scholarly journals Tinjauan Sistem Penyelenggaraan Rekam Medis Menurut Standart Akreditasi Puskesmas di Puskesmas Pangakalan Berandan Tahun 2020

2021 ◽  
Vol 6 (2) ◽  
pp. 108-118
Author(s):  
Esraida Simanjuntak ◽  
Fajar Insani
Keyword(s):  
Health Center ◽  
Medical Record ◽  
Medical Records ◽  
Clinical Information ◽  
Record Management ◽  
Registration Process ◽  
Accreditation Standards ◽  
Icd 10 ◽  
Research Population ◽  
Access Rights

Puskesmas are required to maintain medical records containing data and information on patient care. Implementation according to accreditation standards, namely criteria 3.2 Registration Process and 3.8 Administration of medical records which are divided into 3.8.1 Coding, 3.8.2 Medical Record Access Rights 3.8.3 Clinical Information Filling and 3.8.4 Storage. The purpose of the study was to find out the implementation of the medical record management system according to the Puskesmas accreditation standards at the Pangkalan Berandan Health Center in 2020. This type of research was qualitative with a Phenomenology approach. The place of research was conducted at the Pangkalan Berandan Health Center. Time of study in July 2020. Research population is all medical record officers at the Pangkalan Berandan Health Center. The research sample is 5 officers. The research instrument was interview guide and check list sheet for observation. The results of the study revealed that the outpatient registration process had been carried out according to criteria 3.2 but there was no inpatient numbering of medical records. Coding was not carried out according to criteria 3.8.1, namely the absence of coding SOPs carried out by doctors using ICD 10, Medical Record Access Rights were carried out according to criteria 3.8. 2 but the implementation is not fully carried out in accordance with the SOP, the lending process is not recorded in the expedition book, Assembling is in accordance with criteria 3.8.3 but recording corrections are carried out using stip-ex and the storage process has been carried out according to criteria 3.8.4 but retention is not carried out according to the guidelines legislation. It is recommended for registration to give medical record numbers to inpatients, coding to make SOPs and given coding training, access rights to medical records to record loans in expedition books, assembling to be given socialization in terms of correcting recording of medical record files and storing tracers as well as in the retention process. given socialization about the implementation of retention.

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 Pengembangan Sistem Informasi Rekam Medis untuk Dinas Kabupaten Grobogan

2014 ◽  
Vol 2 (3) ◽  
pp. 203-208
Author(s):  
Purnaresa Yuliartanto ◽  
Adian Fatchur Rochim ◽  
Ike Pertiwi Windasari
Keyword(s):  
Health Center ◽  
Medical Record ◽  
Medical Records ◽  
Business Processes ◽  
Health Department ◽  
Health Centers ◽  
Process Data ◽  
Record Keeping ◽  
Storage And Retrieval ◽  
Number Of Patients

Abstract - Health services include the recording of the patient's medical record . Medical records were used to aid the treatment process. The number of medical records continues to grow proportional to the number of patients. Tens of thousands of sheets of paper used to record medical record requires effort , time and place great . The amount of effort will continue to grow each day. Search one sheet of medical records among a set of storage shelves requires considerable time and risk data is not found. The risk of error in the search and storing will increase every day. The development of technology allows the implementation of technology in the process of record-keeping. Changes in the form of digital medical records will reduce the need of a previous process. Labor, time and place required by the help of information systems will be reduced significantly . Storage process data stored in the cloud will provide more value for the system as a patient's medical records from a health center can be accessed from other health centers. The development of this system will reduce the risk of inappropriate storage and retrieval of medical records. Grobogan Health Department that oversees health center in Grobogan are office that are ready to migrate business processes into the digital age. Development of medical record information system for the health center expected to improve the quality of service of health centers , especially in health care.

scholarly journals Medical Record Storage System Analysis On The Effectiveness Of Patient Services

2021 ◽  
Vol 1 (1) ◽  
pp. 28-38
Author(s):  
Yoki Muchsam ◽  
Ilham Rizkiana Muharam
Keyword(s):  
Public Health ◽  
Health Center ◽  
Medical Record ◽  
Medical Records ◽  
System Analysis ◽  
Storage System ◽  
Health Care Facilities ◽  
Public Health Center ◽  
Additional Tool ◽  
Alignment System

