scholarly journals DESCRIPTION OF THE MANAGEMENT OF MEDICAL RECORD INPATIENT OF SYEKH YUSUF DISTRICT HOSPITAL GOWA 2019

2021 ◽  
Vol 20 (1) ◽  
Author(s):  
Zilfadhilah Arranury ◽  
Surahmawati Surahmawati, ◽  
Muhammad Rusmin ◽  
Tri Addya Karini ◽  
Dian Rezki Wijaya ◽  
...  
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Medical Support ◽  
Double Burden ◽  
Descriptive Research ◽  
Patient Loyalty ◽  
Record Data ◽  
Qualitative Descriptive ◽  
Selection Of

In the current era of global competition, it requires every hospital as a health service facility to be able to provide quality services in order to foster patient loyalty as service users. The medical record is one of the medical support services which is the basis for assessing the quality of medical services. Completeness of medical record files in RSUD Syekh Yusuf Kab. Gowa in a period of three years has fluctuated, namely 20% in 2017, 66% in 2018, and decreased in 2020 to 17%. This study aims to determine the description of medical record data management at RSUD Syekh Yusuf Kab. Gowa 2019.This study used a qualitative descriptive research method with the selection of informants using a purposive technique, and 6 informants were obtained, including 4 medical record officers, 1 head of the inpatient room, and 1 head of the medical records department.The results of the interview showed that the personnel in the medical records department were deemed insufficient, the flow and SOP were not implemented, the facilities and infrastructure were inadequate. In the implementation of medical records, there are still files that are filled in incompletely which results in delays in making reports.It is hoped that the hospital management will increase the number of personnel so that there is no double burden on officers, provide training for medical record officers, and pay attention to facilities and infrastructure to switch from a conventional system to an electronic-based system.

scholarly journals Prediction of active filing shelf in medical record unit - General hospital Dr. H. Soewondo Kendal 2020 – 2024

2020 ◽  
Vol 13 (3) ◽  
pp. 001-007
Author(s):  
Prasetya Jaka ◽  
Isworo Slamet
Keyword(s):  
Linear Regression ◽  
General Hospital ◽  
Medical Record ◽  
Medical Records ◽  
Sampling Technique ◽  
Systematic Sampling ◽  
Regression Equations ◽  
Medical Support ◽  
Observation Results

General hospital Dr. H. Soewondo Kendal is a local government hospital. Improving medical support services, especially the quality of medical record archiving services, is essential to maintain the quality of hospitals in the context of good hospital standards. This study aims to predict the need for archive shelves between 2015-2019. The type of research used is descriptive with accidental sampling technique. Patient medical records were collected using a systematic sampling technique. The observation results showed that the average thickness of medical record documents was 0.85 cm based on measurements on 30 samples of medical record documents. The hospital has 48 shelves with 5 sub-shelves on each shelf. The length of the available archives is 525 cm and by 2024 a total of 37 shelfs will be needed. Modeling results based on linear regression equations have decreased medical record documents since 2015-2019 y = - 782.9x +30636. However, the linear regression validation for the cumulative medical record documents for 2015-2019 shows an increase based on the regression equation y = 28439 x + 1112.2, therefore it is necessary to immediately save the medical record document in an active state. The conclusion delivered by Dr. H. Soewondo Kendal does not need an additional archive shelf, but it does require inactive document storage.

scholarly journals FAKTOR-FAKTOR YANG MEMPENGARUHI KETERLAMBATAN PENGEMBALIAN BERKAS REKAM MEDIS RAWAT JALAN DI UPT RUMAH SAKIT KHUSUS PARU TAHUN 2019

2020 ◽  
Vol 5 (1) ◽  
pp. 108-113
Author(s):  
Ali Sabela Hasibuan
Keyword(s):  
Service Delivery ◽  
Medical Record ◽  
Medical Records ◽  
Sampling Technique ◽  
Medical Record Data ◽  
Patient Medical Record ◽  
Descriptive Research ◽  
Record Data ◽  
Quantitative Descriptive ◽  
Time Required

