scholarly journals Literature Review: Analisis Faktor Penyebab Keterlambatan Pengembalian Rekam Medis di Rumah Sakit

2021 ◽  
Vol 9 (1) ◽  
pp. 21-29
Author(s):  
Alfita Dewi ◽  
Ilma Nuria Sulrieni ◽  
Chamy Rahmatiqa ◽  
Fajrilhuda Yuniko
Keyword(s):  
Literature Review ◽  
Medical Record ◽  
Medical Records ◽  
Research Literature ◽  
Record System ◽  
Medical Record System ◽  
Causes Of Delays ◽  
Process Component ◽  
Method Factors

AbstractThe quality of medical records describes the quality of health services provided. The return of the medical record file starts from the file being in the treatment room until the file is returned to the medical record unit. Incomplete and not immediately filled out medical resumes cause delays in returning medical records. Therefore, the return of the medical record system is quite important in the medical record unit. This study is a literature review, to see the causes of delays in returning medical records at hospitals in Indonesia. Sources of data come from published research literature, with a total of 18 research articles. Data collection was carried out from March to June 2020. The factor causing the delay in returning medical records was the highest due to the input component. From all journals, 100% of the delays in returning medical records were caused by the input component (Man, Money, Materials, Method, Machine) and 33.3% by the process component. Of the input components, 83.3% were caused by Man factors, 77.8% Method factors, 33.3% Materials factors, 27.8% Machine factors, and 5.5% Money factors. Each hospital must have a clear and firm policy in overcoming delays in returning medical records, with clear and firm policies, the causative factors such as Man, Money, Material, Method, Machine can be minimized and the accuracy of returning medical records can be maximized.Keywords: return, incompleteness, medical records, literature, reviewAbstrakMutu rekam medis menggambarkan mutu pelayanan kesehatan yang diselenggarakan. Pengembalian Rekam Medis dimulai dari berkas tersebut berada diruang rawat sampai berkas tersebut kembali ke unit rekam medis. Pengisian resume medis yang tidak lengkap dan tidak segara dilakukan menyebabkan keterlambatan pengembalian rekam medis. Maka dari itu, pengembalian rekam medis sistem yang cukup penting di unit rekam medis. Penelitian ini merupakan literature review, untuk melihat penyebab keterlambatan pengembalian rekam medis di Rumah Sakit di Indonesia. Sumber data berasal dari literatur hasil penelitian yang telah dipublikasikan, dengan jumlah artikel penelitian sebanyak 18 artikel. Pengambilan data dilakukan dari bulan Maret-Juni 2020. Faktor penyebab keterlambatan pengembalian rekam medis tertinggi disebabkan oleh komponen input.  Dari semua jurnal sebanyak 100% keterlambatan pengembalian rekam medis disebabkan oleh komponen input (Man, Money, Materials, Methode, Machine) dan sebanyak 33,3% oleh komponen proses. Dari komponen input tersebut, sebanyak 83,3 % disebabkan oleh faktor Man, 77,8% faktor Methode, 33,3% faktor Materials, 27,8% faktor Machine, dan 5,5% faktor Money. Setiap rumah sakit harus memiki kebijakan yang jelas dan tegas dalam mengatasi keterlambatan Pengembalian Rekam Medis, dengan kebijakan yang jelas dan tegas, faktor penyebab seperti Man, Money, Material, Method, Machine dapat di minimalisir dan ketepatan Pengembalian Rekam Medis dapat dilakukan secara maksimal.Keywords: keterlambatan, pengembalian, rekam medis, literature review 

ANDROID MEDICAL RECORDS APP UNTUK MENYIMPAN CATATAN MEDIS PASIEN PUSKESMAS KECAMATAN PORSEA

2020 ◽  
Vol 3 (2) ◽  
pp. 175-180
Author(s):  
Herman Saputra ◽  
Adi Prijuna Lubis ◽  
Maulana Dwi Sena
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Health Centers ◽  
Record System ◽  
Medical Record System ◽  
Medical Records System ◽  
The Right ◽  
And Storage ◽  
Computerized System

