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 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 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

scholarly journals Medical students’ experience with accessing medical records in Saudi Arabia: a descriptive study

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Jwaher A. Almulhem
Keyword(s):  
Saudi Arabia ◽  
Medical Students ◽  
Medical Record ◽  
Medical Records ◽  
Medical Curriculum ◽  
National Guard ◽  
Cross Sectional Study ◽  
General Information ◽  
Record System ◽  
Cross Sectional

Abstract Background Medical students can enhance their knowledge by accessing patients’ medical records and documenting patient care. This study assessed medical students’ access to paper medical records and electronic health records (EHRs) in Saudi Arabia and compared students’ experience of accessing paper medical records and EHR from their perspective. Methods This cross-sectional study enrolled second-year to intern medical students randomly from different medical colleges in Saudi Arabia. A self-developed survey was administered to them. It comprised 28 items in three sections: general information about medical students and their level of accessing medical records, their experience with the medical record system used in hospitals, and their preference for the medical record type. Results 62.8% of participants had access to medical records, with 66.1% of them having access to EHRs and 83.27% had read-only access. The EHR group and paper group mostly liked being able to reach medical records effortlessly (70.1% and 67.1%, respectively). The EHR group had a better experience compared to the paper group with U = 5200, Mean Rank = 122.73, P = .04. Students who trained in University – owned and National Guard hospitals had better experiences compared to students who trained in other hospitals with Mean Ranks =122.35, and 147.99, respectively. Conclusion Incorporating EHR access into the medical curriculum is essential for creating new educational opportunities that are not otherwise available to medical students.

scholarly journals Designing and Evaluation of a Professional Iranian Software Package for Electronic Medical Record Documentation of Patients Referred to Periodontics Departments

2018 ◽  
Vol 9 (1) ◽  
pp. 1-6
Author(s):  
Jaber Yaghini ◽  
Ania Aminzadeh ◽  
Ahmad Moghareh Abed ◽  
Alireza Saeidi ◽  
Narges Naghsh
Keyword(s):  
Medical Record ◽  
Electronic Medical Record ◽  
Patient Information ◽  
Medical Records ◽  
Software Package ◽  
Advanced Search ◽  
Dental Records ◽  
Reduced Time ◽  
Medical Record Documentation

Background. This project aimed to design, develop and evaluate an integrated professional software package for filing the medical records of patients referred to periodontics departments. The software was intended to provide a range of features, including the availability of voice commands and retrieval of patient information based on different indices and characteristics. Methods. The overall percentage of satisfaction with the software was 90%. Moreover, 86.66% of the respondents preferred digital dental records to conventional records. Satisfaction in the reduced time of information registration and the advanced search options and availability of voice commands were 84% and 100%, respectively. Results. The overall percentage of satisfaction with the software was 90%. Moreover, 86.66% of the respondents preferred digital dental records to conventional records. Satisfaction in the reduced time of information registration and the advanced search options and availability of voice commands were 84% and 100%, respectively. Conclusion. According to the users' opinions, different features of the software, availability of voice commands and advanced search options, facilitated its use and decreased the timerequired for filing medical records. These features increased the users’ interest in the software

Selected Impressions on the Beginning of the Electronic Medical Record and Patient Information

2004 ◽  
Vol 43 (05) ◽  
pp. 537-542 ◽  
Author(s):  
R. Klar
Keyword(s):  
Medical Record ◽  
Electronic Medical Record ◽  
Electronic Medical Records ◽  
Patient Information ◽  
Medical Records ◽  
Data Set ◽  
The 1960S ◽  
User Friendly ◽  
Support Evaluation

Summary Objectives: To present an overview of early European and American work on Electronic Medical Records and patient information. Method: The invited lectures of “pioneers of electronic patient information” given at the farewell symposium of Wolfgang Giere in Frankfurt, Germany, are summarized and discussed. Results: The origin of medical record writing goes back to Hippocrates and over many centuries this important medical duty was regarded as an annoying, laborious and error-prone task. First steps towards a better medical record started in 1936 with punch cards. In the 1960s the minimum basic data set, a unique patient ID was introduced and even for outpatients first com-puterized medical record systems were developed applying some important standards and well accepted data structures. Nowadays multimedia are included in patient record systems, highly specialized subsystems e.g. for radiology or cardiology are available, and semantic and statistic mining techniques as well as medical classifications and standardized terminologies support evaluation. All these methods should primarily improve the quality of care, reduce errors, improve communication between multiple specialists, reduce wait times for patients and improve efficiency. Conclusions: Over decades it became obvious that the structure of a medical record notably for coded data but also for narrative text and pictures must be carefully modelled. Well maintained standardized health terminologies and medical classifications are important issues for a user-friendly electronic medical record, which bring benefits for clinicians and patients.

