scholarly journals Tinjauan Pelepasan Informasi Rekam Medis Kepada Pihak Ketiga Di RSU Imelda Pekerja Indonesia Medan

2021 ◽  
Vol 6 (2) ◽  
pp. 183-188
Author(s):  
Erlindai Purba ◽  
Hesty Afriani Sidabutar
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Research Method ◽  
Quantitative Methods ◽  
Health Workers ◽  
Death Certificates ◽  
Or Education ◽  
Patient Medical Record ◽  
Objective State ◽  
Regular Training

The Imelda Workers General Hospital of Indonesia does not yet have specific routines regarding the release of medical record information to third parties. however, they have used regular procedures for providing information and borrowing medical records in general, This study aims to determine the number of requests for medical record information. This type of research is descriptive, namely the research method carried out with the aim of making an objective state. The population was 4 people and the sample size was 4 people as the total sampling with the research methodology using quantitative methods. How to collect data by interview and observation. The results showed that the services of the Imelda Hospital for Indonesian Workers in Medan according to legalized death certificates amounted to 34 percent (0.56%), claims for raharja services amounted to 56 percent (0.92%), audits and insurance claims were 69 percent (1.14%) , research or education as much as 54 percent (0.89), post mortem as much as 28 percent (0.46%), BPJS as much as 5,790 percent (99.00%). Based on the results of the study, it is known that knowing the data on the number of requests for medical record information in January-June 2020 is 6,224 with a percentage (99.97%). As well as the absence of a special SPO on procedures and utilization of medical record information of deceased patients, however, they have used the permanent procedure of providing information and borrowing medical records in general. It is recommended that hospitals and medical record officers provide regular training or coaching to officers. And to health workers, especially medical records, in order to maintain the confidentiality of patient medical record information and carry out the established procedures properly.                   

Analisis Unsur Manajemen dalam Pengolahan Rekam Medis di Rumah Sakit TNI AU Lanud Roesmin Nurjadin

2018 ◽  
Vol 1 (1) ◽  
pp. 20-25
Author(s):  
Henny Maria Ulfa
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Processing Method ◽  
Qualitative Approach ◽  
Check List ◽  
Training Material ◽  
Patient Medical Record ◽  
Qualitative Descriptive ◽  
Material Element ◽  
Descriptive Method

Hospitals must conduct a medical record activities according to Permenkes NO.269 / MENKES / PER / III / 2008 about Medical Record, to achieve the purpose of medical record processing required 5 management elements are: man, money, material, machine, and method. The medical record processing that has been implemented at the Hospital TNI AU LANUD Roesmin Nurjadin that is coding, coding only done for BPJS patients whose conducted by the officer with education background of D3 nursing, it be impacted to the storage part is wrong save and cannot found patient medical record file because are not returned. The purpose of this research is to know the element of management in the processing of medical records at the Hospital TNI AU LANUD Roesmin Nurjadin. This research is done by Qualitative descriptive method, Qualitative approach, instrument of data collection of interview guidance, observation guidance, check list register, and stationery, number of informant 6 people with inductive way data analysis. The result of this research found that Mans elements only amounts to 2 people so that officers work concurrently and have never attended training, material element and machines elements of medical record processing not yet use SIMRS and tracer, while processing method elements follow existing habits and follow the policy of hospital that is POP organization. Keywords: Management elements, medical record processing

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).

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 Diagnosis and treatment of patients with antiphospholipid syndrome: a mixed-method evaluation of care in The Netherlands

2020 ◽  
Vol 4 (2) ◽  
Author(s):  
Mirthe J Klein Haneveld ◽  
Caro H C Lemmen ◽  
Tammo E Brunekreef ◽  
Marc Bijl ◽  
A J Gerard Jansen ◽  
...  
Keyword(s):  
The Netherlands ◽  
Focus Groups ◽  
Medical Record ◽  
Medical Records ◽  
Quantitative Methods ◽  
Medical Record Review ◽  
Anticoagulant Treatment ◽  
Medical Specialists ◽  
Record Review ◽  
Fragmentation Of Care

