scholarly journals Relationship of Nurse's Knowledge Concerning Medical Recording With Nursing Care Document Completeness

2021 ◽  
Vol 1 (1) ◽  
Author(s):  
Dewi Mardiawati ◽  
Linda Handayuni ◽  
Ririn Afrima Yenni ◽  
Fitria Septi Aryani
Keyword(s):  
Medical Record ◽  
Direct Observation ◽  
Nursing Care ◽  
Medical Records ◽  
Outpatient Services ◽  
Relationship Of ◽  
Complete Medical Record ◽  
Lack Of Knowledge

Background: Completeness of medical records is a medical record that is completely filled out by a doctor within ≤ 24 hours of completion of outpatient services or after an inpatient is decided to go home.Methods: This type of research is descriptive. The data were collected using a questionnaire and direct observation. The data were processed by editing, coding, processing, and cleaning, which were analyzed using computerization.Results: The results showed that less than half (46.7%) of the medical record files were incomplete and 33.3% had low knowledge of nurses.Conclusions: The conclusion in this study was that less than half (46.7%) of nurses did not complete medical record files and it was found that nurses lack of knowledge in filling out nursing care documents completely. It is better if reward should be done for nursing care documents.

scholarly journals Implementation of Documentation of Nursing Care in Wates Hospital

2019 ◽  
Vol 6 (2) ◽  
pp. 68
Author(s):  
Erna Kurniawandari ◽  
Fatma Siti Fatimah
Keyword(s):  
Data Analysis ◽  
Data Collection ◽  
Medical Record ◽  
Frequency Distribution ◽  
Nursing Care ◽  
Medical Records ◽  
Care Process ◽  
Nursing Process ◽  
Nursing Documentation ◽  
Operational Procedure

<p><em>The documentation of nursing care is the important part nurse duty, the best documentation of nursing care process that sees best and have a certain quality should be acurate, complete, and standard. Curently documenting of nursing care in Wates Hospital is practically not yet done according to Standard Operational Procedure. This study aims to know the description of the nursing care of documentation in Inpatient Room of Wates Hospital. This research is descriptive quantitatif which take the sample from inpatient documentation of nursing care in March 2017. The population was about 1106 documents of medical records which the sample obout 111 documents. The technique to take the sample was using cluster random. The research was held on June 2017. The data collection used medical record of patient. The univariat of data analysis used frequency distribution. This research showd that the completeness os documenting of nursing care in assessment aspect (77,5%), diagnosis (93,7%), planning (73,9%), action (45,9%), evaluation (76,6%), nursing care note (45%). The completeness of documentation of nursing care in Inpatient Room of Wates Hospital Kulon Progo is claimed complete (27,9%).</em></p><p> </p><strong>Keywords:</strong> Nursing documentation, nursing process

scholarly journals Kelengkapan Rekam Medik Kasus Kekerasan Fisik akibat Tindak Pidana di RSUP Prof. Dr. R. D. Kandou Periode September 2017- Agustus 2018

2019 ◽  
Vol 11 (1) ◽  
pp. 29
Author(s):  
Cherryl A. Lumentut ◽  
Erwin G. Kristanto ◽  
James F. Siwu
Keyword(s):  
Retrospective Study ◽  
Informed Consent ◽  
Law Enforcement ◽  
Blood Transfusion ◽  
Health Service ◽  
Medical Record ◽  
Medical Records ◽  
Physical Violence ◽  
The Other ◽  
Complete Medical Record