Abstract : Efforts to improve the quality of health services at the Porsea health center make a medical records system to facilitate the administration and storage of data properly, Porsea health centers still use medical records or forms manually. To make it easy for patients to have a continuous medical history quickly discovered. One of the preparations is to find the right application to be used as a manual medical record system that is digitalized. A simple and easy-to-use medical record system that makes it easy for puskesmas to do patient medical records is the Android Medical Records App Application system, with this application what is expected by the puskesmas can increase the knowledge of Porsea puskesmas employees to use the medical record application, and increase the use of the computerized system, and it is also easy for people who seek treatment to be able to save their medical record data and can be seen traces of their existing medical history.Keywords: android; medical records Abstrak: Upaya meningkatakan mutu pelayanan kesehatan puskemas porsea membuat sistem catatan medis untuk mempermudah administrasi dan penyimpanan data dengan baik, puskesmas porsea masih menggunakan catatan medis atau formulir secara manual. Untuk mempermudah agar riwayat kesehatan pasien berkesinambungan dengan cepat  ditemukan. Salah satu persiapan yang dilakukan adalah mencari aplikasi yang tepat untuk digunakan menjadi sistem rekam medis yang manual menjadi digitalisasi. Sistem rekam medis yang simpel dan mudah digunakan dalam memudahkan pihak puskesmas untuk melakukan pencatatan medis pasien adalah sistem Aplikasi Android Medical Records App, dengan adanya aplikasi ini maka apa yang diharapkan pihak puskesmas dapat Meningkatkan pengetahuan pegawai puskesmas porsea untuk menggunakan aplikasi rekam medis, dan meningkatkan penggunaan sistem terkomputerisasi, dan juga mempermudah masyarakat yang berobat untuk bisa di simpan data catatan medisnya dan dapat dilihat jejak riwayat kesehatannya yang sudah ada. Kata Kunci: android; rekam medis

Impact of Wireless Electronic Medical Record System on the Quality of Patient Documentation by Emergency Field Responders during a Disaster Mass-Casualty Exercise

2011 ◽  
Vol 26 (4) ◽  
pp. 268-275 ◽  
Author(s):  
Theodore C. Chan ◽  
William G. Griswold ◽  
Colleen Buono ◽  
David Kirsh ◽  
Joachim Lyon ◽  
...  
Keyword(s):  
Medical Record ◽  
Electronic Medical Records ◽  
Medical Records ◽  
Electronic Medical Record System ◽  
Mass Casualty ◽  
Record System ◽  
Medical Record System ◽  
Patient Documentation ◽  
Field Exercise

AbstractIntroduction: The use of wireless, electronic, medical records and communications in the prehospital and disaster field is increasing.Objective: This study examines the role of wireless, electronic, medical records and communications technologies on the quality of patient documentation by emergency field responders during a mass-casualty exercise.Methods: A controlled, side-to-side comparison of the quality of the field responder patient documentation between responders utilizing National Institutes of Health-funded, wireless, electronic, field, medical record system prototype (“Wireless Internet Information System for medicAl Response to Disasters” or WIISARD) versus those utilizing conventional, paper-based methods during a mass-casualty field exercise. Medical data, including basic victim identification information, acuity status, triage information using Simple Triage and Rapid Treatment (START), decontamination status, and disposition, were collected for simulated patients from all paper and electronic logs used during the exercise. The data were compared for quality of documentation and record completeness comparing WIISARD-enabled field responders and those using conventional paper methods. Statistical analysis was performed with Fisher’s Exact Testing of Proportions with differences and 95% confidence intervals reported.Results: One hundred simulated disaster victim volunteers participated in the exercise, 50 assigned to WIISARD and 50 to the conventional pathway. Of those victims who completed the exercise and were transported to area hospitals, medical documentation of victim START components and triage acuity were significantly better for WIISARD compared to controls (overall acuity was documented for 100% vs 89.5%, respectively, difference = 10.5% [95%CI = 0.5–24.1%]). Similarly, tracking of decontamination status also was higher for the WIISARD group (decontamination status documented for 59.0% vs 0%, respectively, difference = 9.0% [95%CI = 40.9–72.0%]). Documentation of disposition and destination of victims was not different statistically (92.3% vs. 89.5%, respectively, difference = 2.8% [95%CI = -11.3–17.3%]).Conclusions: In a simulated, mass-casualty field exercise, documentation and tracking of victim status including acuity was significantly improved when using a wireless, field electronic medical record system compared to the use of conventional paper methods.

