinani Fajariani ◽  
Noer Bahry Noor ◽  
Hasnawati Amqam

At Makassar City Hospital, one of the service indicators that has not been achieved is in incomplete medical record files and medical record files that are returned more than 2x24 hours after service. This study aims to analyze the implementation of the completeness of filling in and the timeliness of returning inpatient medical record files at the Makassar City Hospital. This type of research is mixed methods research. The study design used a cross-sectional approach. The study was conducted in September - October 2020. The results showed that the implementation of completeness of filling in and the timeliness of returning medical record files was still low, this has led to the accumulation of medical record files in the treatment room and delays in returning the files of inpatients to the medical record installation of the City Hospital Makassar. Training on the implementation of medical records has not been comprehensive for all officers at the Makassar City Hospital. The result of the delay in returning the documents is the delay in payment of insurance claims to the hospital. Accumulation of medical records in the treatment room from incomplete medical records and returned to the treatment room. Health workers who forget to fill in complete medical records are only given a sanction in the form of a warning during a meeting with the medical committee. Availability of SOP on filling and returning medical record files at the hospital. The facilities and infrastructure in the implementation of medical records are still insufficient for medical record employees at Makassar City Hospital. It is recommended that the hospital improve the implementation of the completeness and timeliness of returning medical record files, provide incentives or rewards for completing filling in, increase the number of computers and expand the room in the medical record installation, and review the medical record format at Makassar City Hospital


SOEPRA ◽  
2020 ◽  
Vol 5 (2) ◽  
pp. 215
Author(s):  
Prilian Cahyani ◽  
Astutik Astutik

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.


2021 ◽  
Vol 1 (1) ◽  
pp. 30-35
Author(s):  
Rasniah Sarumi ◽  
Elna Sari ◽  
Nur Yazlim

Baground: One form of service in the administration room is the caring behavior of health workers where the caring attitude will be intertwined with a relationship of mutual trust, compassion and honesty. Patients and their families will feel satisfied if the health services received are in accordance with the patient's expectations and can feel disappointed if the caring health workers received are not in line with their expectations so that patients will tend to choose health services that can provide good caring. The purpose of this study was to know the caring of health workers in administrative services on patient satisfaction in inpatients at the Muna Regency General Hospital.. Method: The research design uses a cross sectional study approach involving a sample of 52 people. The data collection method used primary data and secondary data. Data analysis using Univariate and Bivariate analysis. Results: there is a relationship between caring for health workers in administrative services to patient satisfaction in inpatients at the Muna Regency General Hospital with a value of 0,017. Conclusions: there is a relationship between caring for health workers in administrative services to patient satisfaction in inpatients at the Muna Regency General Hospital. Keywords: career, health workers, administrative services, patient satisfaction   Pendahuluan: Salah satu bentuk pelayanan diruangan administrasi adalah perilaku caring petugas kesehatan dimana sikap caring akan terjalin dengan adanya hubungan saling percaya, belas kasih dan kejujuran. Pasien maupun keluarga pasien akan merasa puas apabila pelayanan kesehatan yang diterima sesuai dengan harapan pasien dan dapat merasa kecewa bila caring petugas kesehatan yang diterima tidak sesuai dengan harapannya sehingga pasien akan cenderung memilih pelayanan kesehatan yang dapat memberikan caring dengan baik. Tujuan penelitian ini adalah diketahinya caring petugas kesehatan pada pelayanan administrasi terhadap kepuasan pasien di  rawat inap Rumah Sakit Umum Daerah Kabupaten Muna.   Metode: Desain Penelitian menggunakan  pendekatan Cross Sectional Study yang melibatkan sampel sebesar 52 orang. Metode pengumpulan data menggunakan data primer dan data sekunder. Analisis data menggunakan analisis Univariat dan Bivariat. Hasil: ada hubungan caring petugas kesehatan pada pelayanan administrasi terhadap kepuasan pasien di  rawat inap Rumah Sakit Umum Daerah Kabupaten Muna dengan nilai ρ sebesar 0,017. Kesimpulan: ada hubungan caring petugas kesehatan pada pelayanan administrasi terhadap kepuasan pasien di  rawat inap Rumah Sakit Umum Daerah Kabupaten Muna Kata kunci: caring, petugas kesehatan, pelayanan administrasi, kepuasan pasien