Abstract Objectives The aims were to gain insight into the care provided to patients with APS in The Netherlands and to identify areas for improvement from the perspective of both patients and medical specialists. Methods APS care was evaluated using qualitative and quantitative methods. Perspectives on APS care were explored using semi-structured interviews with medical specialists, patient focus groups and a cross-sectional, online patient survey. In order to assess current practice, medical records were reviewed retrospectively to collect data on clinical and laboratory manifestations and pharmacological treatment in six Dutch hospitals. Results Fourteen medical specialists were interviewed, 14 patients participated in the focus groups and 79 patients completed the survey. Medical records of 237 patients were reviewed. Medical record review showed that only one-third of patients were diagnosed with APS within 3 months after entering specialist care. The diagnostic approach and management varied between centres and specialists. Almost 10% of all patients and 7% of triple-positive patients with thrombotic APS were not receiving any anticoagulant treatment at the time of medical record review. Correspondingly, poor recognition and fragmentation of care were reported as the main problems by medical specialists. Additionally, patients reported the lack of accessible, reliable patient education, psychosocial support and trust in physicians as important points for improvement. Conclusion Delayed diagnosis, variability in management strategies and fragmentation of care were important limitations of APS care identified in this study. A remarkable 10% of patients did not receive any anticoagulant treatment.

scholarly journals Completeness of informed consent in supporting national standard accreditation of patient and family rights 5 hospitals at Ropanasuri surgical special hospital in Padang

2019 ◽  
Vol 6 (11) ◽  
pp. 4639
Author(s):  
Yastori .
Keyword(s):  
Informed Consent ◽  
Medical Record ◽  
Medical Records ◽  
National Standards ◽  
National Standard ◽  
National Hospital ◽  
Microsoft Excel ◽  
Patient Medical Record ◽  
Special Hospital ◽  
Descriptive Method

Background: Completeness of informed consent is one indicator in supporting the accreditation of national hospital standards through the assessment of patient and family rights (PFR) assessment standards 5. In the health service process, informed consent can also be used as evidence and has a strong legal value in the form of a sheet of paper containing the doctor’s explanation about the diagnosis of the disease and the actions that will be performed on the patient.Methods: This research uses descriptive method with a qualitative approach. The population used was the entire patient medical record file in 2018, which was 3.093 medical record files. Sampling was done by random sampling using a formula according to Notoatmodjo for the calculation of the number of samples and obtained 355 files of medical records. Data processing using Microsoft Excel computer programs. For observing the completeness of the standard rights of patients and families using national standards for hospital accreditation.Results: Based on the analysis of 355 medical record files at Ropanasuri specialty hospital it is known that 296 pieces of informed consent were filled in with a percentage of 83.38%, 59 sheets of informed consent were incomplete with a percentage of 16.62%. The results showed the greatest incompleteness found in filling the informed consent items of witness signatures of 2.81%, providing information on the completeness of filling the doctor's identity by 2.54% and the name of the witness 1.70% on filling the authentication.Conclusions: 296 pieces of informed consent were filled in with a percentage of 83.38%, 59 sheets of informed consent were incomplete with a percentage of 16.62%.

scholarly journals INFORMASI DATA REKAM MEDIS PASIEN DI RS BEDAH MITRA KABUPATEN LAMONGAN DENGAN METODE NAIVE BAYES DAN CLUSTERING DALAM PENENTUAN PENYAKIT HYPERTENSI

JOUTICA ◽  
2017 ◽  
Vol 2 (1) ◽  
Author(s):  
Kemal Farouq Mauladi
Keyword(s):  
Data Base ◽  
Medical Record ◽  
Medical Records ◽  
Medical Service ◽  
Computer Data ◽  
Patient Medical Record ◽  
Number Of Patients ◽  
Record Data ◽  
Record Card ◽  
Computer Data Base

Medical records have a very broad sense, not only as a recording activity, but has a notion as a system of medical record recordings that start recording during the patient get medical service, followed by handling medical records file that includes the storage and the release of files from the storage for Serve requests or loans if from patients or for other purposes. Documents of patient medical record data from patient card data, especially patients with hypertension who at the time of control to the partner surgery hospital will from the medical record card document will be scanned or scanned into computer data base as data base storage efficiently and regularly , To then be tested with data mining by using clustering and naive baiyes to determine the number of patients based on the place or area of patients who are frequently treated at the partner surgical hospital.