scholarly journals NFC Based Electronic Medical Record

2019 ◽  
Vol 13 (03) ◽  
pp. 4
Author(s):  
Noor Cholis Basjaruddin ◽  
Edi Rakhman ◽  
Kuspriyanto Kuspriyanto ◽  
Mikhael Bagus Renardi
Keyword(s):  
Medical Record ◽  
Electronic Medical Records ◽  
Mobile Phones ◽  
Medical Records ◽  
Near Field ◽  
Near Field Communication ◽  
Important Data ◽  
Record System ◽  
Medical Record System ◽  
Beta Testing

Near Field Communication (NFC) technology enables mobile phones to store important data safely and reliably. The data can be sent to another phone equipped with NFC or read by NFC reader. Through special applications the data can also be added, subtracted, or modified. This NFC capability allows the phone to be developed into a device that can store important data such as e-money or electronic medical records. In this research has been developed medical record system based on Near Field Communication (NFC). The results of alpha and beta testing show that the developed application has good performance.

scholarly journals Authorized Shared Electronic Medical Record System with Proxy Re-Encryption and Blockchain Technology

Sensors ◽  
2021 ◽  
Vol 21 (22) ◽  
pp. 7765
Author(s):  
Weizhe Chen ◽  
Shunzhi Zhu ◽  
Jianmin Li ◽  
Jiaxin Wu ◽  
Chin-Ling Chen ◽  
...  
Keyword(s):  
Access Control ◽  
Medical Record ◽  
Electronic Medical Record ◽  
Electronic Medical Records ◽  
Medical Records ◽  
Data Privacy ◽  
Data Access ◽  
Electronic Medical Record System ◽  
Record System ◽  
Medical Record System

With the popularity of the internet 5G network, the network constructions of hospitals have also rapidly developed. Operations management in the healthcare system is becoming paperless, for example, via a shared electronic medical record (EMR) system. A shared electronic medical record system plays an important role in reducing diagnosis costs and improving diagnostic accuracy. In the traditional electronic medical record system, centralized database storage is typically used. Once there is a problem with the data storage, it could cause data privacy disclosure and security risks. Blockchain is tamper-proof and data traceable. It can ensure the security and correctness of data. Proxy re-encryption technology can ensure the safe sharing and transmission of relatively sensitive data. Based on the above situation, we propose an electronic medical record system based on consortium blockchain and proxy re-encryption to solve the problem of EMR security sharing. Electronic equipment in this process is connected to the blockchain network, and the security of data access is ensured through the automatic execution of blockchain chaincodes; the attribute-based access control method ensures fine-grained access to the data and improves the system security. Compared with the existing electronic medical records based on cloud storage, the system not only realizes the sharing of electronic medical records, but it also has advantages in privacy protection, access control, data security, etc.

A provider-interactive medical record system can favorably influence costs and quality of medical care

1990 ◽  
Vol 20 (4) ◽  
pp. 267-279 ◽  
Author(s):  
Kenric W. Hammond ◽  
Robert J. Prather ◽  
Vishvanath V. Date ◽  
Carol A. King
Keyword(s):  
Medical Care ◽  
Medical Record ◽  
Record System ◽  
Medical Record System ◽  
Quality Of Medical Care

scholarly journals Electronic health records and online medical records: an asset or a liability under current conditions?

2018 ◽  
Vol 42 (1) ◽  
pp. 59 ◽  
Author(s):  
Judith Allen-Graham ◽  
Lauren Mitchell ◽  
Natalie Heriot ◽  
Roksana Armani ◽  
David Langton ◽  
...  
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Discharge Summary ◽  
Medical Data ◽  
Record System ◽  
Health Records ◽  
Medical Record System ◽  
Surgical History ◽  
Electronic Health ◽  
Discharge Summaries