scholarly journals Analisis Kelengkapan Penulisan Soap, KIE, dan ICD X pada Rekam Medis di Poli Umum dan KIA-KB Puskesmas X Surabaya

2018 ◽  
Vol 5 (2) ◽  
pp. 139
Author(s):  
Ayunda Zilul Gosanti ◽  
Ernawaty Ernawaty
Keyword(s):  
Public Health ◽  
Family Planning ◽  
Health Center ◽  
Medical Record ◽  
Medical Records ◽  
Random Sampling ◽  
Health Workers ◽  
Public Health Center ◽  
Descriptive Research ◽  
Mother And Child

Based on the standart that Public Health Center “X” completeness of SOAP, KIE, and ICD X must be 100%. The aim of research was to analyze how the completeness of writing SOAP, KIE, and ICD X inGeneral Poly and Health of Mother and Child Family Planning Public Health Center “X”. This study was descriptive research with 500 medical records that consist of 260 for January and 240 for February as sample and they taken by random sampling. The result showed that completeness of SOAP, KIE, and ICD X on January in General Poly were 48% and decrease on February became 45,8%.While Health Mother and Child Family Planning Poly showed that completeness on January were 97,8% and increase on February became 98,6%. The incompleteness of medical records can be influenced by several factors is compliance the health workers who responsible in filling the medical records and they have multi job in Public Health Center “X” also the patient was increase. To minimize the incompleteness of SOAP, KIE, and ICD X, medical staff needs to expose by socialization of medical record to remember their responsibilty of their job description.Keywords : Completeness, medical record, Public Health Center

scholarly journals An Overview Of The Provision Time Of Inpatient Medical Record Documents In Sumber Waras Hospital Cirebon Regency

2021 ◽  
Vol 8 (1) ◽  
pp. 39-43
Author(s):  
Sri Dewi Wulan Sari ◽  
Loura Weryco Latupeirissa ◽  
Eka Martaviantika Gusana
Keyword(s):  
Medical Record ◽  
Public Service ◽  
Medical Records ◽  
Total Sample ◽  
Quantitative Approach ◽  
Research Instrument ◽  
The Public ◽  
Descriptive Research ◽  
Service Standards

Minimum service standards are a technical spesification regarding service benchmarks provided by public service bodies to the public. Minimum service standards have several fields especially in the field of medical records. One the indicators in the field of medical record is the time of provision of inpatient medical record documents. Minimum service standards based on Kepmenkes 129 of 2008 ≤ 15 minutes. The purpose of this study was to determine the time provision of inpatient medical record documents in Hospital Sumber Waras Cirebon Regency.  The type of research used is descriptive research with a quantitative approach. The population in this study was 1.242 documents with a total sample of 92 documents and sampling in this study using accidental sampling. The research instrument used wa an observasion sheet in the form of a checklist sheet. Dat collection procedure is done by determining the inclusion and exclusion.  Based on the results of research when providing inpatient medical record documents as much as 53% of 49 documents and 47% of 43 documents that are not appropriate. The average time for providing inpatient medical record documents is 23 minute 13 seconds.  The conclusions obtained in this study are time for providing inpatient medical record documents in Hospital Sumber Waras Cirebon Regency source not in accordance with Kepmenkes standard number 129 of 2008, that for the time of providing inpatient medical record documents is ≤ 15 minutes.

scholarly journals GAMBARAN KARAKTERISTIK PETUGAS PENDISTRIBUSIAN BERKAS REKAM MEDIS RAWAT JALAN DI UPT RUMAH SAKIT KHUSUS PARU TAHUN 2019

2020 ◽  
Vol 5 (2) ◽  
pp. 200-206
Author(s):  
Ali Sabela Hasibuan
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Research Method ◽  
Total Population ◽  
Data Entry ◽  
Sampling Technique ◽  
High School Education ◽  
Descriptive Research ◽  
Sorting Data ◽  
Objective Description