This study aims to determine and analyze the medical record storage system on the effectiveness of patient care at the Cikole Public Health Center. The research method used is quantitative with inferential statistical analysis techniques. Data collection techniques by means of observation, interviews and questionnaires. Cikole Lembang Public Health Center is one of the first level health care facilities. Based on observations, the storage system used is a regional storage system in which each region starts from the first digit. There are 2 officers who work in the medical records section of the Cikole Public Health Center. With the storage system used, there are several shortcomings, namely the occurrence of misfiles and duplication. To find out whether there is an analysis of the medical record storage system on the effectiveness of the service, the author gives a questionnaire to the Cikole Public Health Center officers. The results of the questionnaire also show that the highest percentage level is found in item no.7, namely the decentralized storage system is in accordance with the target of 71%. Then the second is item no. 8, namely a decentralized storage system that allows the provision of medical record files on time by 61%. From the results of interviews with medical records officers, suggestions and input were given: (1). The storage system used was changed to centralization so that the alignment system was not duplicated; (2). The use of bindex as an additional tool to make storage neater and easier.

scholarly journals Aplikasi Filling Rekam Medis Menggunakan Metode Algoritma Turbo Boyer Moore

2020 ◽  
Vol 5 (2) ◽  
pp. 259
Author(s):  
Beni Harzani ◽  
Diana Diana
Keyword(s):  
Health Center ◽  
Medical Record ◽  
Medical Records ◽  
Community Health Centers ◽  
Processing System ◽  
Patient Data ◽  
Search Problem ◽  
Test Results ◽  
Medical Record Data ◽  
Record Data

Nagaswidak Health Center is one of the community health centers that is quite large and has complete facilities. But the problem that is often faced by officers in the puskesmas is the medical record data processing system which is still manual, causing the accumulation of patient medical record file data, in addition to patients who have been checked before and lost their medical records, it is very difficult for officers to find back, so the officer made a new medical record data. To overcome this problem, a Medical Records Filling Application was made at the Nagaswidak Health Center which includes the processing of medical records, patient data, drug data, action data, doctor data, and admin logins. So that the data search problem is not difficult, the turbo boyer moore algorithm method is applied which is expected to later be able to facilitate the search for patient data in the medical record filling application. Based on the test results Boyer Moore's Algorithm successfully applied to search for the beginning of a word, middle word, and final word. And the level of ease and usefulness of medical records application using Boyer Moore's algorithm obtained results that the level of ease is 80% and 100% usability rate.

scholarly journals PERANCANGAN SISTEM INFORMASI REKAM MEDIS BERBASIS WEB (STUDI KASUS DI KLINIK BERSALIN SRIATI KOTA SUNGAI PENUH – JAMBI)

2016 ◽  
Vol 2 (2) ◽  
Author(s):  
Tiara Handayani ◽  
Gerson Feoh
Keyword(s):  
Information System ◽  
Life Cycle ◽  
Medical Record ◽  
Medical Records ◽  
Systems Development ◽  
Patient Data ◽  
Web Based ◽  
Development Life Cycle ◽  
Icd 10 ◽  
Maternity Clinic