ABSTRAK   Unit rekam medis merupakan bagian yang penting dalam suatu rumah sakit, karena rekam medis memuat kegiatan mulai dari penerimaan pasien, pencatatan, pengelolaan data rekam medis pasien, penyimpanan dan pengembalian berkas rekam medis.Selain itu, unit rekam medis harus mampu melayani permintaan informasi yang berkaitan dengan data rekam medis dengan cepat, tepat dan akurat pada waktu yang dibutuhkan.Salah satu faktor yang berpengaruh dalam kecepatan pemberian pelayanan kepada pasien adalah ketepatan waktu pengembalian berkas rekam medis ke unit rekam medis.Tujuan umum dari peneliti ini adalah untuk mengetahui faktor keterlambatan pengembalian berkas rekam medis rawat inap di UPT Rumah Sakit Khusus Paru Medan.Jenis penelitian ini menggunakan metode penelitian deskriptif kuantitatif.Populasi dalam penelitian petugas yang berkaitan dengan pengisian rekam medis diRS Khusus Paru yang berjumlah 15 orang, dengan teknik pengambilan sampel adalah total sampling yaitu berjumlah 15 orang.Berdasarkan hasil penelitian yang telah dilakukan  peneliti bahwa faktor yang paling mempengaruhi keterlambatan adalah menjalankan prosedur yang telah ditetapkan dan ketidaklengkapan  dalam pengisian dokumen rekam medis baik dalam identitas pasien dan ketepatan dalam pengisian diagnosis juga mempengaruhi keterlambatan dalam pengembalian berkas rekam medis dan menjalankan prosedur yang telah ditetapkan di rumah sakit pengembalian berkas rekam medis paling lama 1x24 jam, apabila pengembalian berkas rekam medis mengalami keterlambatan maka akan sangat berpengaruh terhadap assembling,analisis,coding,indixing,filling dan laporan. Kata Kunci                 : Pengembalian Rekam Medis. ABSTRACT   Medical record unit is an important part in a hospital, because medical records contain activities ranging from receiving patients, recording, managing patient medical record data, storing and returning medical record files. In addition, medical record units must be able to service requests for information relating with medical record data quickly, precisely and accurately at the time required. One of the factors that influence the speed of service delivery to patients is the timeliness of returning medical record files to the medical record unit. inpatient medical record at UPT Medan Special Lung Hospital. This type of research uses quantitative descriptive research methods. Population in the study of officers relating to filling medical records in the Special Lung RSR totaling 15 people, with the sampling technique is the total sampling which amounted to 15 people . Brilliant The results of research that have been conducted by researchers that the factors that most influence the delay are carrying out established procedures and incompleteness in filling medical record documents both in the patient's identity and accuracy in filling out the diagnosis also affect the delay in returning the medical record file and carry out the procedures specified in the hospital returns the medical record file for a maximum of 1x24 hours, if the return of the medical record file is delayed it will greatly affect the assembling, analysis, coding, indixing, filling and reporting.   Keywords: Returning Medical Records.

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 La ética en la investigación de posgrado

2017 ◽  
Vol 21 (2) ◽  
pp. 1
Author(s):  
Juan Manuel Piña-Osorio ◽  
Hilda Berenice Aguayo-Rousell
Keyword(s):  
Doctoral Programs ◽  
Logical Structure ◽  
Two Dimensions ◽  
Sources Of Information ◽  
Descriptive Research ◽  
Formal Presentation ◽  
Lack Of Commitment ◽  
Minimum Quality ◽  
Selection Of

This article presents the results of an exploratory-descriptive research with empirical referents. The objective was to document, systematize and evaluate some features of 15 postgraduate theses in education, with the intention to make visible some recurring dishonest practices of students and teachers. The postgraduate programs from which the theses were obtained are located in the metropolitan area of Mexico City. The selection of documents was carried out between July and November 2015. Two Likert scales were used to assess two dimensions separately: 1) content, in which originality, congruence, dominance and relevance of authors, findings and relevant conclusions were considered; and 2) presentation, which examined style, logical structure, spelling and punctuation, citations, references and sources of information. Each indicator was assigned a numerical value and this one was given an evaluative characteristic: 5: excellent, 3: regular and 1: deficient. Subsequently, percentages were obtained. The results indicated that only a third of the theses could be classified as excellent for the quality of the content and the impeccable presentation; a similar percentage were works that fulfilled the necessary but didn’t count with the rigor and originality of the first ones. The remaining papers had serious deficiencies, both in content and in the formal presentation of the document, without achieving the minimum quality demanded by a postgraduate thesis. The analysis of these investigations made it possible to visualize some of the dishonest practices of people graduating from various educational programs and the lack of commitment to their research. The results about the quality of the research in various doctoral programs indicate that there is little responsibility in students, personal tutor and the reviewer. The results allow the authorities of each program to observe the problem and seek practical solutions to solve it.

scholarly journals EFEKTIVITAS MANAJEMEN PENDIDIKAN DALAM PEMBELAJARAN AGAMA ISLAM UNTUK MEMBINA SIKAP DAN PENGAMALAN KEAGAMAAN SISWA DI KELAS V DAN VI SD PLUS AL-ISLAM KECAMATAN WANAYASA KABUPATEN PURWAKARTA

2017 ◽  
Vol 2 (2) ◽  
pp. 211-236
Author(s):  
Hilman Hamdani
Keyword(s):  
Learning Outcomes ◽  
Implementation Process ◽  
Religious Practice ◽  
Quality Of Education ◽  
Management Effectiveness ◽  
Religious Knowledge ◽  
Descriptive Research ◽  
Qualitative Descriptive ◽  
Religious Material

