scholarly journals Pengaruh Pemberian Kode Warna Wilayah Pada Folder Terhadap Ketepatan Penyimpanan Berkas Rekam Medis Di Puskesmas Wadaslintang 1

2021 ◽  
Vol 6 (2) ◽  
pp. 101-107
Author(s):  
Deni Gunawan

A Medical records are files containing notes and documents regarding the patient's identity, examination, treatment, actions and other services that have been provided to patients. So that a medical file is strictly protected so that it is not damaged or lost.Based on observations, it was found that there were several files of medical records that were interchanged or not in the normal filling rack. Medical record files can be exchanged due to the large number of regional shelf columns so that alternatives and innovations are needed to increase the accuracy of returning and retrieving medical record files correctly.Troubleshooting efforts are being made, namely by providing a regional color code in the medical record file folder so that errors in taking and returning medical record files can be minimized.Based on the results of observations made by the author, it was found that there was an effect before and after color coding the region in the medical record file folder.

Author(s):  
Zubir Zubir

Completeness of laboratory critical values reporting and documentation in medical records is important for patient safety, hospital accreditation, and legality. Preliminary study in Dr. Soetomo Hospital’s ward showed the laboratory critical value report and documentation was 0% complete, 4% incomplete, and 96% undocumented. This was a quasi experimental study with one group pretest and posttest design. Technical guidance of laboratory critical values reporting and documentation in medical records and supervision were given to 26 doctors. The results evaluated were doctor knowledge and attitude towards critical value reporting, completeness of documentation in medical records, and turn around time (TAT). Reporting critical values samples number was 72 before and after the intervention. The critical values samples taken by purposive sampling. The data was analyzed using Mann-Whitney test. There were significant differences in the level of knowledge, doctor’s attitudes, and completeness of critical values documentation before and after the intervention. Doctors with good knowledge increased from 3.85% to 92.31%. The attitude to complete critical values documentation improved from 0% to 76%. Completeness of critical values documentation in medical records improved from 100% undocumented to 19.44% undocumented, 11.11% incomplete, and 69.45% complete. There were no significant differences of TAT before and after the intervention, all of TAT were less than 30 minutes and meeting the TAT category. The intervention succeeded in increasing doctor knowledge, attitude, and completeness of the laboratory critical values reporting and documentation in the patient's medical record. Keywords: Laboratory critical value, medical record, turn around time.


2020 ◽  
Vol 15 (3) ◽  
pp. 167
Author(s):  
Ahmad Muthi Abdillah ◽  
Ahmad Sulaeman ◽  
Tiurma Sinaga

Cholesterol-lowering herbal treatment made from natural ingredients are believed to be able to replace modern medicine even though it has not been scientifi cally proven. Purpose of this study was to test perceptions of customers and eff ects of mixed herbal drink on lipid profi le of consumers with hypercholesterolemia. Study was conducted using cross sectional study design consisted of three stages, that is survey, questionnaire data collection, and medical record data collection. The research subjects were selected by stratifi ed random sampling, which subjects were consumers of mixed herbal drink in total of 55 people, both men and women. Data was collected through interviews of questionnaires covering subject characteristics, subject perceptions of mixed herbal drink, and their medical record data before and after consumption of mixed herbal drinks. Paired T-test were used to observe the diff erences in subject lipid profi le before and after consumption of mixed herbal drink. Consumer perceptions toward health aspects showed that 83.7% of subjects experienced a decrease in cholesterol after consuming mixed herbal drink. Consumer emotional perception showed that 90.9% of subjects feel healthier and fi lter after consuming mixed herbal drink. Results of subject medical records on lipid profi le showed a decrease in total cholesterol, LDL, and triglycerides (p<0.05). Based on perceptions and medical records, it is known that mixed herbal drink can be used as an alternative to traditional cholesterol-lowering medicines.


Crisis ◽  
2020 ◽  
Vol 41 (5) ◽  
pp. 367-374
Author(s):  
Sarah P. Carter ◽  
Brooke A. Ammerman ◽  
Heather M. Gebhardt ◽  
Jonathan Buchholz ◽  
Mark A. Reger

Abstract. Background: Concerns exist regarding the perceived risks of conducting suicide-focused research among an acutely distressed population. Aims: The current study assessed changes in participant distress before and after participation in a suicide-focused research study conducted on a psychiatric inpatient unit. Method: Participants included 37 veterans who were receiving treatment on a psychiatric inpatient unit and completed a survey-based research study focused on suicide-related behaviors and experiences. Results: Participants reported no significant changes in self-reported distress. The majority of participants reported unchanged or decreased distress. Reviews of electronic medical records revealed no behavioral dysregulation and minimal use of as-needed medications or changes in mood following participation. Limitations: The study's small sample size and veteran population may limit generalizability. Conclusion: Findings add to research conducted across a variety of settings (i.e., outpatient, online, laboratory), indicating that participating in suicide-focused research is not significantly associated with increased distress or suicide risk.


