scholarly journals THE MANAGEMENT OF MEDICAL REPORT COMPLETENESS FOR THE LEGALITY OF MEDICAL RECORD DOCUMENTS AT RSUD KRMT WONGSONEGORO (RSWN) SEMARANG CITY

2021 ◽  
Vol 20 (2) ◽  
Author(s):  
Suyoko Suyoko
Keyword(s):  
Informed Consent ◽  
Medical Record ◽  
Medical Records ◽  
Hospital Services ◽  
Human Element ◽  
Machine Element ◽  
Medical Disputes ◽  
Machine Elements ◽  
Medical Record Documentation

ABSTRACTBackground: Quality hospital services is reflected in the achieving of medical records. Improper medical record documentation would negatively affect the quality of service delivered to patients and it would disadvantage the hospital when medical disputes occur.Objective:Analyzing the management of medical record completeness at RSWN to guarantee the legality of medical record documents and its effect in supporting the completeness of medical record documents.Method:In this qualitative research,  observation and interviews were conducted to 60 PJRM officers in the Arimbi ward, Banowati, Nakula I and Prabukresna. The obtained data were qualitatively and quantitatively analyzed based on several underlying theories.Results:The results showed that the completeness of some aspects includinghuman, money, method, material and machine elements was proper. The quantitative analysis showed 100%, while the qualitative analysis showed a percentage of 100% with the exception on the informed consent component with the potential for loss of 99%.Conclusions:The human element required periodic outreach to PPA. In the machine element, special computerswere needed for PJRM officers, and the importance of informed consent for patients undergoing hemodialysis to obtain medical records with strong legal force. Key Words           :Management, Medical Record Completeness, Legality of Medical Records.

Faktor-Faktor yang Mempengaruhi Mutu Pelayanan Rekam Medis di Rumah Sakit

2019 ◽  
Vol 14 (2) ◽  
pp. 59
Author(s):  
Rindi Rendarti
Keyword(s):  
Service Quality ◽  
Human Resources ◽  
Medical Record ◽  
Medical Records ◽  
Services Quality ◽  
Medical Services ◽  
Quality Of Services ◽  
Hospital Services ◽  
Incomplete Filling

Background: Medical record units as part of supporting medical services in hospitals have an important role in improving the quality of services in hospitals. The indicator of service quality in hospital is measured by incomplete inpatient medical record files. Based on several studies in various hospitals, the complete of inpatient medical record files is around 70% - 80% from 100%. Based on the preliminary data in action research in PKU Muhammadiyah hospital, there were 60 % incomplete in filling the medical resume from 100% target. There are many things that occurred, one of them are about human resources that is affected by behavior, the implementation of operational standards in filling medical records, punish and reward files. Objective: To review the factors that affect the quality of service in medical record units related to improving the quality of hospital services.  Methods: the method of this study used relevant health databases including Scholars by using a combination of  terms: hospital service quality indicators, incompleteness in filling medical medical records, quality of medical record services. Results: The result of this study said that there were related between medical record services and quality of hospital services. The quality indicator in the medical record can be able to be measured was the number of incomplete filling in medical record files. Filling of incomplete medical record files has the potential to reduce the overall quality of hospital services Keywords: quality of medical record services, quality of hospital medical services, incomplete medical record filling

Tinjauan Faktor Penyebab Ketidaklengkapan Pengisian Formulir Informed Consent di RSUD Dr. H. Moch Ansari Saleh Banjarmasin

2021 ◽  
Vol 6 (1) ◽  
pp. 91
Author(s):  
Eka Rahma Ningsih ◽  
Ravenalla S ◽  
Novia Lestiani ◽  
Aus Anhar ◽  
Mohammad Imam
Keyword(s):  
Informed Consent ◽  
Medical Record ◽  
Information Content ◽  
Medical Records ◽  
Legal Aspects ◽  
Consent Form ◽  
Patient Identification ◽  
Informed Consent Form ◽  
Descriptive Survey

ABSTRACTCompleteness of filling in the informed consent sheet in the medical record file is very important because it will affect the legal aspects of the medical record and the quality of the medical record so that in filling in the completeness of the data in the informed consent sheet it is necessary to carry out maximum implementation .. RSUD dr. H. Moch. Ansari Saleh Banjarmasin in 2012 showed that the level of incompleteness in the approval of medical treatment in the hospital room (surgery) was below 90% with the May period with a percentage of 46.7%. June with a percentage of 31.7% and 36.6%. The research objective was to determine the factors causing the incompleteness of filling out the informed consent form at RSUD DR. H. Moch Ansari Saleh Banjarmasin. Qualitative research method is descriptive survey. Respondents were 1 gynecologist, 1 head of medical records and 1 reporting officer for emdis records. Collecting data using interviews and observation of informed consent sheets. The results of the study identified the incomplete informed consent form by examining the patient identification component, the information content component, and the patient identification component. As well as identifying the availability of standard operating procedures (SOP) for approval of medical action. Based on the research results, it can be concluded that the informed consent form did not meet the national and standard filling standards in RSUDdr. H. Moch Ansari Saleh Banjarmasin because for the standard of completeness, the informed consent must be 100% complete. The filling of informed consent was not complete 100% in two components, namely the information content component (18.2% complete and 81.7% incomplete) and the patient's authentication component (90.7% completeness and 9.3% incomplete). The factor of incompleteness in filling out the informed consent based on the results of the research carried out was because the responsible doctor did not fill in the informed consent form again, both the content component and the patient authentication component) because he was busy providing services to other patients and there was no training related to filling the informed consent form. Keyword : informed consent, Factors Causing Incompleteness

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.

