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 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 Diagnosis Code Accuracy Analysis Of Acute Gastroenteritis Disease Based on Medical Record Document in Balung Hospital Jember

1970 ◽  
Vol 2 (2) ◽  
pp. 12
Author(s):  
Rinda Nurul Karimah ◽  
Dony Setiawan ◽  
Puput Septining Nurmalia
Keyword(s):  
Medical Record ◽  
Acute Gastroenteritis ◽  
Medical Records ◽  
Disease Diagnosis ◽  
Accuracy Analysis ◽  
Diagnosis Code ◽  
Diagnosis Codes ◽  
Icd 10

Accuracy analysis of replenishment diagnosis codes on the document medical records is very important because if the diagnosis code is not right or not in accordance with the ICD-10, it can cause a decline in the quality of care in hospitals as well as the influence of data, information reporting, and accuracy rates of INA-CBG's that are currently used as a method of payment for patient care. The purpose of this study was to analyze the accuracy of diagnosis codes acute gastroenteritis disease in hospitalized patients by medical record documents in the first quarter of 2015 in the Balung Hospital Jember. This research used qualitative data. Acquisition of data from this study through interviews and observations. Results obtained from the observation of medical record documents at the inpatient unit in the first quarter 2015 in Balung Hospital Jember, there are some numbers determining the accuracy of disease diagnosis codes as many as 17 medical record documents with acute gastroenteritis illness and the determination of improper diagnosis codes as many as 63 medical records document acute gastroenteritis illness. After analyzing, the cause of the problem is the accuracy of the diagnosis that affects the accuracy of writing code, beside it has never been disseminated to physicians and medical records personnel related to the management of medical records. Therefore, it is necessary to carry out activities that can improve the accuracy of disease diagnosis code and quality of human resources, among others, include doctors and medical records personnel in training and socialization related to the management of medical records. Key Words : Diagnosis codes , medical record, acute gastroenteritis

scholarly journals Tinjauan Pelaksanaan Review Berkas Rekam Medis Sesuai Standar Manajemen Informasi Dan Rekam Medik (MIRM 13.4) Di Rumah Sakit Imelda Pekerja Indonesia Tahun 2020

2021 ◽  
Vol 6 (1) ◽  
pp. 7-13
Author(s):  
Esraida Simanjuntak ◽  
Mustamil Alwi Dasopang
Keyword(s):  
Medical Record ◽  
Information Management ◽  
Medical Records ◽  
Research Method ◽  
Medical Personnel ◽  
Education Assessment ◽  
Management Standards ◽  
Hospital Worker ◽  
Quality Of Health Services

  One of the parameters for determining the quality of health services in the hospital is data or information from good and complete medical records. Medical records are an important part of helping the implementation of service delivery to patients at the hospital. Standards relating to medical records in SNARS Edition 1 are in the group of hospital management standards, namely Medical Record Information Management (MIRM) regarding medical record document processing including provision, filling of medical records and reviewing medical records. This research method is descriptive with the method of observation. When this research was conducted in July 2020 at the Imelda Hospital Worker Indonesia Medan. The population taken was 705 medical record documents while the sample in this study was 87 medical record documents. Based on the results of the study, in the review the accuracy of returning medical record documents was 57.4% and 42.5% were incorrect. Readability review of ER assessment as much as 63.2%, assessment of Inpatient as much as 56.3%, CPPT as much as 60.9%, approval for action as much as 77%, reports of anesthesia as much as 68.9%. 3 forms of completeness review are complete, namely Education Assessment, rejection and education form (100%). Suggestions in this study are that review officers must be more assertive to remind every doctor or other medical personnel to pay attention to the accuracy of the restoration, the legibility of medical record files and the completeness of medical record documents. As well as regularly socializing the elements of the MIRM 13.4 assessment.

scholarly journals ANALYSIS CLAIM BPJS REVIEW FROM COMPLETENESS OF MEDICAL RECORD DOCUMENTS AND ACCURACY DIAGNOSIS CODES IN RSUD. dr. ISKAK TULUNGAGUNG