One form of service at the hospital is the distribution of medical record files. Distribution is a process of delivering goods or services from producers to consumers and users, when the goods or services are needed. The purpose of this study was to determine the distribution of outpatient medical record files at the UPT Special Paru Hospital in 2019. This study used a descriptive research method with the aim of making an objective description or description of a situation with a total population of all medical record staff employees, namely 5 people and the sampling technique in this study is total sampling with the characteristics of all medical record officers. So the researchers analyzed the data starting from editing, coding, sorting, data entry, cleaning. The results of the study based on the majority of high school education were 3 people (60%) minority DIII medical records as many as 1 person (20%) and S1 education as many as 1 person (20%), based on the majority of 1-5 years working duration as many as 4 people ( 80%), and a minority of 6-10 years of work as many as 1 person (20%). So it can be concluded that the implementation of the distribution of outpatient medical record files is said to be sufficient, the length of the process of distributing medical record files and there are still a few medical record officers who are educated in DIII medical records and can be expected to improve the process of sending medical record files and the addition of officers with DIII medical record education.

scholarly journals Identifikasi Prioritas Masalah Unit Rekam Medis di Puskesmas Nusukan

2020 ◽  
Vol 3 (1) ◽  
pp. 24-28
Author(s):  
Puguh Ika Listyorini
Keyword(s):  
Health Center ◽  
Medical Record ◽  
Medical Records ◽  
Group Discussion ◽  
Multiple Criteria ◽  
Medical Services ◽  
Utility Assessment ◽  
Descriptive Research ◽  
Workforce Needs

Health services consist of two kinds, namely medical and non-medical services. One of the non-medical services provided by the medical record unit. In providing medical record unit services do not always run well, therefore it is necessary to identify the priority determination of the problem to find out what problems must be solved first. The Multiple Criteria Utility Assessment (MCUA) method is a method of determining priority problems with scoring techniques. The purpose of this study was to determine the priority of problems in the medical record unit of the Nusukan Health Center using the MCUA Method. This research uses descriptive research design with 4 speakers. According to the results of the identification of problems carried out by the Group Group Discussion (FGD) that there are 3 problems in the medical record unit of the Nusukan Public Health Center, namely the lack of resources for medical records, medical record documents, and the availability of rooms for managing medical records that are still limited. The priority problem with the MCUA method shows that the problem with the highest value is the lack of medical record personnel. Before making additional workforce, it is recommended to calculate the workforce needs in the medical record unit according to the workload of the medical record officer so that the additional workforce is in accordance with the workload of the officer.AbstrakPelayanan kesehatan terdiri dari dua macam yaitu pelayanan medis dan non medis. Pelayanan non medis salah satunya diberikan  oleh unit rekam medis.  Dalam memberikan pelayanan unit rekam medis tidak selalu berjalan dengan baik, oleh karena itu perlu dilakukan identifikasi penentuan prioritas masalah untuk mengetahui masalah apa saja yang harus diselesaikan terlebih dahulu. Metode Multiple Criteria Utility Assessment (MCUA) adalah salah satu metode penentuan prioritas masalah dengan tekhnik scoring. Tujuan penelitian ini untuk mengetahui prioritas masalah di unit rekam medis Puskesmas Nusukan menggunakan Metode MCUA. Penelitian ini menggunakan desain penelitian deskriptif dengan 4 orang narasumber. Menurut hasil identifikasi masalah yang dilakukan dengan Forum Group Discussion (FGD) bahwa terdapat 3 masalah di unit rekam medis Puskesmas Nusukan, yaitu kurangnya sumber daya tenaga rekam medis, missfile dokumen rekam medis, dan ketersediaan ruagan untuk penggelolaan rekam medis yang masih terbatas. Prioritas masalah dengan metode MCUA menunjukkan masalah dengan nilai paling tinggi adalah kurangnya sumber daya tenaga rekam medis. Sebelum melakukan penambahan tenaga kerja, maka disarankan agar menghitung kebutuhan tenaga kerja di unit rekam medis menurut beban kerja petugas rekam medis agar penambahan tenaga kerja sesuai dengan beban kerja petugas.

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.

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