scholarly journals PENINGKATAN PENGETAHUN MASYARAKAT TERKAIT PENTINGNYA REKAM MEDIS BAGI PASIEN DI FASILITAS PELAYANAN KESEHATAN

2021 ◽  
Vol 5 (1) ◽  
pp. 163
Author(s):  
Romaden Marbun ◽  
Rea Ariyanti ◽  
Vincensia Dea
Keyword(s):  
Health Care ◽  
Health Service ◽  
Medical Record ◽  
Medical Records ◽  
Health Workers ◽  
Personal Information ◽  
Care Facility ◽  
Health Care Facilities ◽  
Public Knowledge ◽  
Maximum Point

ABSTRAKRekam medis merupakan bagian dari arsip yang menggambarkan segala aktivitas sebuah fasilitas pelayanan kesehatan dalam kurun waktu tertentu. Rekam Medis ialah berkas yang berisikan catatan dan dokumen tentang identitas pasien, pemeriksaan, pengobatan, tindakan, dan pelayanan lain yang telah diberikan kepada pasien. Rekam medis ini memiliki fungsi penting bagi pasien dan juga dokter. Oleh karena itu pengisian rekam medis ini harus lengkap dan tidak boleh ditunda pengisiannya baik bagi pasien ataupun tenaga kesehatan. Namun, banyak masyarakat yang belum mengetahui fungsi penting dari melengkapi rekam medis dan keterbukaan informasi pribadinya yang harus diberikan kepada fasilitas pelayanan kesehatan bahkan tenaga kesehatan yang merawatnya dalam menunjang mutu informasi pada rekam medis tersebut. Tujuan kegiatan ini adalah meningkatkan pengetahuan masyarakat khususnya RT 09 Kelurahan Bandulan Kota Malang tentang pentingnya rekam medis bagi masyarakat yang berobat di fasilitas pelayanan kesehatan. Metode penyuluhan dilakukan secara tidak langsung atau dalam jaringan (daring) dengan berkoordinasi via online grup whatsapp selama 3 kali pertemuan serta dikirimkan materi presentasi serta video pembelajaran. Masyarakat yang terlibat sebanyak 34 orang. Tahap evaluasi dilakukan melalui google form. Hasil kegiatan diperoleh peningkatan pengetahuan masyarakat dari rata-rata 37,53 menjadi 79,06 dengan point maksimal 100. Kegiatan berjalan dengan baik dan perlu adanya monitoring lebih lanjut. Kata kunci: pengetahuan; masyarakat; rekam medis; fasilitas pelayanan kesehatan. ABSTRACTThe medical record is part of the archive that describes all the activities of a health care facility within a certain period of time. Medical Record is a file that contains records and documents about the patient's identity, examination, treatment, action, and other services that have been provided to the patient. This medical record has an important function for patients as well as doctors. Therefore, the filling of this medical record must be complete and the filling should not be delayed either for the patient or the health worker. However, many people do not know the important function of completing medical records and the disclosure of personal information that must be provided to health care facilities and even health workers who take care of them in supporting the quality of information in the medical record. The purpose of this activity is to increase public knowledge, especially RT 09 RW 05 Kelurahan Bandulan Malang City about the importance of medical records for people who seek treatment at health service facilities. The counseling method is carried out indirectly or online by coordinating via online WhatsApp groups for 3 meetings and sending presentation materials and learning videos. There were 34 people involved. The evaluation stage is carried out through a google form. The results of the activity obtained an increase in public knowledge from an average of 37.53 to 79.06 with a maximum point of 100. The activity went well and needed further monitoring. Keywords: knowledge; public; medical records; health service facilities.