2018 ◽  
Vol 1 (1) ◽  
pp. 1-12
Author(s):  
Sukiatun Sukiatun
Keyword(s):  
Logistic Regression ◽  
Medical Record ◽  
Medical Records ◽  
Sampling Technique ◽  
Significance Level ◽  
Diagnostic Codes ◽  
Diagnosis Codes ◽  
Study Population ◽  
Diagnosis Accuracy ◽  
The Cost

Hospitals to document incomplete information, it is possible that the diagnostic codes are also inaccurate and have an impact on the cost of health services. The inaccuracies of the diagnostic codes and the completeness of the medical record will affect data and report information that ultimately affects the patient. The objective of the research was to analyze the BPJS Claim in terms of Document Record and Document Diagnosis Accuracy at RSUD dr. Iskak Tulungagung. The research design used was observational analysis. The study population was All Medical Record Document Inpatient BPJS patients in RSUD dr. Iskak Tulungagung. The sample size ware 140 by using systematic random sampling technique. Independent variable of research is Document Record and Document Diagnosis Accuracy. The dependent variable was BPJS Claims. Data was collected using Check list, then the data were analyzed using logistic regression with a significance level of α ≤ 0.05. The result showed that have the most medical record documents are incomplete resume as many as 52,1%, most have anaaccurate diagnosis code as much as 58,6% and the majority of escape document claims after verification by BPJS officials as many as 78,6%. Results logistic regression analysis obtained by vulue off overall statistics (p) 0,794, which means that documents medical records and the accuracy of diagnosis codes did not affect claims BPJS.  There are several factors that make BPJS claims that are not all medical records are subject to BPJS claims, complete medical record documents but still require clarification, any diagnosis if the code may be included on the INA CBG's software and in certain cases a copy of the investigation, action and evidence of medical device is required.

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

scholarly journals Description Of Factors Affecting Delay Return Of Hospitalization Medical Record

2021 ◽  
Vol 1 (1) ◽  
Author(s):  
Linda Handayuni ◽  
Dewi Mardiawati ◽  
Ririn Afrima Yenni ◽  
Elda Nelfia
Keyword(s):  
Human Resources ◽  
Medical Record ◽  
Medical Records ◽  
Research Method ◽  
Rate Of Return ◽  
Inclusion Criteria ◽  
Literature Study ◽  
Factors Affecting ◽  
And Training

Background: The restoration of medical records is an important part of the medical record unit, because it is the beginning of activities before the start of processing the patient's medical records. Many factors influence the delay in returning medical records, namely the medical resume form sheets that have not been filled in completely by doctors and nurses who handle patients and the lack of good responsibility in returning inpatient medical records. The purpose of this literature study is to determine the factors that influence the delay in returning hospitalized medical records.Methods: The research method used is literature study with data search using google shoolar. The inclusion criteria used were journals to determine the factors that influenced the delay in returning fully accessed inpatient medical records.Results: The results of the literature study show that the rate of delay in returning inpatient medical records is still high 50%, late which is influenced by 44.4% poor responsibility for returning medical records, and doctor's discipline in filling in complete 70% complete medical resume.Conclusions: Based on the results of this study, it can be concluded that the rate of return of medical records in hospitals is still high. Researchers suggest cooperation between nurses and doctors in filling and returning medical records to improve the quality of hospital medical records, as well as the need to improve human resources and training.

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 SOSIALISASI PELAKSANAAN SISTEM PENGGUNAAN TRACER SEBAGAI PELACAK BERKAS REKAM MEDIS PADA RUMAH SAKIT NAILI DBS PADANG

2019 ◽  
Vol 3 (2) ◽  
pp. 172
Author(s):  
Yastori Yastori
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Fast Time ◽  
Length Of Service ◽  
File Storage ◽  
Quality Of Health Services ◽  
Health Services Needs ◽  
Frequent Problem ◽  
Record Section