Abstract: Complete medical record is clearly important to health service of a hospital. In cases of violence, medical records play a significant role in law enforcement. Prof. Dr. R. D. Kandou Hospital is categorized as type A service hospital that has been fully accredited in 2015. Therefore, its medical personnels should be responsible for the completeness of each patient’s medical record, especially of violence cases. This study was aimed to determine the completeness of physical violence cases’ medical records due to criminal acts at Prof. Dr. R. D. Kandou Hospital in the period of September 2017-August 2018. This was a descriptive retrospective study. The results obtained as many as 40 cases of physical violence due to criminal acts. The medical record completeness of physical violence cases due to criminal acts were as follows: in Emergency Care 40%, inpatients 12%, surgery 58.82%, anesthesia/ sedation 45.45%, blood transfusion 66.67%, and informed consent 96.87%. Conclusion: In physical violence cases due to criminal acts, the medical record completeness with informed consent had higher percentage than the other medical record documents.Keywords: completeness of medical record, physical violence casesAbstrak: Kelengkapan rekam medik merupakan hal penting dalam pelayanan kesehatan dari suatu rumah sakit. Dalam kasus kekerasan, rekam medik berperan dalam penegakan hukum. RSUP Prof. Dr. R. D. Kandou sebagai rumah sakit pelayanan tipe A yang telah terakreditasi paripurna pada tahun 2015, sudah seharusnya kelengkapan rekam medis bagi setiap pasien menjadi tanggung jawab tenaga medis terutama rekam medik kasus kekerasan yang ada di RSUP. Prof. Dr. R. D. Kandou. Penelitian ini bertujuan untuk mengetahui kelengkapan rekam medik kasus kekerasan fisik akibat tindakan pidana di RSUP Prof. Dr. R. D. Kandou periode September 2017 - Agustus 2018. Jenis penelitian ialah deskriptif retrospektif. Hasil penelitian mendapatkan sebanyak 40 kasus kekerasan fisik akibat tindak pidana. Secara keseluruhan kelengkapan rekam medik pada kasus kekerasan fisik akibat tindak pidana di Instalasi Rawat Darurat sebesar 40%, rawat inap 12%, tindakan operatif 58,82%, tindakan anestesi/sedasi 45,45%, transfusi darah 66,67%, dan informed consent 96,87%. Simpulan: Pada kasus kekerasan fisik akibat tindakan pidana, kelengkapan rekam medik dengan informed consent memiliki persentase yang lebih tinggi daripada berkas rekam medik lainnya.Kata kunci: kelengkapan rekam medik, kasus kekerasan fisik

scholarly journals Analysis of the time of provision of outpatient medical record documents at Bhayangkara Hospital in Padang 2019

2020 ◽  
Vol 7 (2) ◽  
pp. 420
Author(s):  
Dewi Oktavia
Keyword(s):  
Qualitative Research ◽  
Medical Record ◽  
Medical Records ◽  
Quantitative Research ◽  
Descriptive Analysis ◽  
Sampling Technique ◽  
Outpatient Services ◽  
Research Results ◽  
Service Institution ◽  
Service Standards

Background: The hospital is a health service institution that plays a role in efforts to improve the degree of public health. One of the important roles in a hospital is the medical recorder installation. One of the minimum service standards for medical records at a hospital is the length of time to provide medical records for outpatient services, which is less than 10 minutes. The purpose of this study was to determine the length of time and to analyze the factors causing the length of time for the provision of medical records for inpatients at Bhayangkara Hospital in 2019.Methods: This research is a combination of research with a sequential explanatory design conducted at the Bhayangkara Hospital in Padang in November 2018 to June 2019. In quantitative research, the sampling technique was by means of the accidental sampling technique and descriptive analysis. While the qualitative research techniques for determining informants were used by purposive sampling and analysis by using content analysis techniques.Results: Quantitative research results, obtained an average time for providing medical records for outpatients is 9 minutes 6 seconds. The qualitative research results obtained that the input of the implementation of the medical record service system is not optimal and the process of implementing the medical record is also not well implemented.Conclusions: The time for providing outpatient medical records is fast according to the minimum hospital medical record service standard, but the implementation is not in accordance with standard operating procedures.

scholarly journals Analysis of Affecting Factors of the Medical Record Service Waiting Time of Outpatient Ambulatory in Sundari Medan Hospital

2021 ◽  
Vol 2 (2) ◽  
pp. 78-85
Author(s):  
Lilya Lunanda ◽  
Mappeaty Nyorong ◽  
Achmad Rifai
Keyword(s):  
Human Resources ◽  
Medical Record ◽  
Waiting Time ◽  
Medical Records ◽  
Waiting Times ◽  
Qualitative Approach ◽  
Affecting Factors ◽  
Outpatient Services ◽  
Outpatient Visits ◽  
Excellent Service

Administering outpatient medical records is required to provide excellent service to create patient satisfaction, especially with short waiting times. The purpose of this study was to determine how the factors that influence the waiting time for outpatient medical record services at Sundari Hospital, Medan.This type of research is descriptive analytic with a qualitative approach. The informants in this study consisted of 7 people, namely 4 registration officers and 3 patients who made outpatient visits. The data analysis used descriptive qualitative and the validity of the data used was data triangulation. The results show that the waiting time for outpatient medical record services for patients who register manually is longer than 60 minutes, the SOP for outpatient registration services has been implemented, it's just not done perfectly, Human resources in outpatient medical record services Sundari Hospital does not match educational qualifications, the facilities available in the outpatient medical record service at Sundari Hospital are incomplete, the technology has not been running well because the bridging system and administrative requirements for outpatients are not in accordance with Permenkes No. 28 of 2014.It is recommended that Sundari General Hospital be able to implement the requirements for outpatient administration in accordance with Permenkes No. 28/2014 and be able to implement a bridging system in outpatient services so that services can be carried out effectively and efficiently.