2017 ◽  
Vol 8 (3) ◽  
Author(s):  
Ova Nurisma Putra

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.


Author(s):  
Henny Maria Ulfa

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


2018 ◽  
Vol 68 (suppl 1) ◽  
pp. bjgp18X697133
Author(s):  
Richard Fitton ◽  
Amir Hannan ◽  
Ingrid Brindle ◽  
Shafia Begum ◽  
Sarwar Shah

BackgroundPatients with higher health literacy enjoy better health outcomes and are more compliant with treatment. Health literacy is a product of memory, reason and imagination. Patients who can access their records have potentially more memory (knowledge) and make less phone calls to and have less consultations with their GP, practice nurse, HCA and other professionals.AimThe study aims to measure the knowledge that twenty Bangladeshi patients with poor English have of their medical history before and after access to their electronic record.Method55% of patients at Thornley House have access to their medical records. A simple questionnaire was given to 20 Bangladeshi patients before and 5 months after access to their electronic record. The questionnaires recorded the patients’ knowledge of their medical histories. The scores of the completed before and after questionnaires were compared to see if record access had increased patients’ knowledge.ResultsFive patients completed before and after questionnaires. Each achieved a higher score after record access. The differences in scores for the five patients were 2, 5, 1, 10, and 1, respectively.ConclusionHealth literacy for patients is similar to medical literacy for doctors. It requires knowledge, skills and attitudes. We will see whether record access can increase knowledge. Further studies might measure whether that increased knowledge improves skills and attitudes.


2015 ◽  
Vol 43 (4) ◽  
pp. 827-842
Author(s):  
Anya E.R. Prince ◽  
John M. Conley ◽  
Arlene M. Davis ◽  
Gabriel Lázaro-Muñoz ◽  
R. Jean Cadigan

The growing practice of returning individual results to research participants has revealed a variety of interpretations of the multiple and sometimes conflicting duties that researchers may owe to participants. One particularly difficult question is the nature and extent of a researcher’s duty to facilitate a participant’s follow-up clinical care by placing research results in the participant’s medical record. The question is especially difficult in the context of genomic research. Some recent genomic research studies — enrolling patients as participants — boldly address the question with protocols dictating that researchers place research results directly into study participants’ existing medical records, without participant consent. Such privileging of researcher judgment over participant choice may be motivated by a desire to discharge a duty that researchers perceive themselves as owing to participants. However, the underlying ethical, professional, legal, and regulatory duties that would compel or justify this action have not been fully explored.


2018 ◽  
Vol 11 (1) ◽  
Author(s):  
Fera Siska

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.


1994 ◽  
Vol 28 (1) ◽  
pp. 99-104 ◽  
Author(s):  
Dale B. Christensen ◽  
Barbara Williams ◽  
Harold I. Goldberg ◽  
Diane P. Martin ◽  
Ruth Engelberg ◽  
...  

OBJECTIVE: To determine the completeness of prescription records, and the extent to which they agreed with medical record drug entries for antihypertensive medications. SETTING: Three clinics affiliated with two staff model health maintenance organizations (HMOs). PARTICIPANTS: Randomly selected HMO enrollees (n=982) with diagnosed hypertension. METHODS: Computer-based prescription records for antihypertensive medications were reviewed at each location using an algorithm to convert the directions-for-use codes into an amount to be consumed per day (prescribed daily dosage). The medical record was analyzed similarly for the presence of drug notations and directions for use. RESULTS: There was a high level of agreement between the medical record and prescription file with respect to identifying the drug prescribed by drug name. Between 5 and 14 percent of medical record drug entries did not have corresponding prescription records, probably reflecting patient decisions not to have prescriptions filled at HMO-affiliated pharmacies or at all. Further, 5–8 percent of dispensed prescription records did not have corresponding medical record drug entry notations, probably reflecting incomplete recording of drug information on the medical record. The percentage of agreement of medical records on dosage ranged from 68 to 70 percent across two sites. Approximately 14 percent of drug records at one location and 21 percent of records at the other had nonmatching dosage information, probably reflecting dosage changes noted on the medical record but not reflected on pharmacy records. CONCLUSIONS: In the sites studied, dispensed prescription records reasonably reflect chart drug entries for drug name, but not necessarily dosage.


Author(s):  
Richard Gibson ◽  
Lampros Laios

Three graphic methods of presenting scheduling information were compared with each other and with a conventional, numerical presentation. The graphic methods were based on the Gantt chart, and all three proved more effective than the numerical presentation in helping the subjects produce efficient schedules. One method in particular which used a machines-by-time organization and identified machines by color code proved superior to the others. This is explained in terms of the perceptual nature of problem solution using these methods. It is suggested that this organization of information be adopted when the primary criterion for schedule evaluation is machine utilization and there are limitations on the display space and color-coding available.


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