Peningkatan mutu layanan kesehatan perlu dilakukan terutama bagi rumah sakit. Rekam medis yang hilang, salah letak, missfile sulit ditemukan dalam waktu yang cepat menjadi permasalahan yang sering terjadi dan mempengaruhi kualitas pelayanan dan menjadi pemicu permasalahan terjadinya berkas rekam medis ganda sehingga mempersulit pengembalian berkas rekam medis sesuai urutan dan mengakibatkan lamanya pelayanan terhadap pasien. Berdasarkan survei pendahuluan, rumah sakit Naili DBS belum menggunakan tracer untuk menandai berkas keluar. Metode yang digunakan adalah observasi dengan wawancara dan diskusi mengenai permasalahan dibagian rekam medis terutama bagian penyimpanan dan pelacakan berkas rekam medis. Pendidikan diberikan melalui sosialisasi pentingnya penggunaan tracer, sistem penggunaan dan tahapan dalam mempersiapkan tracer. Kegiatan ini bertujuan untuk menciptakan budaya  pemanfaatan tracer sebagai kartu pelacak berkas rekam medis keluar dari rak penyimpanan berkas, dilaksanakan pada 11 April 2019 dan berjalan lancar. Hasil yang diperoleh yaitu bahwa di rumah sakit Naili DBS belum menggunakan tracer dan cara pelacakan berkas rekam medis dengan melihat nomor rekam medis pada saat pasein melakukan pendaftaran sehingga membutuhkan waktu yang lebih lama jika dibandingkan dengana adanya tracer. Setelah diadakan sosialisasi ini, bagian rekam medis di rumah sakit Naili DBS memahami akan pentingnya tracer pada bagian rekam medis di rumah sakit.  Kata kunci : Tracer, Rekam Medis, Missfile ABSTRACT Improving the quality of health services needs to be done especially for hospitals. Missing medical records, misplaced, missfiles are difficult to find in a fast time that is a frequent problem that affects the quality of service and triggers problems with the occurrence of multiple medical record files, making it difficult to return the medical record files in order and result in length of service to patients. Based on preliminary surveys, the Naili DBS hospital has not used tracers to mark outgoing files. The method used is observation with interviews and discussions about problems in the medical records section, especially the storage and tracking of medical record files. Education is given through the socialization of the importance of using tracers, usage systems and stages in preparing tracers. This activity aims to create a culture of utilizing tracers as tracking cards for medical record files off the file storage shelves, held on April 11, 2019 and running smoothly. The results obtained are that the Naili DBS hospital has not used tracer and how to track medical record files by looking at the medical record number at the time of registration so that it takes longer than the tracer. After this socialization, the medical records section at Naili DBS Hospital understood the importance of tracers in the medical record section at the hospital. Keywords: Tracer, Medical Record, Missfile

scholarly journals Perancangan Sistem Informasi Peminjaman dan Pengembalian Rekam Medis Rawat Jalan di Rumah Sakit Muhammadiyah Bandung

2021 ◽  
Vol 6 (2) ◽  
pp. 139-151
Author(s):  
Israwati ◽  
Sali Setiatin ◽  
Falaah Abdussalaam
Keyword(s):  
Information System ◽  
Medical Record ◽  
Software Design ◽  
Medical Records ◽  
Research Method ◽  
Qualitative Method ◽  
Due Date ◽  
Study Approach ◽  
Microsoft Access ◽  
Descriptive Approach

This research was conducted based on the problem of managing the borrowing and returning outpatient medical records at the Muhammadiyah Hospital Bandung which aims to find solutions to these problems to support the effectiveness of medical record services. The research method used in this research is a qualitative method with a descriptive approach. The data collection techniques used were interviews, observation, and study approach. In making the software design the writer uses the waterfall method and the supporting applications used are Microsoft Visual Studio 2010 and Microsoft Access 2013. From the results of the research conducted, the authors found several problems in the management of borrowing and returning outpatient medical records, namely: (1). There were no medical records found on the storage shelf; (2). Recording of borrowing and returning medical records still uses a manual system; (3). The absence of reports on borrowing and returning medical records. The suggestions that can be given by the author, namely : (1). It is better if the borrowing of medical records is determined by the due date so that there are no more medical records that are late to be returned to the storage room; (2). An information system is needed on borrowing and returning medical records to support activities in the hospital, especially in making reports on borrowing and returning medical records. The result of this research is an information system for borrowing and returning medical record files at Muhammadiyah Hospital Bandung.

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