scholarly journals Perancangan dan Implementasi Sistem Informasi Rekam Medis (Studi Kasus: Puskesmas Onekore)

2021 ◽  
Vol 1 (2) ◽  
pp. 61-70
Author(s):  
Andy Ahmad ◽  
Ferdinandus Lidang Witi

The medical record information system is an information system that manages patient data and documents containing patient identities, examination results, payments and other services that have been provided to patients. The existing medical record information system at the Onekore Health Center is still processed manually, namely using a ledger for recording and also takes up a lot of storage space. So that patient service at the Onekore Health Center becomes less effective and efficient. Therefore, we need a concept for processing patient medical record data by considering the time efficiency and safety required for the patient data collection process. The purpose of this study is to build a computerized medical record information system in order to provide convenience for medical officers in providing health services to patients to be more effective and also easier in making reports. This medical record information system is designed using the Microsoft Visual Studio programming language and MySQL as the database. The research method used in this research is descriptive qualitative method. While the testing technique uses the Blackbox testing method.

2020 ◽  
Vol 5 (2) ◽  
pp. 259
Author(s):  
Beni Harzani ◽  
Diana Diana

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.


Author(s):  
Wahyu Wijaya Widiyanto ◽  
Sri Wulandari

Aims: Based on the observations of researchers, some health facilities still use manual processes / have not been documented by the information system resulting in slow service, this study aims to improve health services with a medical record information system. Methodology: The method used in this study is an analysis of information systems with the waterfall method and accuracy testing with ISO 9126. Results: The results of this medical record management information system run well based on black-box testing and white box results obtained both from an average value of 82 based on the ISO 9126 scale conversion table. Conclusion: Based on the results of the average value obtained from the validation test carried out on 3 expert examiners, it can be concluded that the application for the validation system for the validation and distribution of this letter has met the ISO 9126 standard with an average good interpretation of a total value of 82, and according to be able to simplify the process of Patient Medical Record Data Management without neglecting the safety aspects of the validation and distribution process, minimizing data loss, simplifying the reporting process and facilitating the processing of patient medical record data.


2021 ◽  
Vol 4 (1) ◽  
pp. 69-78
Author(s):  
TM Zaini ◽  
M Iqbal Kadafi Nasution

The information system at Kampung Sawah Community Health Center has several features such as patient registration, patient medical records, patient services, queues, and medical reports. Aim of this information system development is to facilitate the performance of administrators and doctors of Kampung Sawah Community Health Center in terms of searching patients’ data, storing the patient data, adding and storing the medical records, making the reports, and speeding up the data entry and identity data of the patients through fingerprint feature. This system facilitated the officials and doctors to process anywhere and the patient data was safe from physical disturbances because this system was connected to the internet.This medical record information system was built through PHP programming language supported by MySQL database. The design of this system involved the data flow diagrams. The result of this system was that the web-based information system for medical record had successfully been created and used by Kampung Sawah Community Health Center.Keywords: Information Systems, Medical Record, Web, Fingerprint


Author(s):  
Amir Ali

The use of information management systems that are owned by hospitals is still limited to being used only for the operation of daily patient service transactions and making reports only. The use of SIMRS is not optimal, it should pile the data stored in the database server can be used to generate new information if we dig deeper with the IT approach. This study uses data mining techniques with K-Means clustering method to cluster the patient's medical record data. The results of this study produce column 4 clusters consisting of districts, diagnoses of diseases, age and sex.The results of this study produce column 4 clusters consisting of districts, diagnoses of diseases, age and sex. Cluster 1 produced many patients consisting of 79(15%) female patients, Cluster 2 produced many patients consisting of 214(50%) male patients. Likewise Cluster 3 produced 89(17%) female patients. people and cluster 4 produced many patients consisting of 152(28%) female patients.The grouping of patient medical record data produces new information about the pattern of grouping of disease spread in each district based on the patient's medical record data from Anwar Medika Hospital as much as 534 data with a completion time of 0.06 seconds


2021 ◽  
Vol 5 (2) ◽  
pp. 306-314
Author(s):  
Aprilia Ningsi ◽  
◽  
Kristina Sara ◽  
Anastasia Mude ◽  
◽  
...  

