scholarly journals Review Procedures Borrowing And Return Record Files Medical Outpatient Medical Record in Health Unit River Candle

2021 ◽  
Vol 1 (9) ◽  
pp. 898-901
Author(s):  
Ariska Nurlaila ◽  
Devita Farita
Keyword(s):  
Medical Record ◽  
Working Hours ◽  
Health Unit ◽  
Descriptive Research ◽  
Financial Research

The borrowing of medical record documents at the puskesmas is used for internal or external purposes which include needs in aspects of the usefulness of medical record documents such as administrative, medical, legal, financial, research, and educational aspects. Based on a survey at the puskesmas, the procedure for borrowing and returning medical record files has not been carried out effectively, for example, the return of outpatient medical record files is often not in accordance with the provisions, namely a maximum of 1 (one) hour before the end of working hours, thus hampering the implementation of medical record retrieval at any time. The time is needed by patients, doctors, and parties who need medical record files. The purpose of this study was to determine the procedure for borrowing and returning outpatient medical record files. This research is a type of descriptive research. The object of the research is the procedure for borrowing and returning medical record files of outpatients in the medical record unit. The instruments used are observation guidelines and interview guidelines.

scholarly journals Music as a Therapeutic Assistant: Strategy to Reduce Work Stress

10.3823/2299 ◽  
2017 ◽  
Vol 10 ◽  
Author(s):  
Dereck Sena de Lima ◽  
Jamilton Alves Farias ◽  
Aurilene Josefa Cartaxo Gomes de Arruda ◽  
Cesar Cavalcanti da Silva ◽  
Maurício Caxias de Souza ◽  
...  
Keyword(s):  
Data Collection ◽  
Research Ethics ◽  
Work Stress ◽  
Health Sciences ◽  
Ethics Committee ◽  
Quantitative Approach ◽  
Health Unit ◽  
Basic Health ◽  
Descriptive Research ◽  
Nursing Professionals

Objective: to understand the influence of music as a therapeutic assistant in reducing work stress of nursing professionals in a basic health unit. Method: it is an exploratory and descriptive research with a quantitative approach, developed with 9 nursing professionals from UBS Integrated Nova Esperança in João Pessoa, Paraíba. Data collection began after approval of the Research Ethics Committee of the Health Sciences Center of the Federal University of Paraíba, nº. 0508/16, CAAE: 58741916.6.0000.5188. Results: we identified that 33.3% of nursing professionals presented signs of stress, of the 33.3% who presented stress, 100% demonstrated to be in the resistance phase, 100% of the nursing professionals evaluated the musical strategy in a positive way. Conclusion: the musical strategy received extremely positive evaluations by the participants of the research, about 100% of professionals said that listening to music can reduce work stress.

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 Description of Gestational Mellitus Diabetes in the General Hospital Dr. Zainoel Abidin Banda Aceh in 2018

2020 ◽  
Vol 2 (2) ◽  
pp. 236-240
Author(s):  
Cut Meurah Yeni ◽  
Aldilo Talima ◽  
Hijdrian Milzam
Keyword(s):  
Diabetes Mellitus ◽  
Pregnant Woman ◽  
General Hospital ◽  
Medical Record ◽  
Glucose Intolerance ◽  
Secondary Data ◽  
Delivery Outcome ◽  
Descriptive Research ◽  
Banda Aceh

Gestasional diabetes mellitus (GDM) is a glucose intolerance of variable severity with onset or first recognition during pregnancy. This is a silence occurred disease by the patient so it made much of morbidity for baby and the mother. Purpose of the research is to found the prevalence of GDM in RSUDZA and how was the delivery outcome in 2018. This is a descriptive research which use medical record as a secondary data. Sample of the research is all of pregnant woman who diagnosed with GDM and got treatment at RSUDZA in 2018. From the research we got from 2538 pregnant woman there are 55 of them was diagnosed with GDM. 15 of them (27,3%) had a baby with birthweight >4000gr, and 6 of them (10,9%) had a baby with birthweight <2500gr.

scholarly journals PENGELOLAAN LKP PADA MASA PENDMIK COVID-19

2021 ◽  
Vol 4 (1) ◽  
pp. 15-22
Author(s):  
Zhahara Yusra ◽  
Rufran Zulkarnain ◽  
Sofino Sofino
Keyword(s):  
Learning Process ◽  
Working Hours ◽  
Study Groups ◽  
Face To Face ◽  
Descriptive Research ◽  
The Face ◽  
Qualitative Descriptive ◽  
Data Validity ◽  
Face To Face Learning ◽  
Made In