<p>ABSTRACT<br />The records officer at Maternity Clinic Sriati Sungai Penuh - Jambi in its management and reporting of patient data are still using manual systems. It has caused a delay in the delivery of information and report on daily data patients. Thus, it needs a system of web-based medical record information that can assist officers in the medical record of the patient data management processing. This system design method uses development life cycle (Systems Development Life Cycle-SDLC) which consists of planning, analysis, design, implementation, and use. Meanwhile, the purpose and benefits of the design of this information system is to produce a system of web-based medical record information in Maternity Clinic Sriati River Sungai Penuh - Jambi. With this information system, it eases medical records clerk in the management of patient data whichh includes patient registration process, the recording of patient medical records, physician data recording, data recording space, the search code ICD 9 CM and ICD code search 10. In addition, this information system produces a variety of reports and patient medical record information that is required for management decision making.<br />Keywords: Information Systems, Medical Record, Maternity Clinic, Web.<br />ABSTRAK<br />Petugas rekam medis di Klinik Bersalin Sriati Kota Sungai Penuh - Jambi dalam pengelolaan dan pembuatan laporan data pasien masih menggunakan sistem manual. Hal ini menyebabkan terjadinya keterlambatan dalam penyampaian informasi dan pelaporan data harian pasien. Maka diperlukan sebuah sistem informasi rekam medis berbasis web yang dapat membantu petugas rekam medis dalam proses pengelolaan data pasien tersebut. Metode perancangan sistem ini menggunakan siklus hidup pengembangan sistem (Systems Development Life Cycle-SDLC) yang terdiri dari tahap perencanaan, analisis, desain, implementasi, dan penggunaan. Sedangkan tujuan dan manfaat dari perancangan sistem informasi ini yaitu menghasilkan sebuah sistem informasi rekam medis berbasis web di Klinik Bersalin Sriati Kota Sungai Penuh - Jambi. Dengan adanya sistem informasi ini, dapat memudahkan petugas rekam medis dalam pengelolaan data pasien yang meliputi proses pendaftaran pasien, pencatatan rekam medis pasien, pencatatan data dokter, pencatatan data ruang, pencarian kode ICD 9 CM, dan pencarian kode ICD 10. Selain itu sistem informasi ini menghasilkan berbagai laporan-laporan serta informasi rekam medis pasien yang dibutuhkan pihak manajemen untuk pengambilan keputusan.<br />Kata kunci: Sistem Informasi, Klinik Bersalin, ICD 9 CM, ICD 10</p>

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 Pelaksanaan Penyimpanan Rekam Medis Berdasarkan Unsur Manjemen 5M di Puskesmas Medan Johor

2021 ◽  
Vol 6 (2) ◽  
pp. 152-160
Author(s):  
Valentina ◽  
Winda Andryani Sinaga
Keyword(s):  
Health Center ◽  
Medical Record ◽  
Medical Records ◽  
Good Health ◽  
Phenomenological Approach ◽  
Check List ◽  
Machine Element ◽  
Interview Guide ◽  
Material Element ◽  
Audio Recorder

The implementation of medical records carried out at the puskesmas requires management in managing all existing activities with the aim of creating good health services, in accordance with procedures and guidelines. To achieve the goal of processing medical records, 5 elements of management are needed, namely man, money, material, machine, and method. The purpose of this study was to determine the management elements of man, money, material, machine, and method in the implementation of medical records carried out at the Medan Johor Health Center. This type of research uses qualitative research methods with a phenomenological approach. The study was conducted from May to July 2020. The population was all medical record officers at the Medan Johor Health Center. The research sample amounted to 5 people who were taken by saturated sampling. The research instrument is an interview guide and recorded using an audio recorder and a check list sheet for observation. The results showed that the man element was 5 people and none of them had a medical record background and had never received training, the money element was the funding obtained from JKN and APBD, the material element was that a family folder was used to store all patient forms, while the use of tracers and register books has not been used to control the borrowed files out of the storage rack, and the filling cabinet is used as a tool to store medical record files, the machine element is a primary care application to register patients, the SIMPUS application is used for reporting, the method element is Not all SOPs in medical records exist. The advice given is to provide training to medical record officers so that their officers better understand the importance of medical records.

Accuracy and Validity Outpatient Diagnosis Code Base On ICD-10 at Imogiri I Health Center Bantul Yogyakarta

2022 ◽  
Vol 2 (1) ◽  
pp. 26-31
Author(s):  
Hendra Rohman
Keyword(s):  
Health Center ◽  
Medical Record ◽  
Total Sample ◽  
Accurate Diagnosis ◽  
Diagnosis Code ◽  
Validation Data ◽  
Diagnosis Codes ◽  
Code Base ◽  
Icd 10