scholarly journals Motivasi internal perawat terhadap pelaksanaan dokumentasi edukasi terintegrasi di ruang rawat inap

2020 ◽  
Vol 14 (4) ◽  
pp. 529-535
Author(s):  
Dewi Kusumaningsih ◽  
Agustina Sianturi
Keyword(s):  
Medical Record ◽  
Quantitative Study ◽  
Educational Intervention ◽  
Nursing Care ◽  
Medical Records ◽  
P Value ◽  
Nursing Documentation ◽  
Cross Sectional ◽  
Internal Motivation ◽  
Health Educational Intervention

The health educational intervention and inpatient documentation execution  and an internal motivation among nursesBackground: Documentation of the health educational to inpatient is a nursing that evidence record the service of nursing care given to the patients that is useful for patients, nurses, health staffs and hospital. Most of the hospital in Bandar Lampung in the pre-survey, there were of 30% medical records was incomplete filled such as time and date when giving nursing care and signed by nurses, and mostly regarding in health educational documentations.Purpose: To identify the nursing documentation perfection (health education to the inpatient) and an internal motivation among nurses to executionMethod: A quantitative study with cross-sectional approach. The population and the sample were all inpatient nurses at Immanuel Hospital of Bandar Lampung in 2019 of 75 respondent and 75 medical records. The instrument as a questionnaire to explore nurses' internal motivation. Medical record to observe nursing note.Results: Finding of 52.0% respondent has made an incomplete nursing documentation and 46.7% respondents exhibited a poor in internal motivation. The p value was 0.004; and OR 4.643.Conclusion: There was a correlation between nurses' internal motivation and the completeness of health educational documentation. The nurse supervisor should regularly do evaluation the completeness of health educational documentation and hospital management to encourage nurses's internal motivation.Keywords: The health educational; Intervention; Inpatient documentation; Execution; An internal motivation; NursesPendahuluan: Dokumentasi edukasi keperawatan merupakan bukti tertulis perawat atas pelayanan asuhan keperawatan yang diberikan kepada pasien yang berguna untuk kepentingan pasien, perawat, tim kesehatan lain dan rumah sakit. Saat pre survey didapatkan 30% dokumentasi edukasi pasien tidak terisi waktu dan tanggal pelaksanaan, 10% dokumentasi edukasi dalam pasien tidak terisi bagaimana kebutuhan edukasi, selain itu sebanyak 10%  pasien pindahan dalam lembar edukasi tidak terisi tujuan pemberi edukasi di dalam form tersebut.Tujuan: Diketahui hubungan motivasi internal perawat terhadap kelengkapan dokumentasi edukasi di ruang bangsal dewasa Rumah Sakit Imanuel Bandar Lampung tahun 2019.Metode: Jenis penelitian kuantitatif, desain penelitian analitik pendekatan cross sectional. Populasi dan sampelnya  seluruh perawat pelaksana di ruang bangsal  Rumah Sakit Imanuel Bandar Lampung, sejumlah 75 responden dan 75 catatan keperawatan dalam medical record. Instrumen berupa angket untuk mengetahui motivasi internal perawatHasil: Diketahui dari 75 responden sebanyak (52,0% responden melakukan pendokumentasian tidak lengkap. Diketahui dari 75 responden sebanyak 46,7% responden yang mempunyai motivasi internal kategori rendah. Didapatkan hasil p-value=0,004; OR 4,643.Simpulan: Ada hubungan motivasi perawat terhadap kelengkapan dokumentasi edukasi di ruang bangsal dewasa Rumah Sakit Imanuel Bandar Lampung tahun 2019. Saran diharapkan kepala ruangan dapat mengevaluasi secara rutin tentang kelengkapan pengisian dokumentasi edukasi

scholarly journals Analysis Of Time Analysis Of Outstanding Medical Records To Improve The Quality Of Services At Dustira Hospital, Cimahi

2021 ◽  
Vol 1 (1) ◽  
pp. 1-5
Author(s):  
Imam Rosadi ◽  
Muhammad Iqbal Purnama
Keyword(s):  
Quality Of Service ◽  
Medical Record ◽  
Medical Records ◽  
Quality Of Services ◽  
Accurate Information ◽  
Outpatient Services ◽  
The Hours ◽  
Time Standards ◽  
Service Standards