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 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 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.

scholarly journals The efficient of beds used based on graphic Barber Johnson at Semen Padang Hospital in 2017

2019 ◽  
Vol 6 (12) ◽  
pp. 5071
Author(s):  
Sayati Mandia
Keyword(s):  
Statistical Analysis ◽  
Length Of Stay ◽  
Medical Record ◽  
Medical Records ◽  
Average Length ◽  
Sampling Technique ◽  
Occupancy Rate ◽  
Bed Occupancy ◽  
Average Length Of Stay

Background: Quality of hospital services can be seen from the bed usage. Statistical analysis of efficiency bed usage can be mesured based on inpatient medical records. To determine the efficiency requires four parameters namely bed occupancy rate (BOR), average length of stay (ALoS), turnover interval (TI), and bed turnover (BTR). parameters can be presented using Graphic Barber Johnson. This study aims to determine the efficiency of bed usage at Semen Padang Hospital in 2017.Methods: This research was conducted at Semen Padang Hospital, West Sumatera, Indonesia from January to December 2017. The study used a descriptive method with a qualitative approach. The data was collected from medical records department. The population is all abstraction data of in-patient medical record in 2017, 9796 medical record used total sampling technique. Data analysis was performed by calculating the values of ALoS, BOR, BTR, and TI. Data will be presented based on graphic Barber Johnson. Excel 2010 and graphic Barber Johnson method were applied for data analysis.Results: Number of daily inpatient censuses in 2017 are 31227 and number of service days are 31362. Number of beds 144. Statistical analysis results obtained total BOR 60%, BTR 67 times, TI 2 days and ALoS 3 days. The highest value of bed occupancy rate is 66% on August.Conclusions: Based on statistical, value of bed occupancy rate (60%) and turnover interval (2 days) are efficient at Semen Padang Hospital in 2017. Average length of stay (3 days) and bed turnover rate (67 times) are not efficient.

scholarly journals Completeness of informed consent in supporting national standard accreditation of patient and family rights 5 hospitals at Ropanasuri surgical special hospital in Padang

2019 ◽  
Vol 6 (11) ◽  
pp. 4639
Author(s):  
Yastori .
Keyword(s):  
Informed Consent ◽  
Medical Record ◽  
Medical Records ◽  
National Standards ◽  
National Standard ◽  
National Hospital ◽  
Microsoft Excel ◽  
Patient Medical Record ◽  
Special Hospital ◽  
Descriptive Method

Background: Completeness of informed consent is one indicator in supporting the accreditation of national hospital standards through the assessment of patient and family rights (PFR) assessment standards 5. In the health service process, informed consent can also be used as evidence and has a strong legal value in the form of a sheet of paper containing the doctor’s explanation about the diagnosis of the disease and the actions that will be performed on the patient.Methods: This research uses descriptive method with a qualitative approach. The population used was the entire patient medical record file in 2018, which was 3.093 medical record files. Sampling was done by random sampling using a formula according to Notoatmodjo for the calculation of the number of samples and obtained 355 files of medical records. Data processing using Microsoft Excel computer programs. For observing the completeness of the standard rights of patients and families using national standards for hospital accreditation.Results: Based on the analysis of 355 medical record files at Ropanasuri specialty hospital it is known that 296 pieces of informed consent were filled in with a percentage of 83.38%, 59 sheets of informed consent were incomplete with a percentage of 16.62%. The results showed the greatest incompleteness found in filling the informed consent items of witness signatures of 2.81%, providing information on the completeness of filling the doctor's identity by 2.54% and the name of the witness 1.70% on filling the authentication.Conclusions: 296 pieces of informed consent were filled in with a percentage of 83.38%, 59 sheets of informed consent were incomplete with a percentage of 16.62%.

scholarly journals Analysis of Nursing Documentation Implementation In Outpatient Room

2020 ◽  
Vol 2 (2) ◽  
pp. 25
Author(s):  
Muhamad Nurudin ◽  
Vivi Yosafianti Pohan ◽  
Tri Hartiti
Keyword(s):  
Medical Record ◽  
Nursing Care ◽  
Initial Assessment ◽  
Nursing Management ◽  
Management Skills ◽  
Nursing Documentation ◽  
Nursing Support ◽  
Service Unit ◽  
Medical Record Documentation

The quality of nursing care is a key element of service quality in hospitals. To realize good quality nursing service and quality in the Outpatient Institution, qualified human resources are also needed and good nursing management skills are needed from a manager or head of the service unit. For the implementation of nursing care documentation in outpatient installations to be carried out optimally, it is necessary to carry out management activities in the form of supervision by carrying out nursing support activities in stages. The purpose of this analysis is to determine the implementation of outpatient nursing medical record documentation. The use of action methods in this analysis aims to develop new skills or new approaches and be applied directly and reviewed the results. From the results of the assessment found several nursing management problems and the priority is the completeness of outpatient nursing medical record documentation which is still low. The action taken is by providing refresher activities or material refreshing on nursing documentation, initial assessment of outpatients, simulations of filling out initial outpatient assessment documentation, making and disseminating supervision forms and techniques for tiered supervision using the supervision form. The activity was attended by 23 participants consisting of the head of the room, the team leader and the nurse executing from the polyclinic or outpatient installation. Evaluation after carrying out activities on the completeness of outpatient nursing medical record documentation was 70%  (14 of 20 samples).

Sign in / Sign up

Export Citation Format

Share Document