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.

scholarly journals Tinjauan Pelaksanaan Sistem Penyimpanan Rekam Medis Berdasarkan Standar Akreditasi Di UPTD Puskesmas Kotanopan Mandailing Natal

2021 ◽  
Vol 6 (1) ◽  
pp. 14-22
Author(s):  
Zulham Andi Ritonga ◽  
Hasran Ependi Lubis
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Storage System ◽  
Patient Medical Record ◽  
Biological Damage ◽  
Descriptive Research ◽  
Accreditation Standards ◽  
File Storage ◽  
Speed Up ◽  
Storage Racks

Storage of medical records is one of the assessments in puskesmas accreditation standards. The medical record file storage system is very important to do in health care institutions, because the storage system can make it easier for medical record files to be stored in storage racks, speed up the recovery or retrieval of medical record files stored on storage racks, easy to return, and protect record files. from theft, physical, chemical and biological damage. The purpose of this study was to determine how the implementation of a medical record storage system based on puskesmas accreditation standards, which was carried out in August 2020. The research method used was descriptive research with a qualitative approach. The number of research informants was 4 people. Storage of medical records had not used tracers and expedition book as a means of replacing medical record files and notes in and out of borrowed medical record files. Meanwhile, tracer and expedition books can assist officers in searching for missing / out of place medical record files. This can hamper the provision of patient medical record files that are needed. It is hoped that the UPTD Puskesmas Kotanopan will provide regular training or debriefing to medical record officers

scholarly journals PENGARUH KELENGKAPAN PENGISIAN FORMULIR TRANSFER PASIEN INTERNAL TERHADAP MUTU REKAM MEDIS

2021 ◽  
Vol 10 (2) ◽  
pp. 124-131
Author(s):  
Indar Farwanti Wahyuni
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Random Sampling ◽  
Health Workers ◽  
Sampling Technique ◽  
Simple Random Sampling ◽  
Patient Transfer ◽  
Literature Study ◽  
Number Of Patients

Abstract Internal patient transfer is the process of transferring patients from one room to another in a hospital while still being oriented towards quality and patient safety. The results of the observations showed that the filling of the internal patient transfer form was not optimal so that there were still incomplete forms due to the large number of patients and the weak coordination between health workers. To determine the effect of the completeness of filling out the internal patient transfer form on the quality of medical records. The research method used is quantitative with a descriptive approach. Data collection techniques used are observation, questionnaires and literature study. The sampling technique was simple random sampling technique so as to obtain a sample of 91 internal patient transfer forms. From the results of observations, 22% of the internal patient transfer forms were found that were not completely filled in, especially in the signature and clear name. The two variables have a strong relationship. The effect of the variable completeness of the internal patient transfer form on the medical record quality variable is 90.1% and the remaining 9.9% is influenced by other factors. Based on these studies, it can be concluded that the lack of accuracy and coordination of nurses, doctors and other officers in filling out internal patient transfer forms so that this affects the quality of medical records in the aspect of accuracy. Keyword : Completeness, Internal Patient Transfer Form, Medical Record Quality   Abstrak Transfer pasien internal merupakan proses pemindahan pasien dari satu ruangan ke ruangan yang lain di dalam satu rumah sakit dengan tetap berorientasi pada mutu dan keselamatan pasien. Hasil observasi menunjukkan bahwa belum optimalnya pengisian formulir transfer pasien internal sehingga masih terdapat formulir yang tidak lengkap disebabkan oleh faktor dari banyaknya pasien dan lemahnya koordinasi antara tenaga kesehatan. Untuk mengetahui pengaruh kelengkapan pengisian formulir transfer pasien internal terhadap mutu rekam medis. Metode penelitian yang digunakan yaitu kuantitatif dengan pendekatan deskriptif. Teknik pengumpulan data yang digunakan adalah observasi, kuesioner dan studi pustaka. Teknik pengambilan sampel adalah teknik simple random sampling sehingga memperoleh sampel sebanyak  91 formulir transfer pasien internal. Dari hasil observasi ditemukannya formulir transfer pasien internal yang belum terisi lengkap sebanyak 22% terutama pada tandatangan dan nama jelas. Kedua variabel memiliki hubungan yang kuat. Pengaruh variabel kelengkapan formulir transfer pasien internal terhadap variabel mutu rekam  medis sebesar 90,1% dan sisanya 9,9% dipengaruhi oleh faktor lain. Berdasarkan penelitian tersebut dapat disimpulkan bahwa kurangnya ketelitian dan koordinasi perawat, dokter dan petugas lain dalam pengisian formulir transfer pasien internal sehingga hal ini mempengaruhi mutu rekam medis pada aspek keakuratan. Kata kunci: Kelengkapan, Formulir Transfer Pasien Internal, Mutu Rekam Medis

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