Background: Analysis of accuracy and validity fill code diagnosis on medical record document is very important because if diagnosis code is not appropriate with ICD-10, will cause decline in quality services health center, generated data have this validation data level is low, because accuracy code very important for health center such as index process and statistical report, as basis for making outpatient morbidity report and top ten diseases reports, as well as influencing policies will be taken by primary health center management. This study aims to analyze accuracy and validity diagnosis disease code based on ICD-10 fourth quarter in 2020 Imogiri I Health Center Bantul.Methods: Descriptive qualitative approach, case study design. Subject is a doctor, nurse, head record medical and staff. Object is outpatients medical record document in Imogiri I Health Center Bantul. Total sample 99 medical record file. Obtaining data from this study through interviews and observations.Results: Number of complete accurate diagnosis codes is 60 (60,6%), incomplete accurate diagnosis codes is 26 (26.3%) and inaccurate diagnosis codes is 13 (13.1%). Inaccuracies include errors in determining code, errors in determining 4th character ICD-10 code, not adding 4th and 5th characters, not including external cause, and multiple diseases.Conclusions: Inaccuracy factors are not competence medical record staff, incomplete diagnosis writing and no training, no evaluation or coding audit has been carried out, and standard operational procedure is not socialized.

scholarly journals Vaccine Safety Datalink infrastructure enhancements for evaluating the safety of maternal vaccination

2021 ◽  
Vol 12 ◽  
pp. 204209862110212
Author(s):  
Allison L. Naleway ◽  
Bradley Crane ◽  
Stephanie A. Irving ◽  
Don Bachman ◽  
Kimberly K. Vesco ◽  
...  
Keyword(s):  
Real Time ◽  
Medical Record ◽  
Gestational Age ◽  
Medical Records ◽  
Vaccine Safety ◽  
Live Births ◽  
International Classification Of Disease ◽  
Safety Studies ◽  
Icd 10

Background: Identifying pregnancy episodes and accurately estimating their beginning and end dates are imperative for observational maternal vaccine safety studies using electronic health record (EHR) data. Methods: We modified the Vaccine Safety Datalink (VSD) Pregnancy Episode Algorithm (PEA) to include both the International Classification of Disease, ninth revision (ICD-9 system) and ICD-10 diagnosis codes, incorporated additional gestational age data, and validated this enhanced algorithm with manual medical record review. We also developed the new Dynamic Pregnancy Algorithm (DPA) to identify pregnancy episodes in real time. Results: Around 75% of the pregnancy episodes identified by the enhanced VSD PEA were live births, 12% were spontaneous abortions (SABs), 10% were induced abortions (IABs), and 0.4% were stillbirths (SBs). Gestational age was identified for 99% of live births, 89% of SBs, 69% of SABs, and 42% of IABs. Agreement between the PEA-assigned and abstractor-identified pregnancy outcome and outcome date was 100% for live births, but was lower for pregnancy losses. When gestational age was available in the medical record, the agreement was higher for live births (97%), but lower for pregnancy losses (75%). The DPA demonstrated strong concordance with the PEA and identified pregnancy episodes ⩾6 months prior to the outcome date for 89% of live births. Conclusion: The enhanced VSD PEA is a useful tool for identifying pregnancy episodes in EHR databases. The DPA improves the timeliness of pregnancy identification and can be used for near real-time maternal vaccine safety studies. Plain Language Summary Improving identification of pregnancies in the Vaccine Safety Datalink electronic medical record databases to allow for better and faster monitoring of vaccination safety during pregnancy Introduction: It is important to monitor of the safety of vaccines after they have been approved and licensed by the Food and Drug Administration, especially among women vaccinated during pregnancy. The Vaccine Safety Datalink (VSD) monitors vaccine safety through observational studies within large databases of electronic medical records. Since 2012, VSD researchers have used an algorithm called the Pregnancy Episode Algorithm (PEA) to identify the medical records of women who have been pregnant. Researchers then use these medical records to study whether receiving a particular vaccine is linked to any negative outcomes for the woman or her child. Methods: The goal of this study was to update and enhance the PEA to include the full set of medical record diagnostic codes [both from the older International Classification of Disease, ninth revision (ICD-9 system) and the newer ICD-10 system] and to incorporate additional sources of data about gestational age. To ensure the validity of the PEA following these enhancements, we manually reviewed medical records and compared the results with the algorithm. We also developed a new algorithm, the Dynamic Pregnancy Algorithm (DPA), to identify women earlier in pregnancy, allowing us to conduct more timely vaccine safety assessments. Results: The new version of the PEA identified 2,485,410 pregnancies in the VSD database. The enhanced algorithm more precisely estimated the beginning of pregnancies, especially those that did not result in live births, due to the new sources of gestational age data. Conclusion: Our new algorithm, the DPA, was successful at identifying pregnancies earlier in gestation than the PEA. The enhanced PEA and the new DPA will allow us to better evaluate the safety of current and future vaccinations administered during or around the time of pregnancy.