Objective The aim of the present study was to audit the current use of medical records to determine completeness and concordance with other sources of medical information. Methods Medical records for 40 patients from each of five Melbourne major metropolitan hospitals were randomly selected (n=200). A quantitative audit was performed for detailed patient information and medical record keeping, as well as data collection, storage and utilisation. Using each hospital’s current online clinical database, scanned files and paperwork available for each patient audited, the reviewers sourced as much relevant information as possible within a 30-min time allocation from both the record and the discharge summary. Results Of all medical records audited, 82% contained medical and surgical history, allergy information and patient demographics. All audited discharge summaries lacked at least one of the following: demographics, medication allergies, medical and surgical history, medications and adverse drug event information. Only 49% of records audited showed evidence the discharge summary was sent outside the institution. Conclusions The quality of medical data captured and information management is variable across hospitals. It is recommended that medical history documentation guidelines and standardised discharge summaries be implemented in Australian healthcare services. What is known about this topic? Australia has a complex health system, the government has approved funding to develop a universal online electronic medical record system and is currently trialling this in an opt-out style in the Napean Blue Mountains (NSW) and in Northern Queensland. The system was originally named the personally controlled electronic health record but has since been changed to MyHealth Record (2016). In Victoria, there exists a wide range of electronic health records used to varying degrees, with some hospitals still relying on paper-based records and many using scanned medical records. This causes inefficiencies in the recall of patient information and can potentially lead to incidences of adverse drug events. What does this paper add? This paper supports the concept of a shared medical record system using 200 audited patient records across five Victorian metropolitan hospitals, comparing the current information systems in place for healthcare practitioners to retrieve data. This research identifies the degree of concordance between these sources of information and in doing so, areas for improvement. What are the implications for practitioners? Implications of this research are the improvements in the quality, storage and accessibility of medical data in Australian healthcare systems. This is a relevant issue in the current Australian environment where no guidelines exist across the board in medical history documentation or in the distribution of discharge summaries to other healthcare providers (general practitioners, etc).

scholarly journals Tinjauan Literatur: Faktor-Faktor Penyebab Kelengkapan Pengisian Rekam Medis Rawat Inap Rumah Sakit

2020 ◽  
Vol 3 (2) ◽  
pp. 46-52
Author(s):  
Putu Adiz Siwayana ◽  
Ika Setya Purwanti ◽  
Putu Ayu Sri Murcittowati
Keyword(s):  
Quality Of Service ◽  
Literature Review ◽  
Medical Record ◽  
Medical Records ◽  
Health Workers ◽  
Medical Personnel ◽  
Google Scholar ◽  
Incomplete Filling ◽  
Evaluation And Monitoring

Every health facility, whether it is primary, secondary, tertiary, is required to maintain medical records in order to achieve administrative order. Incomplete (incomplete) medical records will affect the service process provided by health workers and have an impact on the quality of service of a hospital. This study aims to determine the factors causing the incomplete filling of inpatient medical records. This study uses a literature review method. The strategy in searching literature reviews is using Google Scholar. In the search phase, articles are limited to publications from 2015-2020. The keywords used are the factors causing incomplete medical record filling. The search results obtained 10 articles and then 5 articles were taken. The results of the literature review show that the factors causing the incompleteness of filling in medical records as a whole can be seen from the lack of knowledge, motivation and awareness of medical personnel about medical records. The meeting as a means of communication between caregivers and management has not yet been implemented to discuss evaluation and monitoring as well as sanctions for officers who do not complete medical records. lack of socialization on filling out medical records. Unsystematic arrangement of medical record forms. Limited availability of funds or budget to support medical record service activities. Conclusion Hospitals need to pay attention to the factors causing the incompleteness of filling in medical records so that filling in medical records is complete according to standards. So that the quality of service, especially the quality of patient medical records.AbstrakSetiap fasilitas kesehatan baik tingkat primer, sekunder, tersier wajib menyelenggarakan rekam medis agar tercapainya tertib administrasi. Ketidaklengkapan (Incomplete) rekam medis akan berpengaruh terhadap proses pelayanan yang diberikan oleh petugas kesehatan dan berdampak pada kualitas pelayanan suatu rumah sakit. Penelitian ini bertujuan untuk mengetahui faktor penyebab ketidaklengkapan pengisian rekam medis rawat inap. Penelitian ini menggunakan metode literatur review. Strategi dalam pencarian literatur review menggunakan Google Scholar. Pada tahap pencarian artikel dibatasi terbitan dari tahun 2015-2020. Kata kunci yang digunakan adalah Faktor Penyebab ketidaklengkapan pengisian rekam medis. Hasil penelusuran artikel didapatkan 10 artikel dan selanjutnya diambil 5 artikel. Hasil dari literatur review didapatkan faktor penyebab ketidaklengkapan pengisian rekam medis secara keseluruhan, penyebabnya dapat dilihat dari kurangnya pengetahuan, motivasi dan kesadaran dari petugas rekam medis tentang rekam medis. Belum terlaksananya rapat sebagai wadah komunikasi antara pemberi asuhan dan manajemen yang membahas evaluasi dan monitoring serta sanksi bagi petugas yang tidak mengisi rekam medis dengan lengkap. kurangnya sosialisasi pengisian rekam medis. Susunan formulir rekam medis yang tidak sistematis. Terbatasnya ketersediaan dana atau anggaran untuk mendukung kegiatan pelayanan rekam medis. Kesimpulan Rumah sakit perlu memperhatikan  faktor penyebab ketidaklengkapan pengisian rekam medis sehingga pengisian rekam medis menjadi lengkap sesuai dengan standar. Sehingga  mutu dari pelayanan terutama mutu rekam medis pasien.

