Electronic Medical Record as Literature Study

2022 ◽  
Vol 2 (1) ◽  
pp. 45-51
Author(s):  
Yuli Mardi
Keyword(s):  
Human Resources ◽  
Medical Record ◽  
Electronic Medical Records ◽  
Medical Records ◽  
Health Care Services ◽  
Scientific Journal ◽  
Data Entry ◽  
Health Facilities ◽  
Literature Study ◽  
Planning Stage

Background: Medical records can be created manually or electronically. In the world of health, the development of information and communication technology is currently affecting health care services as a whole, including the implementation of electronic medical records. The application of electronic medical records must go through a careful planning stage, this is because electronic medical records involve many parties in health facilities and and require a lot of costs. For this reason, a comprehensive study of electronic medical records is needed. One way is to conduct a literature study of several articles related to the electronic medical record.Methods: In conducting this research, the literature review method was used, where the search for articles was not carried out systematically, but the scientific journal articles reviewed were selected by the researcher on one research topic, and selected based on the knowledge and experience possessed by the researcher (traditional review).Results: In this study, 7 articles were reviewed related to electronic medical records. There are some similarities in terms of benefits or obstacles in the application of electronic medical records in health facilities. Among the benefits of electronic medical records are the efficiency of using paper/medical record files, efficiency in the use of space/storage media, time efficiency in searching data and distributing medical record data, efficiency of human resources in finding medical record files and being able to detect errors in data entry. While some of the common obstacles to implementing electronic medical records in health facilities are the unpreparedness of officers at health facilities, so it takes time for socialization and training of human resources, problems with the network, lack of IT resources at health facilities that specifically handle electronic medical records, high implementation costs. expensive (hardware software) and there is no legal umbrella.Conclusions: There is a need for comprehensive research using the semantic review method of articles related to electronic medical records, so that the results can be used as a reference for health facilities in implementing electronic medical records. Thus, it is hoped that the migration and implementation process from manual medical records to electronic medical records can be carried out as expected.

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.

ANALISIS PELAKSANAAN REKAM MEDIS DI RUMAH SAKIT IBU DAN ANAK (RSIA ) WIDIYANTI

2018 ◽  
Vol 11 (1) ◽  
Author(s):  
Fera Siska
Keyword(s):  
Qualitative Research ◽  
Data Analysis ◽  
Data Collection ◽  
Human Resources ◽  
Medical Record ◽  
Medical Records ◽  
Depth Information ◽  
Operational Procedure ◽  
Patient Registration ◽  
Qualitative Research Design

ABSTRACTBackground : Medical record is one of the most important pillars that can not be considered trivial in a hospital, with the development of medical scienceCommon Purpose : To find in-depth information about the implementation of medical records at the hospital Widiyanti PalembangResearch Method : Qualitative research design with data collection techniques are conducted in triangulation, The data analysis is inductive, and the results of the study are emphasized more at the meaning than the generalization. The Research Results : the Implementation of medical records have been running but there is no medical record organization, the implementation of medical record activities done by rolling. Human Resources (HR) medical records should be placed specifically in the medical record along with clear tasks. Method of organizing medical record has been run although the result is not optimal, because Standard Operational Procedure (SOP) that made not socialized. Facilities and infrastructure that support the implementation of the medical record is good, marked by the existence of a special records archive medical records. Facilities and infrastructure such as chairs, desks, computers, patient registration books and outpatient registration and inpatient services are available, do not have budget funds for medical record implementation, especially by sending medical recruiter for trainingConclusion : Implementation of medical records have been running but not optimal.

scholarly journals Study Literature Review On Returning Medical Record Documents Using HOT-FIT Method

2021 ◽  
Vol 1 (1) ◽  
pp. 61-65
Author(s):  
Deni Maisa Putra ◽  
Oktamianiza Oktamianiza ◽  
Mega Yuniar ◽  
Washi Fadhila
Keyword(s):  
Literature Review ◽  
Medical Record ◽  
Medical Records ◽  
Descriptive Analysis ◽  
Net Benefit ◽  
Literature Study ◽  
Return Policy ◽  
Record Section ◽  
Doctors And Nurses

The return of medical record files is a system that is quite important in medical records, because the return of medical records starts from the file in the inpatient room until it returns to the medical record section in accordance with the return policy, which is 2x24 hours. The method used is a literature study with descriptive analysis which is done by describing the facts that exist then being analyzed, described, looking for similarities, views, and summaries of several studies. The results of the literature study show that humans are not responsible for returning medical record files, the organization lacks supervision from the management of returning files, technology (technology) with technology can assist in returning medical record files. So it is necessary to pay attention to the 3 components, so that it can produce a benefit (Net Benefit) from returning the medical record document. Based on the results of the study, it can be concluded that the factors that influence the return of medical record documents are in terms of the HOT-FIT method, (human) where the officers lack a sense of responsibility for medical record documents, and doctors and nurses do not pay attention to the form of filling out record documents medical records, so that it becomes an obstacle in returning medical record documents. It's good to have good supervision from the management.

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).