The purpose of this study was to determine and describe in detail the management of LKP during the pandemic. This research is a qualitative descriptive research. This study uses interview data collection techniques, observation, and documentation. Data validity checking used time triangulation, subject triangulation and technical triangulation. The result of the research was that in the process of curriculum adjustment involving Mrs. Rosilah as the head of the LKP, Mr. Erwin as the curriculum organizer and Mrs. Leni Susanti as the tutor, curriculum adjustments were made in the form of dividing study groups into 2x a week, there was no change in instructors in the learning process, changes working hours in accordance with face-to-face changes, and the application of health protocols in the face-to-face learning process and during the implementation of competency exams.

scholarly journals Gambaran Hasil Uji Widal Berdasarkan Lama Demam pada Pasien Suspek Demam Tifoid

2016 ◽  
Vol 5 (3) ◽  
Author(s):  
Vika Rahma Velina ◽  
Akmal M. Hanif ◽  
Efrida Efrida
Keyword(s):  
Typhoid Fever ◽  
Medical Record ◽  
Salmonella Typhi ◽  
Definitive Diagnosis ◽  
Widal Test ◽  
Descriptive Research ◽  
Antibody Titers ◽  
O Antigens

AbstrakDiagnosis definitif demam tifoid adalah dengan biakan, tetapi pada beberapa daerah sering tidak tersedia fasilitas untuk biakan, maka cara lain untuk membantu menegakkan diagnosis yang praktis dan tersedia di rumah sakit yaitu uji Widal. Tujuan penelitian ini adalah untuk mengetahui gambaran hasil uji Widal pada pasien suspek demam tifoid. Penelitian ini dilakukan di Bagian Rekam Medik  RS Dr. M. Djamil Padang. Jenis penelitian ini adalah retrospektif deskriptif yang telah dilaksanakan dari Juli 2013 sampai Februari 2014. Jumlah sampel yang didapatkan adalah sebanyak 46 orang. Dari 46 sampel didapatkan hasil uji Widal dengan titer antibodi terhadap antigen O 1:80 sebanyak 6,51%, 1:160 sebanyak 73,89%, 1:320 sebanyak 19,54%, dan 1:640 sebanyak 0%. Titer antibodi terhadap antigen H 1:80 sebanyak 4,34%, 1:160 sebanyak 47,80%, 1:320 sebanyak 45,63%, dan 1:640 sebanyak 2,17%. Kesimpulan hasil studi ini ialah 1:160 adalah titer yang tersering ditemukan dengan titer antibodi terhadap antigen O tertinggi yakni 1:320 lebih sering ditemukan pada lama demam dengan rentang 6 – 8 hari sedangkan titer antibodi terhadap antigen H tertinggi yakni 1:640 ditemukan pada lama demam dengan rentang 6 – 8 hari.Kata kunci: demam tifoid, uji Widal, Salmonella typhi AbstractThe definitive diagnosis of typhoid fever is  proven by culture, but in some areas is often no way of culture. There is another examination that has been found to help the diagnosis that is practical and available in hospital which is called Widal test. The objective of this study was to describe the results of Widal test in patients with suspected typhoid fever. This research was conducted at the medical record of Dr. M. Djamil Padang Hospital. This is a descriptive research which was held in July 2013 – February 2014. The number of samples obtained are as many as 46 people.  The 46 samples obtained Widal test, the results was made with titres of antibodies against O antigens 1:80 as much as 6,51%, 1:160 as much as 73,89%, 1:320 as much as 19,54%, and 1:640 as much as  0%. Titers of antibodies against H antigens 1:80 as much as 4,34%, 1:160 as much as 47,80%, 1:320 as much as 45,63%, and 1:640 as much as 2,17%. The conclusion is 1:160 is the most often titres found in patients with suspected typhoid fever with the highest value of antibody titers against the O antigens that is 1:320, is more common in duration of fever with a range of 6-8 days and the highest value of antibody titers against H antigens that is 1:640 has found in duration of fever with range 6-8 days.Keywords: typhoid fever, Widal test, Salmonella typhi

scholarly journals Tinjauan Pelaksanaan Sistem Penyimpanan Rekam Medis Berdasarkan Standar Akreditasi Di UPTD Puskesmas Kotanopan Mandailing Natal

2021 ◽  
Vol 6 (1) ◽  
pp. 14-22
Author(s):  
Zulham Andi Ritonga ◽  
Hasran Ependi Lubis
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Storage System ◽  
Patient Medical Record ◽  
Biological Damage ◽  
Descriptive Research ◽  
Accreditation Standards ◽  
File Storage ◽  
Speed Up ◽  
Storage Racks