2020 ◽  
Vol 14 (4) ◽  
pp. 529-535
Author(s):  
Dewi Kusumaningsih ◽  
Agustina Sianturi

The health educational intervention and inpatient documentation execution  and an internal motivation among nursesBackground: Documentation of the health educational to inpatient is a nursing that evidence record the service of nursing care given to the patients that is useful for patients, nurses, health staffs and hospital. Most of the hospital in Bandar Lampung in the pre-survey, there were of 30% medical records was incomplete filled such as time and date when giving nursing care and signed by nurses, and mostly regarding in health educational documentations.Purpose: To identify the nursing documentation perfection (health education to the inpatient) and an internal motivation among nurses to executionMethod: A quantitative study with cross-sectional approach. The population and the sample were all inpatient nurses at Immanuel Hospital of Bandar Lampung in 2019 of 75 respondent and 75 medical records. The instrument as a questionnaire to explore nurses' internal motivation. Medical record to observe nursing note.Results: Finding of 52.0% respondent has made an incomplete nursing documentation and 46.7% respondents exhibited a poor in internal motivation. The p value was 0.004; and OR 4.643.Conclusion: There was a correlation between nurses' internal motivation and the completeness of health educational documentation. The nurse supervisor should regularly do evaluation the completeness of health educational documentation and hospital management to encourage nurses's internal motivation.Keywords: The health educational; Intervention; Inpatient documentation; Execution; An internal motivation; NursesPendahuluan: Dokumentasi edukasi keperawatan merupakan bukti tertulis perawat atas pelayanan asuhan keperawatan yang diberikan kepada pasien yang berguna untuk kepentingan pasien, perawat, tim kesehatan lain dan rumah sakit. Saat pre survey didapatkan 30% dokumentasi edukasi pasien tidak terisi waktu dan tanggal pelaksanaan, 10% dokumentasi edukasi dalam pasien tidak terisi bagaimana kebutuhan edukasi, selain itu sebanyak 10%  pasien pindahan dalam lembar edukasi tidak terisi tujuan pemberi edukasi di dalam form tersebut.Tujuan: Diketahui hubungan motivasi internal perawat terhadap kelengkapan dokumentasi edukasi di ruang bangsal dewasa Rumah Sakit Imanuel Bandar Lampung tahun 2019.Metode: Jenis penelitian kuantitatif, desain penelitian analitik pendekatan cross sectional. Populasi dan sampelnya  seluruh perawat pelaksana di ruang bangsal  Rumah Sakit Imanuel Bandar Lampung, sejumlah 75 responden dan 75 catatan keperawatan dalam medical record. Instrumen berupa angket untuk mengetahui motivasi internal perawatHasil: Diketahui dari 75 responden sebanyak (52,0% responden melakukan pendokumentasian tidak lengkap. Diketahui dari 75 responden sebanyak 46,7% responden yang mempunyai motivasi internal kategori rendah. Didapatkan hasil p-value=0,004; OR 4,643.Simpulan: Ada hubungan motivasi perawat terhadap kelengkapan dokumentasi edukasi di ruang bangsal dewasa Rumah Sakit Imanuel Bandar Lampung tahun 2019. Saran diharapkan kepala ruangan dapat mengevaluasi secara rutin tentang kelengkapan pengisian dokumentasi edukasi


2020 ◽  
Vol 15 (3) ◽  
pp. 167
Author(s):  
Ahmad Muthi Abdillah ◽  
Ahmad Sulaeman ◽  
Tiurma Sinaga