The role of electronic medical records in improving the quality of health care services: Comparative study

2019 ◽  
Vol 127 ◽  
pp. 63-67 ◽  
Author(s):  
Omar Ayaad ◽  
Aladeen Alloubani ◽  
Eyad Abu ALhajaa ◽  
Mohammad Farhan ◽  
Sami Abuseif ◽  
...  
Keyword(s):  
Health Care ◽  
Comparative Study ◽  
Electronic Medical Records ◽  
Quality Of Health Care ◽  
Medical Records ◽  
Health Care Services ◽  
Care Services

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 Mixed-methods feasibility study of blood pressure self-screening for hypertension detection

BMJ Open ◽  
2019 ◽  
Vol 9 (5) ◽  
pp. e027986 ◽  
Author(s):  
Alice Tompson ◽  
Susannah Fleming ◽  
Mei-Man Lee ◽  
Mark Monahan ◽  
Sue Jowett ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Mixed Methods ◽  
Medical Record ◽  
Electronic Medical Records ◽  
Feasibility Study ◽  
Medical Records ◽  
Alternative Methods ◽  
Hypertension Detection ◽  
Technical Problems ◽  
The Cost

ObjectiveTo assess the feasibility of using a blood pressure (BP) self-measurement kiosk—a solid-cuff sphygmomanometer combined with technology to integrate the BP readings into patient electronic medical records— to improve hypertension detection.DesignA concurrent mixed-methods feasibility study incorporating observational and qualitative interview components.SettingTwo English general practitioner (GP) surgeries.ParticipantsAdult patients registered at participating surgeries. Staff working at these sites.InterventionsBP self-measurement kiosks were placed in the waiting rooms for a 12-month period between 2015 and 2016 and compared with a 12-month control period prior to installation.Outcome measures(1) The number of patients using the kiosk and agreeing to transfer of their data into their electronic medical records; (2) the cost of using a kiosk compared with GP/practice nurse BP screening; (3) qualitative themes regarding use of the equipment.ResultsOut of 15 624 eligible patients, only 186 (1.2%, 95% CI 1.0% to 1.4%) successfully used the kiosk to directly transfer a BP reading into their medical record. For a considerable portion of the intervention period, no readings were transferred, possibly indicating technical problems with the transfer link. A comparison of costs suggests that at least 52.6% of eligible patients would need to self-screen in order to bring costs below that of screening by GPs and practice nurses. Qualitative interviews confirmed that both patients and staff experienced technical difficulties, and used alternative methods to enter BP results into the medical record.ConclusionsWhile interviewees were generally positive about checking BP in the waiting room, the electronic transfer system as tested was neither robust, effective nor likely to be a cost-effective approach, thus may not be appropriate for a primary care environment. Since most of the cost of a kiosk system lies in the transfer mechanism, a solid-cuff sphygmomanometer and manual entry of results may be a suitable alternative.

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 Review Of Returning Medical Records In Outpatient Medical Record

2021 ◽  
Vol 1 (1) ◽  
pp. 6-12
Author(s):  
Raden Minda Kusumah ◽  
Jessica Putri Meyliyan
Keyword(s):  
Data Collection ◽  
Health Center ◽  
Medical Record ◽  
Medical Records ◽  
Reporting System ◽  
Standard Operating Procedures ◽  
Literature Study ◽  
Standard Operating ◽  
Descriptive Approach

In returning the outpatient medical record file to thesection of the Medical Record Unit, Assembling there was a delay. This is because the return of medical record files has not been carried out according to Standard Operating Procedures, as a result, causing delays in the reporting system. The method used is qualitative using a descriptive approach. Data collection techniques by observation, interviews and literature study. This study aims to determine the return of former medical records of outpatients at Dayeuhkolot Health Center. The results of the study prove that the delay in returning outpatient medical record files at the Dayeuhkolot Health Center with presentations during the 1 week study amounted to 63 or 22% of 285 medical record files. Efforts have been made to disseminate information to all officers related to the efforts made by the person in charge of COVID-19 patients in returning medical record files on time.

scholarly journals Diabetes Risk Data Mining Method Based on Electronic Medical Record Analysis

2021 ◽  
Vol 2021 ◽  
pp. 1-11
Author(s):  
Yang Liu ◽  
Zhaoxiang Yu ◽  
Yunlong Yang
Keyword(s):  
Data Mining ◽  
Medical Record ◽  
Electronic Medical Record ◽  
Electronic Medical Records ◽  
Medical Records ◽  
Diabetes Risk ◽  
Mining Method ◽  
Training Set ◽  
Medical Field ◽  
Data Mining Method

In today’s society, the development of information technology is very rapid, and the transmission and sharing of information has become a development trend. The results of data analysis and research are gradually applied to various fields of social development, structured analysis, and research. Data mining of electronic medical records in the medical field is gradually valued by researchers and has become a major work in the medical field. In the course of clinical treatment, electronic medical records are edited, including all personal health and treatment information. This paper mainly introduces the research of diabetes risk data mining method based on electronic medical record analysis and intends to provide some ideas and directions for the research of diabetes risk data mining method. This paper proposes a research strategy of diabetes risk data mining method based on electronic medical record analysis, including data mining and classification rule mining based on electronic medical record analysis, which are used in the research experiment of diabetes risk data mining method based on electronic medical record analysis. The experimental results in this paper show that the average prediction accuracy of the decision tree is 91.21%, and the results of the training set and the test set are similar, indicating that there is no overfitting of the training set.

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