scholarly journals SISTEM INFORMASI REKAM MEDIS PASIEN RAWAT JALAN DI UPTD PUSKESMAS KUNINGAN BERBASIS WEB

2019 ◽  
Vol 13 (2) ◽  
pp. 19
Author(s):  
Tatang Saputra ◽  
Erik Kurniadi
Keyword(s):  
Health Care ◽  
Information System ◽  
Health Services ◽  
Medical Record ◽  
Medical Records ◽  
Record System ◽  
Web Based ◽  
Medical Record System ◽  
Health And Illness ◽  
Conducting Research

Puskesmas is a level 1 health facility. More than 40% of Indonesia's population uses health services at the Puskesmas. It is interesting that the Puskesmas is the health care provider that is closest to the community. Recording medical records of patients at the Kuningan Health Center is still done manually. Data search has time constraints. This happens because the same data is often found. Ineffective management of medical records will become a major problem in health services at the Puskesmas. This problem must be overcome so that the puskesmas has good data and information. One way to overcome this problem is to build a computerized medical record information system. Medical Record is a compilation of facts about the health and illness of a patient. Medical Records become a very important thing in the delivery of health services. Because the importance of a medical record, the author is interested in conducting research with the title "Information Systems for Outpatient Medical Records in UPTD Puskesmas Kuningan Web-Based". The medical record information system is expected to help improve the function of the Puskesmas as a place of health care. With the existence of a medical record system, each patient visit can be taken in a database making it easier for officers in the process of finding medical record data when needed. With the database, the compilation of patients forgetting to bring a treatment card can be done by searching the patient's data by the electronic officer. Making a report will be easier because it retrieves data that is done through the request system so as to facilitate the process and minimize errors in data management.Keywords: php, mysql, medical record, outpatient

New Medical Record System in Queen Elizabeth Hospital, Hong Kong

1994 ◽  
Vol 24 (4) ◽  
pp. 131-134 ◽  
Author(s):  
Karen W. H. Szeto
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Hospital Staff ◽  
Queen Elizabeth Hospital ◽  
Record Management ◽  
Record System ◽  
Medical Record System ◽  
Medical Records System ◽  
Complete Access ◽  
New System

During the 1980's, the medical record problems had been identified and it was not until 1991 that Queen Elizabeth Hospital was chosen to be the pilot hospital for the development of a new medical record management system for the Hospital Authority hospitals. The new medical records system was implemented in Queen Elizabeth Hospital in December, 1993. Six month after implementation, a pre-implementation and post-implementation review of the medical record services were conducted to compare the results of the new and old system. The results showed that there were significant improvements in the record retrieval and record integrity in the new system. New medical record services such as the delivery of readmission records to the ward, filing of medical records forms in pre-defined order and filing of loose sheets in the relevant hospital notes are able to facilitate the efficient, effective and complete access to patient information. The support and cooperation of the hospital staff are crucial to the success of the new system. Continuous review and improvement of the new system is essential in order to obtain the best results

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