This study was conducted based on the low of religious practice of students which is the implementation of the learning outcomes of religious knowledge obtained anywhere, especially in SD Plus Al-Islam. Therefore, in the implementation of the school should be able to realize the management of education well, because the success of learning is strongly influenced by management effectiveness formulated. Islamic religious material in SD Plus Al-Islam is a distinctive feature that distinguishes it from other elementary schools. Therefore, the school should really be able to streamline the management of education in Islamic learning to improve the quality or quality of education, especially in religious practice. This study, included in qualitative descriptive research. The author collects data using observation, interview, and documentation methods. The results of research on the effectiveness of management education in Islamic learning to foster attitudes and religious practices of students, especially in performing prayers sunnah duha every morning, reading or memorizing Al-Quran, charity, and say hello. The overall management implementation process includes organizing, implementing and valuing systems. While the religious practice of the students is very diverse, in addition to the school management that must be considered, motivation, coaching, supervision of teachers, and environmental factors must also be considered. So the effectiveness of management in SD Plus Al-Islam Wanayasa Purwakarta was effective and can improve the attitude of religious practice of students.

scholarly journals Aspek Hukum Rekam Medis atau Rekam Medis Elektronik sebagai Alat Bukti Dalam Transaksi Teurapetik

2017 ◽  
Vol 3 (2) ◽  
pp. 359-383 ◽  
Author(s):  
Sudjana Sudjana
Keyword(s):  
Medical Record ◽  
Electronic Medical Record ◽  
Medical Records ◽  
Health Workers ◽  
Legal Aspects ◽  
Literature Study ◽  
Descriptive Research ◽  
Positive Law ◽  
Approach Method ◽  
Administrative Sanctions

This study aims to obtain information on: first, the obligation to create and conceal Electronic Medical Record and its juridical consequences; Secondly, due to the law of absence or error in the manufacture of Electronic Medical Records and the position of Electronic Medical Record as a tool in the theoretical transactions.The research method used is normative juridical approach method, analytical descriptive research specification, research phase is done through literature study to examine primary law material, secondary law material, and tertiary law material. Data collection techniques are conducted through document studies, conducted by reviewing documents on positive law. Furthermore, the method of data analysis is done through normative qualitative.The results of the study indicate: Legal aspects of Medical Record or Electronic Medical Record   in Teurapetik Transactions related to: first, the obligation of health workers in coaching and health services to make Medical Record or Electronic Medical Record correctly and responsible for secrecy because it is the opening of Medical Record or Electronic Medical Record without With the permission of the patient having the consequences of criminal law. The absence or misuse of the Medical Record or Electronic Medical Record means that health workers may be subject to criminal, civil and administrative sanctions. Second, the position of  Medical Record or Electronic Medical Record is evidence in the form of a letter (if given outside the court), and expert information (if delivered in court).

scholarly journals Dinamika Kemandirian Mahasiswa Perantauan

2021 ◽  
Vol 1 (3) ◽  
pp. 167
Author(s):  
Nadia Fauzia ◽  
Asmaran Asmaran ◽  
Shanty Komalasari
Keyword(s):  
Parenting Style ◽  
Sampling Technique ◽  
Research Approach ◽  
Overseas Students ◽  
Descriptive Research ◽  
Change Factors ◽  
The Family ◽  
Qualitative Descriptive ◽  
The Subject ◽  
Selection Of

The purpose of this study is to discuss the dynamics of the independence of UIN Antasari Banjarmasin students and what factors are behind the independence of UIN Antasari Banjarmasin students. The reason is because overseas there are changes in conditions and situations, so that students who leave will experience dynamics of independence. This type of research is a qualitative descriptive research approach. Selection of subjects using purposive sampling technique, which is based on the characteristics of the subject in accordance with the research objectives to be carried out. The object of this research is the dynamics of independence, the subject is 5 overseas students. Data collection techniques using interviews and observations. Based on the results of research that overseas students of UIN Antasari Banjarmasin need a process to be independent in living their lives overseas. That is because overseas there has been a change. Factors that influence the dynamics of independence of overseas students at UIN Antasari Banjarmasin are factors of parenting style, the order of children in the family, age and the education system in schools.