Cholesterol-lowering herbal treatment made from natural ingredients are believed to be able to replace modern medicine even though it has not been scientifi cally proven. Purpose of this study was to test perceptions of customers and eff ects of mixed herbal drink on lipid profi le of consumers with hypercholesterolemia. Study was conducted using cross sectional study design consisted of three stages, that is survey, questionnaire data collection, and medical record data collection. The research subjects were selected by stratifi ed random sampling, which subjects were consumers of mixed herbal drink in total of 55 people, both men and women. Data was collected through interviews of questionnaires covering subject characteristics, subject perceptions of mixed herbal drink, and their medical record data before and after consumption of mixed herbal drinks. Paired T-test were used to observe the diff erences in subject lipid profi le before and after consumption of mixed herbal drink. Consumer perceptions toward health aspects showed that 83.7% of subjects experienced a decrease in cholesterol after consuming mixed herbal drink. Consumer emotional perception showed that 90.9% of subjects feel healthier and fi lter after consuming mixed herbal drink. Results of subject medical records on lipid profi le showed a decrease in total cholesterol, LDL, and triglycerides (p<0.05). Based on perceptions and medical records, it is known that mixed herbal drink can be used as an alternative to traditional cholesterol-lowering medicines.


2020 ◽  
Vol 7 (2) ◽  
pp. 46-49
Author(s):  
Nirma Alfiani ◽  
Dede Setiawan ◽  
Sumarni

Medical records as evidence of health services have an important role in proving law including forms on medical records that have specific functions and meanings in each item. One of which is an operating report that is the contents of an everlasting or perpetuated medical record. The purpose of this research is to know a deeper overview of the completeness of the medical record on the Operation report form at the Sumber Waras Hospital of Cirebon Regency.  The type of research used is descriptive research. Data collection techniques using an observation method with the research instrument sheet Checklist. Simple random sampling techniques. The sample in this study is the medical record of the operating patients in the Cirebon district source Waras Hospital as much as 72 medical record documents.  The results of the medical record in the Operations report form there are 11 documents (15%) a fully stocked and 61 documents (85%.) that are not fully stocked.  The conclusion obtained in this study is that the minimum medical record service standard at Sumber Waras Hospital in Cirebon Regency is not in accordance with Kepmenkes number 129 of 2008.