The provision of medical record files depends on the availability of data, clear and accurate information. The speed of providing medical record files is one indicator of the quality of service in medical records. The purpose of the study was to determine the achievement of the Minimum Service Standards in the medical record unit in providing medical record files. The research method uses descriptive methods with a qualitative approach. Data collection was carried out for 5 days by recording the hours the patient registered in the outpatient registration section until the time the medical record file was found, located at the hospital. Dustira Cimahi. The result is as many as 2090 or 86,1% of medical record files with a provisioning time of ? 10 minutes, 340 or 13,9% of medical record files requiring a provisioning time of> 10 minutes. The conclusion is based on the provision of medical record files at the hospital. Dustira has met the minimum service standards with the set waiting time standards for outpatient services which is an average of <60 minutes, it is recommended to maintain and improve the quality of service.

scholarly journals RANCANG BANGUN SISTEM INFORMASI LAYANAN REKAM MEDIS PRAKTIK DOKTER GIGI BERSAMA DI TABING

2017 ◽  
Vol 5 (2) ◽  
Author(s):  
Annisa Aulia Zaroh ◽  
Dedy Irfan ◽  
Elfi Tasrif
Keyword(s):  
Information System ◽  
Medical Record ◽  
Medical Records ◽  
Database Management System ◽  
Design Data ◽  
Web Based ◽  
Patient Medical Record ◽  
Service Information ◽  
History Of ◽  
Complete Medical Record

The most important thing in the medical world is entering a history of the patient’s health, and this is known as the medical records. The medical records patients are used as references to the doctor for examination of the patient’s health, as well as records of a diagnosis of a disease patients and medical services. According to with the purpose of this final task, to provide design data supporting the medical records is complete and structured to facilitate action. The design of this web based information system using the codeigniter framework, programming PHP (Hypertext Preprocessor) with XAMPP as a Database Management System (DBMS), and sublime Text 3 as editor. Medical record service information system providing data supporting a complete medical record and structured in order to facilitate doing of medical, simplify data searches of patient medical record along with its report. The design of this information systems is performed to produce an information system that can create your medical record is tored neatly and securely in a database, facilitate the search process patient medical record data when data is needed, minimize errors in data processing of patient medical record. The design of the information system displays data, patient medical record, making the reference and the doctor's license. Keywords  : Medical Record, Web, PHP

Hiding Medical Records Behind the Law

1981 ◽  
Vol 2 (2) ◽  
pp. 5-5
Author(s):  
Jane L. Greenlaw
Keyword(s):  
Nursing Home ◽  
Medical Record ◽  
Nursing Care ◽  
Medical Records ◽  
Self Care ◽  
Healthy Woman ◽  
Financial Responsibility ◽  
Medical Status ◽  
Nursing Home Patients ◽  
Physical Care

The nursing home nurses were faced with a troubling problem. An 87 year old woman, who had been a resident of the home for several years, had gradually become disoriented, confused, and nearly unable to communicate. Nursing care for this otherwise healthy woman continued as always — monitoring and maintaining her medical status with a necessary increase in physical care as her own self-care ability diminished. The problem was the woman's son: he was demanding to see his mother's chart because he believed that she had cancer and that this was being concealed from him. What should the nurses do?The issue is complex and can best be examined in stages. The first question is: does the son have a legal right to see his mother's records? The answer is that in no state does a patient's son or other relative have an automatic legal right, by virtue of his relationship to the patient, to see an adult patient's medical record. Often, particularly with nursing home patients, a relative signs an agreement to assume financial responsibility for expenses incurred by a patient.

scholarly journals Review of the Implementation of Minimum Service Standards (SPM) Provision of Outpatient Medical Record Documents for Dr. Panti Wilasa Hospital Cipto Semarang

2021 ◽  
Vol 1 (1) ◽  
Author(s):  
Nurma Khoirunnisa ◽  
Zaenal Sugiyanto
Keyword(s):  
Medical Record ◽  
Operating Procedure ◽  
Medical Records ◽  
Healthcare Service ◽  
Sampling Technique ◽  
Standard Operating Procedure ◽  
Outpatient Services ◽  
Standard Time ◽  
Standard Operating ◽  
Service Standards