Storage of medical records is one of the assessments in puskesmas accreditation standards. The medical record file storage system is very important to do in health care institutions, because the storage system can make it easier for medical record files to be stored in storage racks, speed up the recovery or retrieval of medical record files stored on storage racks, easy to return, and protect record files. from theft, physical, chemical and biological damage. The purpose of this study was to determine how the implementation of a medical record storage system based on puskesmas accreditation standards, which was carried out in August 2020. The research method used was descriptive research with a qualitative approach. The number of research informants was 4 people. Storage of medical records had not used tracers and expedition book as a means of replacing medical record files and notes in and out of borrowed medical record files. Meanwhile, tracer and expedition books can assist officers in searching for missing / out of place medical record files. This can hamper the provision of patient medical record files that are needed. It is hoped that the UPTD Puskesmas Kotanopan will provide regular training or debriefing to medical record officers

Compliance with regulations on recording inpatient obstetric medical records and its influencing factors at Tra Vinh obstetrics and pediatrics hospital in 2020

2021 ◽  
Vol 05 (03) ◽  
pp. 125-132
Author(s):  
Thi Tra Mi Tran ◽  
◽  
Thi Hong Tran
Keyword(s):  
Medical Record ◽  
Patient Information ◽  
Medical Records ◽  
Average Rate ◽  
General Information ◽  
Medical Examination ◽  
Average Percentage ◽  
Descriptive Research ◽  
Research Objects ◽  
Reason For Admission

Background: Medical records are one of the important contents to ensure the monitoring, management of medical examination and treatment, storing and searching patient information, and scientific research. Objects and research methods: Cross descriptive research design with actual sample size of 255 HSBA. Results: The content of the general information section reached the lowest rate in the content of the administrative section of 83.9%. Other contents in this section have the rate of 90.9% - 99.8%. The average rate of general information is 92.9%. Contents of the medical history section, the proportion of satisfactory contents such as the reason for admission to the hospital (99.6%), the questioning part (96.3%) and the medical examination were quite high (97.8%), content of monitoring at the delivery chamber was only 73.7%. The average percentage of medical records meeting the requirements of the medical record part is 91.9%. Content inside medical records: The average rate is 91.1%. Conclusion: The medical records which have 85% to <100% of corrected items accounts for 98.1%. There should be specific instructions on how to record medical records at Tra Vinh Obstetrics and Pediatrics hospital Keywords: Medical record, completeness, timeliness

scholarly journals REVIEW OF MEDICAL RECORD MINIMUM SERVICES STANDARD IN HOSPITAL SUMBER WARAS CIREBON DISTRICT

2019 ◽  
Vol 6 (1) ◽  
pp. 27-31
Author(s):  
Pujairah Pitaloka ◽  
Ani Nurhaeni ◽  
Hendri Rosmawan
Keyword(s):  
Data Collection ◽  
Medical Record ◽  
Information Needs ◽  
Minimum Standard ◽  
Outpatient Services ◽  
Exclusion Criteria ◽  
Descriptive Research ◽  
Observation Method ◽  
Quota Sampling ◽  
Service Standards

Background. Medical record service is a professional supporting activity oriented to health information needs organized according to minimum service standards based on regulation number 129 of the year 2008.  Purpose. The purpose of this study is to find out the minimum standard of medical record services at Sumber Waras Hospital, Cirebon Regency. Method. The research design used was descriptive research. Data collection techniques using the observation method with the research instrument used is a checklist sheet. Data collection procedures are carried out by determining inclusion and exclusion criteria. Sampling in this study uses quota sampling. Result. The results showed that completeness of filling in inpatient medical record documents had 22 documents (73%) complete and 8 documents (27%) incomplete. Completeness of inpatient informed consent was obtained as many as 22 documents (73%) complete and 8 documents (27%) were incomplete. The time to provide medical record documents for outpatient services is provided quickly as many as 13 documents and slow as many as 17 documents. Conclusions. The conclusions obtained in this study are, the minimum standard of medical record service at Sumber Waras Hospital, Cirebon Regency is not in accordance with the Decree of the Minister of Health number 129 of 2008.

scholarly journals Identifikasi Ketidaklengkapan Pengisian Dokumen Rekam Medis Rawat Jalan Berdasarkan Teori Motivasi Ekspektansi

2016 ◽  
Vol 4 (2) ◽  
pp. 86 ◽  
Author(s):  
Alvina Revitasari
Keyword(s):  
Medical Record ◽  
Expectancy Theory ◽  
Driving Factor ◽  
Cross Sectional ◽  
Descriptive Research ◽  
Medical Record Documentation ◽  
Low Motivation