Author(s):  
Henny Maria Ulfa

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


Author(s):  
Yuhemy Zurizah Yuhemy Zurizah ◽  
Rini Mayasari Rini Mayasari

ABSTRACT Low Birth Weight (LBW) was defined as infants born weighing less than 2.500 grams. WHO estimates that nearly all (98%) of the five million neonatal deaths in developing countries. According to City Health if Palembang Departement, infant mortality rate (IMR) in the year 2007 is 3 per 1000 live births, in 2008 four per 1000 live births, and in 2009 approximately 2 per 1000 live births. The cause of LBW is a disease, maternal age, social circumstances, maternal habits factors, fetal factors and environmental factors. LBW prognosis depending on the severity of the perinatal period such as stage of gestation (gestation getting younger or lower the baby's weight, the higher the mortality), asphyxia / ischemia brain, respiratory distress syndromesmetabolic disturbances. This study aims to determine the relationship between maternal age and educations mothers of pregnancy with the incidence of LBW in the General Hospital Dr Center. Mohammad Hoesin Palembang in 2010 This study uses the Analytical Ceoss Sectional Survey. The study population was all mothers who gave birth in public hospitals center Dr. Mohammad Hoesin Palembang in 2010 were 1.476 mothers gave birth with a large sample of 94 studies of maternal taken by systematic random sampling, ie research instument Check List. Data analysis was performed univariate and bivariate. The results of this study show from 94 mothers of LBW was found 45 people (47,9%) Which has a high risk age 26 LBW ( 27,7%) while the distance of low educations LBW (55,3%). From Chi-Square test statistic that compares the p value with significance level α = 0,05 showed a significant correlation between maternal age, where the p value = 0,002, of education mothers of pregnancy p value = 0,003 with LBW. In the general hospital center Dr. Mohammad Hoesin Palembang ini 2010. Expected to researches who will come to examine in more depth.   ABSTRAK Bayi Berat Lahir Rendah (BBLR) telah didefinisikan sebagai bayi lahir kurang dari 2.500 gram. WHO memperkirakan hampir semua (98%) dari 5 juta kematian neonatal di negara berkembang. Menurut Data Dinas Kesehatan Kota Palembang, Angka Kematian Bayi (AKB) pada tahun 2007 yaitu 3 per 1.000 kelahiran hidup, pada tahun 2008 4 per 1.000 kelahiran hidup, dan pada tahun 2009 sekitar 2 per 1.000 kelahiran hidup. Penyebab BBLR adalah penyakit, usia ibu, keadaan sosial, faktor kebiasaan ibu, dan faktor lingkungan. Prognosis BBLR tergantung dari berat ringannya masa perinatal misalnya masa gestasi (makin muda masa gestasi atau makin rendah berat bayi, makin tinggi angka kematian), asfiksia atau iskemia otak, sindrom gangguan pernafasan, gangguan metabolik. Penelitian ini bertujuan untuk mengetahui hubungan antara umur dan pendidikan ibu dengan kejadian BBLR di Rumah Sakit Umum Pusat Dr. Mohammad Hoesin Palembang Tahun 2010. Penelitian ini menggunakan survey analitik Cross sectional. Populasi penelitian ini adalah semua ibu yang melahirkan di Rumah Sakit Umum Pusat Dr. Mohammad Hoesin Palembang tahun 2010 sebanyak 1.476 ibu melahirkan dengan besar sampel penelitian 94 ibu melahirkan yang diambil dengan tehnik acak sistematik, instrumen penelitian yaitu check list. Analisis data dilakukan secara univariat dan bivariat. Hasil penelitian ini menunjukkan dari 94 ibu didapatkan kejadian BBLR 45 orang (47,9%) yang memiliki umur resiko tinggi 26 kejadian BBLR (27,7%) sedangkan yang pendidikan rendah 52 kejadian BBLR (55,3%). Dari statistik uji Chi-square yang membandingkan p value dengan tingkat kemaknaan α = 0,05 menunjukkan bahwa ada hubungan yang bermakna antara umur ibu p value (0,002) , pendidikan p value (0,003) dengan kejadian BBLR di Rumah Sakit Umum Pusat Dr. Mohammad Hoesin Palembang Tahun 2010. Diharapkan bagi peneliti yang akan datang untuk meneliti lebih mendalam.


2018 ◽  
Vol 11 (1) ◽  
Author(s):  
Fera Siska

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.


2015 ◽  
Vol 36 (1) ◽  
pp. 35-42
Author(s):  
Grazielle Cavalcante de Souza Carneiro ◽  
Lívia Maria Correia de Morais ◽  
Leidiane Francis de Araújo Costa ◽  
Talita Helena Monteiro de Moura ◽  
Marly Javorski ◽  
...  

This study aimed to describe the growth during the introduction of complementary feeding to infants assisted in the nursing appointment in childcare. It is a descriptive, cross-sectional, quantitative study developed through research in 51 medical records of children aged 4-8 months, from September to October 2012 in a university hospital in the city of Recife, PE. Data were analyzed using Epi Info software, version 6.04 and described in simple and relative frequencies. It was found that for 33% of the children. complementary foods were introduced at six months. Of these, 88.2%, 69.2% and 57.1% showed ascending weight-for-age growth curves, and 88.2%, 66.7% and 71.4% ascending length-for-age growth curves at six, seven and eight months respectively. Children with appropriate and timely introduction of complementary feeding showed upward growth curves and adequate nutritional status.


Sign in / Sign up

Export Citation Format

Share Document