Study of Incompleteness Medical Records of Inpatient in Appendicitis Cases at Dr. Reksodiwiryo Hospital Padang

2022 ◽  
Vol 2 (1) ◽  
pp. 39-44
Author(s):  
Nurhasanah Nasution
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Research Method ◽  
Digestive Surgery ◽  
Diagnostic Codes ◽  
Diagnosis Codes ◽  
Service Information ◽  
Incomplete Filling ◽  
Existing Data

Background: Incomplete filling of medical record files for inpatients at Dr. Reksodiwiryo hospital medical records will be describe health services and the quality of medical record services. Medical record quality services include the completeness of medical record files, accuracy in providing diagnosis and diagnosis codes, as well as speed in providing service information. The requirements for quality medical records must be accurate, complete, reliable, valid, timely, usable, common, comparable, guaranteed, and easy.Methods: This research method is a descriptive with a retrospective approach or looking at existing data. This study was carried out in September 2021. The population was 70 files cases of inpatient digestive surgery. Samples were taken from 27 files of inpatients with appendicitis cases.Results: From the research that has been done, the highest percentage of incomplete identification components is found on the gender item about 81.48%, the highest percentage of incomplete important report components is obtained on the medical resume and informed consent items about 11.1%. The highest percentage of incomplete authentication components was obtained in the nursing degree about 96.3%. The highest percentage of the components of the recording method was obtained by 59.3%, there are several blank sections about 16 files. The percentage of incomplete diagnostic codes and procedures is 100%  Conclusions: the researcher suggested that the hospital can have an Operational Standart on filling out the completeness of medical records files

scholarly journals Quality of Learning during the Pandemic based on cognitive and affective aspects in Indonesia

2021 ◽  
Vol 1 (2) ◽  
pp. 56-60
Author(s):  
Muhammad Aulia Ramadhana ◽  
Kiki Nofita Hani ◽  
Desy Andri Tri Palupi ◽  
Bagas Pradypta
Keyword(s):  
Information Technology ◽  
Research Methods ◽  
Sampling Technique ◽  
Learning Motivation ◽  
Descriptive Research ◽  
Learning Evaluation ◽  
Quality Of Learning ◽  
Qualitative Descriptive ◽  
Learning Constraints

The purpose of this study is to (1) analyze the quality of learning during the pandemic, and (2) to analyze learning constraints during the pandemic. This research uses qualitative descriptive research methods. The use of qualitative descriptive methods in the study aimed to describe phenomena that focused on interrelationships between activities. The sampling technique is done by purposive sampling, which is based on provinces that have high cases of covid 19 in Indonesia. The quality of learning decreases because students do not have learning motivation. Many of the obstacles experienced during learning related to school unpreparedness relate to aspects of learning evaluation and affective. The quality of learning during the pandemic is largely determined by the optimization of information technology.

scholarly journals Improvement of patient safety through implementation of electronic medical records

2017 ◽  
Vol 1 (4) ◽  
pp. 111-112
Author(s):  
Elahe Gozali ◽  
Marjan Ghazisaiedi ◽  
Malihe Sadeghi ◽  
Reza Safdari
Keyword(s):  
Patient Safety ◽  
Medical Record ◽  
Electronic Medical Record ◽  
Electronic Medical Records ◽  
Medical Records ◽  
Access To Health Care ◽  
Clinical Care ◽  
Drug Management ◽  
Bar Code

Introduction: Today, with the complexity of the process of conducting activities, the increase in diversity and the number of hospital services, and the increase in the expectations of clients - consistent with the fast technological advances - most of the hospitals in Iran have turned to mechanized systems to organize their daily activities and to register the patients' information and the care provided. One of these technologies is electronic medical records, which is known as a valuable system to evaluate patients' information in hospitals. The purpose of this paper was to examine the advantages of running electronic medical records in patient safety. Methods: This study is a review paper based on a structured review of papers published in the Google Scholar, SID, Magiran, Pubmed, and Science Direct databases (from 2007 to 2015) and the books on the benefits of implementing electronic medical records in patient safety and the related keywords. Results: Clinical information systems can have a significant effect on the quality of the outputs and patient safety. Various studies have indicated that the physicians with access to clinical guidelines and features such as computer reminders, doctors who did not have these features, presented more appropriate preventive care. Studies show that electronic medical records play a crucial role in improving the quality of patient health and safety services. Moreover, electronic medical record system is usually in connection with other technological tools: electronic drug management records,  electronic record of time and date of drug management are usually associated with bar code technology. Among the benefits of this system is the possibility to record clinical care by the treatment team, which would be especially beneficial for patient's bedside record. If the treatment personnel forgets to ask the patient a particular question, system reminds him/her. Furthermore, electronic medical record is able to remind the nurses of the patient's allergic reactions and medical history without the need for the patient to remind, which improves patient safety. Conclusion: Implementation of electronic medical records boosts up the quality of health services, patient safety, people's access to health care services, and the speed of patients treatment, leading to lower healthcare costs. Thus, considering the benefits mentioned and some other benefits of this kind, one can use this technology in clinical care provided to patients to come up with a safe and effective clinical care.

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