Completeness of medical record documents becomes important because it describe the practice of quality services. East Java Community Eye Hospital have problems with completeness of medical record documentation.Incompleteness medical record documentation of outpatient at East Java Community Eye Hospital was rated at 87, 67%.The object of this study was to identification the incompleteness of medical record documentation ofoutpatient based on Victor Vroom expectancy theory motivation at East Java Community Eye Hospital. The present study conducts a cross-sectional, descriptive research during May 2016 through to use questionnairesand observation on medical record documentation of outpatient. The respondent of this study were personnel who were filling the outpatient medical record documentation. These people were 5 doctors, 5 refractions, and 6 nurses. The result of the study showed that Filling of the medical record documentation at East Java Community Eye Hospital was low. Motivation has driving factor to the incompleteness of outpatient medical record documentation at East Java Community Eye Hospital. Suggestions given to monitoring the performance to complete the medical record documentation of outpatient.Keywords: hospital, incompleteness, medical record, motivation, outpatient, victor vroom.

scholarly journals VACINA HPV: PERCEPÇÃO DE ADOLESCENTES ATENDIDOS EM UMA UNIDADE BÁSICA DE SAÚDE DO AMAPÁ

2019 ◽  
Vol 10 (2) ◽  
Author(s):  
Maria Nelice Marques Cruz ◽  
Nely Dayse Santos Da Mata ◽  
Camila Rodrigues Barbosa Nemer ◽  
Victor Hugo Oliveira Brito ◽  
Tatiana do Socorro Dos Santos Calandrini
Keyword(s):  
Cervical Cancer ◽  
Data Collection ◽  
Hpv Vaccine ◽  
Structured Interview ◽  
Qualitative Approach ◽  
Age Group ◽  
Health Unit ◽  
Basic Health ◽  
Descriptive Research ◽  
Lack Of Information

Objetivo: analisar a percepção dos adolescentes sobre a vacina HPV. Metodologia: trata-se de uma pesquisa descritiva com abordagem qualitativa, realizada no período de dezembro de 2017 a julho de 2018, em uma Unidade Básica de Saúde do município de Macapá, Estado do Amapá. Participaram do estudo adolescentes de ambos os sexos, na faixa etária de 12 a 14 anos. Para coleta de dados, foi utilizada a entrevista semiestruturada e os dados foram analisados por meio da análise de conteúdo categorial temática. Resultados: emergiram três categorias de análise: categoria 1 – Vacina HPV: falta de informação e destaque da dor; categoria 2 – O saber dos adolescentes sobre câncer de colo uterino e categoria 3 – Adequação do conhecimento acerca dos benefícios da vacina e a influência da escola e a enfermagem. Conclusões: os adolescentes recebem muitas informações distorcidas, equivocadas e incompletas e isso pode ser um dos fatores que comprometem a adesão à vacina.Descritores: Vacinas; Adolescente; Papillomaviridae; Enfermagem.HPV VACCINE: PERCEPTION OF ADOLESCENTS SERVED IN A BASIC HEALTH UNIT OF AMAPÁObjective: to analyze the adolescents perception about the HPV vaccine. Methodology: this is a descriptive research with a qualitative approach, from december 2017 to july 2018, carried out in a Basic Health Unit of the municipality of Macapá, state of Amapá. Adolescents of both sexes, in the age group of 12 to 14 years old, participated in the study. For data collection, the semi-structured interview was used, and the data were analyzed through the analysis of thematic categorical content. Results: three categories of analysis emerged: category 1 - HPV vaccine: lack of information and prominence of pain; category 2 - The knowledge of adolescents about cervical cancer; and category 3 - Adequacy of knowledge about vaccine benefits and the influence of school and nursing. Conclusions: adolescents receive a lot of distorted, misleading, and incomplete information and this may be one of the factors that compromise vaccine adherence.Descriptors: Vaccines; Adolescent; Papillomaviridae Nursing.VACUNA HPV: PERCEPCIÓN DE LOS ADOLESCENTES ATENDIDOS EN UNA UNIDAD BÁSICA DE SALUD DEL AMAPÁObjetivo: analizar la percepción de los adolescentes sobre la vacuna del VPH. Metodología: se trata de una investigación descriptiva con abordaje cualitativo, de diciembre de 2017 a julio de 2018, realizada en una Unidad Básica de Salud del municipio de Macapá, estado de Amapá. Participaron del estudio, adolescentes de ambos sexos, en el grupo de edad de 12 a 14 años. Para la recolección de datos se utilizó la entrevista semiestructurada, y los datos fueron analizados por medio del análisis de contenido categorial temático. Resultados: surgieron tres categorías de análisis: categoría 1 - Vacuna HPV: falta de información y destaque del dolor; categoría 2 - El saber de los adolescentes sobre cáncer de cuello uterino; y categoría 3 - Adecuación del conocimiento sobre los beneficios de la vacuna y la influencia de la escuela y la enfermería. Conclusiones: los adolescentes reciben muchas informaciones distorsionadas, equivocadas, e incompletas y esto puede ser uno de los factores que comprometen la adhesión a la vacuna.Descritores: Vacunas; Adolescente; Papillomaviridae; Enfermería.

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