scholarly journals SOSIALISASI DAN PRAKTEK RETENSI DAN PEMUSNAHAN BERKAS REKAM MEDIS di PUSKESMAS KURANJI

2020 ◽  
Vol 4 (1) ◽  
pp. 63
Author(s):  
Sayati Mandia
Keyword(s):  
Public Health ◽  
Community Health ◽  
Health Center ◽  
Medical Record ◽  
Medical Records ◽  
Community Health Center ◽  
Healthcare Facilities ◽  
The Public ◽  
Patient Health ◽  
The City

Puskesmas merupakan fasilitas pelayanan kesehatan yang menyelenggarakan upaya kesehatan masyarakat dan upaya kesehatan perseorangan tingkat pertama. Dalam melaksanakan tugasnya puskesmas berwenang untuk untuk melaksanakan pencatatan dan pelaporan kesehatan pasien serta melakukan evaluasi terhadap mutu dan cakupan pelayanan kesehatan. Pencatatan dan pelaporan pasien dapat dilihat dari berkas rekam medis pasien. Rekam medis pada sarana kesehatan non rumah sakit wajib disimpan sekurang-kurangnya untuk jangka waktu dua tahun terhitung dari tanggal terakhir pasien berobat. Setelah batas waktu penyimpanan dilampaui maka rekam medis dapat dimusnahkan. Puskesmas Kuranji merupakan salah satu puskemas di kota padang yang berlamat dikecamatan Kuranji. Berdasarkan hasil wawancara dengan petugas rekam medis, hingga saat ini Puskesmas Kuranji belum melakukan retensi dan pemusnahan berkas rekam medis sedangkan ruangan penyimpanan hanya ada satu. Berdasarkan pemaparan masalah di atas, maka pengabdi bermaksud untuk melakukan sosialisasi dan praktik langsung mengenai retensi dan pemusnahan berkas rekam medis di Puskesmas Kuranji Kota Padang. Target dan luaran dari pelaksanaan kegiatan pengabdian kepada masyarakat adalah kegiatan ini dapat dijadikan sebagai bahan pertimbangan untuk pelaksanaan retensi dan penghancuran berkas rekam medis. Target kedepannya agar sosialisi ini dapat digunakan sebagai dasar kegiatan retensi dan penghancuran berkas rekam medis. Kata Kunci: Puskesmas, Retensi, Pemusnahan, Rekam Medis ABSTRACT Public health center (PHC) is a health service facility that organizes public health efforts and first-level individual health efforts. In carrying out its duties PHC is authorized to carry out the recording and reporting of patient health and to evaluate the quality and scope of health services. Patient recording and reporting can be seen from the patient's medical record file. Medical records in non-hospital healthcare facilities must be kept for at least two years from the date the patient was treated. After the storage time limit is exceeded, the medical record can be destroyed. The Kuranji Community Health Center is one of the public health centers in the city of Padang which is well-known in the Kuranji sub-district. Based on the results of interviews with medical record officers, up to now the Kuranji Community Health Center has not retained and destroyed medical record files while there is only one storage room. Based on the explanation of the problem above, the service intends to conduct socialization and direct practice regarding the retention and destruction of medical record files at the Kuranji Health Center in Padang City. The target and output of the implementation of community service activities is that this activity can be used as consideration for the implementation of retention and destruction of medical record files. The future target is that this socialization can be used as a basis for retention and destruction of medical records. Keywords: Puskesmas, Retention, Destruction, Medical Record

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