Background: Minimum Service Standards have set up at Panti Wilasa Hospital Dr. Cipto Semarang that the standard time of outpatient services is 10 minutes which is calculated from the registration process. From the data obtained by the researcher from the assignment in carrying out the Minimal Standard of Service in serving the outpatients has been fully implemented. However, there are still healthcare service workers who do not understand the Minimum Service Standards when interviewing healthcare service  officers in the Outpatient Registration Place section.Methods: This type of research is descriptive research that gives an overview of the data as a result of research. The method used is interviewing the outpatient registration officer and filing. Sampling technique in this study using random sampling data with a sample size of 30 person.Results: There is no specific Standard Operating Procedure (SOP) regarding the provision of outpatient medical records which were interviewed to the head of the medical records, which is already quite a good service at the outpatient registration place Dr. Panti Wilasa Hospital Cipto Semarang and Standard Operating Procedure (SOP) for Minimum Service Standards (SPM) in outpatient registration conducted interviews with the head of the medical record at Panti Wilasa Hospital Dr. Cipto Semarang. Results of the study showed that the average rapidity in medical record document provision was 31 minutes 20 seconds. At the Wilasa Panti Hospital Dr. Cipto Semarang, that the time for providing more medical records is more than ten minutes.Conclusions: The standard time for providing medical records is included in the Standard Operating Procedure (SOP) for the collection and compilation of medical records on a storage rack, so that medical records officers can work on the basis and rules that have been determined and the standard time for providing medical records is included in the quality objectives, The results are announced and written in a place easily seen by officers, Monitoring active medical record storage racks regularly by medical records officers and this can reduce the wrong medical record documents.

Perencanaan Arsitektur Sistem Informasi Rekam Medis dan Monitoring Gizi Buruk Berbasis Cloud Computing (Studi Kasus: Dinas Kesehatan Propinsi Jawa Barat)

2017 ◽  
Vol 8 (3) ◽  
Author(s):  
Ova Nurisma Putra
Keyword(s):  
Cloud Computing ◽  
Information System ◽  
Medical Record ◽  
Medical Records ◽  
Monitoring And Evaluation ◽  
Open Group ◽  
Development Method ◽  
Information System Architecture ◽  
Architecture Framework ◽  
Architecture Development

Abstract. West Java Provincial Health Office still faces difficulties in managing information, especially in medical records. Recording and reporting of malnutrition are still done in some stages starting from collecting data from village midwives, puskesmas, Regency/City Health Office then Provincial Health Office and forwarded to the the central office. It is necessary to manage information through service system by utilizing Cloud Computing based on information technology. This research uses The Open Group Architecture Framework (TOGAF) approach in Architecture Development Method (ADM), from Architecture Capability Iteration to  Architecture Development Iteration. Monitoring and Evaluation (M & E) are two integrated activities in the context of controlling a program. The results of this research are planning a medical record information system architecture and monitoring malnutrition based on Cloud Computing with the name of M2Rec (Medical Record and Monitoring) in the form of integrated recommendation and development between current information system and proposed information system architecture.Keywords: togaf adm, medical record and monitoring, cloud computing Abstrak. Perencanaan Arsitektur Sistem Informasi Rekam Medis dan Monitoring Gizi Buruk Berbasis Cloud Computing. Dinas Kesehatan Propinsi Jawa Barat masih mengalami kesulitan dalam pengelolaan informasi yang baik, terutama pada proses rekam medis, pencatatan dan pelaporan gizi buruk masih dilakukan secara bertingkat mulai pengumpulan data dari bidan desa, puskesmas, Dinas Kesehatan Kabupaten/Kota kemudian Dinas Kesehatan Propinsi dan diteruskan ke pusat. Sehingga perlu diupayakan pengelolaan informasi melalui sistem pelayanan dengan memanfaatkan teknologi informasi berbasis Cloud Computing. Penelitian ini menggunakan pendekatan framework The Open Group Architecture Framework (TOGAF) Architecture Development Method (ADM), yaitu iterasi ke satu pada Architecture Capability Iteration daniterasi ke dua pada Architecture Development Iteration. Monitoring dan Evaluasi (M&E) merupakan dua kegiatan terpadu dalam rangka pengendalian suatu program. Hasil dari penelitian ini adalah perencanaan arsitektur sistem informasi rekam medis dan monitoring gizi buruk berbasis Cloud Computing dengan nama M2Rec (Medical Record and Monitoring) yang berupa rekomendasi integrasi dan pengembangan antara sistem informasi berjalan saat ini dengan arsitektur sistem informasi yang diusulkan.Kata kunci: togaf adm, medical record and monitoring, cloud computing.

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