The administrative process at Kotaratu health center still uses manual means. So, it takes a long time in handling patient visits and making reports. The goal of the study was to build a desktop-based medical record information system using the Microsoft Visual Basic. Net Programming Language and MySQL as its database. Data collection techniques through interviews, observations and literature studies. Meanwhile, to develop software (system) with waterfall method, while testing uses blackbox-testing. Our findings are in the form of a desktop-based information system at Kotaratu health center. Furthermore, Blackbox-testing results show that all components in this system are running well, and all medical record data is stored in the database to provide a convenience in managing patient data, searching for medical records, managing medical records and making reports periodically.


2018 ◽  
Vol 1007 ◽  
pp. 012018 ◽  
Author(s):  
Amir Mahmud H ◽  
Bayu Angga W ◽  
Tommy ◽  
Andi Marwan E ◽  
Rosyidah Siregar

Author(s):  
Rahmi Septia Sari

Pemeliharaan dan pengambilan data rekam medis merupakan fungsi penting dalam pelayanan disetiap fasilitas asuhan kesehatan. Peningkatan tuntutan akan informasi kesehatan ini mengharuskan fasilitas untuk memelihara sistem informasi yang efektif dan efisien. Mengenai sistem penomoran, penyimpanan dan retensi dari manajemen rekam medis di Indonesia banyak jenisnya. Bentuk sistem penomoran dan penyimpanan yang baik merupakan tahap awal dalam pemberian pelayanan terhadap pasien. Pengambilan dan penyimpanan rekam medis yang tepat merupakan elemen penting dalam pemberian pelayanan. Perlu kehati-hatian dalam merencanakan sistem penomoran dan penyimpanan. Tujuan utama dalam melakukan pemberian penomoran adalah mengidentifikasi data pasien. Penulis berpendapat bahwa dengan menggunakan bentuk pemberian nomor metode apapun rahasia pasien dapat terjaga. Pemberian nomor ini dilakukan pada saat pasien mendaftar atau kontak dengan sarana pelayanan kesehatan. Hal tujuan utama dalam melakukan pemberian penomoran adalah mengidentifikasi data pasien. Pemberian nomor dilakukan pada saat pasien mendaftar atau kontak dengan sarana pelayanan kesehatan. Dalam kegiatan ini kami berusaha untuk mengoptimalkan sistem pelayanan kesehatan  di Klinik Puri Medical melalui penyuluhan tentang sistem penomoran dan penyimpanan data Rekam Medis  yang baik dan memudahkan petugas dalam pengambilan dan penyimpanan data Rekam Medis tersebut. Pelaksanaan Pengabdian kepada masyarakat ini kami menguraikan tentang pengelolaan data Rekam medis melalui tatacara sistem penomoran dan penyimpanan data Rekam Medis. Metode yang dilakukan dengan cara memberikan materi dan dipresentasikan serta didiskusikan dengan staf yang hadir dalam Pengabdian tersebut dengan beberapa tahap, antara lain dengan pemaparan materi tentang sistem penomoran dan penyimpanan yang disampaikan kepada staf/petugas bagian Rekam medik yang hadir dalam acara Pengabdian Kepada Masyarakat, setelah itu dilanjutkan dengan praktik lapangan, jika ada hal yang kurang dipahami dalam pelaksanaan maka akan dilanjutkan dengan tahap bimbingan dan konsultasi antara staf rekam medis dengan tim Pengabdian Kepada Masyarakat,tahap akhir dalam jangka beberapa minggu akan dilakukan monitoring dan evaluasi apakah ilmu yang di berikan telah teraplikasi dengan baik di klinik tersebut. Kata kunci: Rekam Medis, Penomoran, Pengarsipan, Klinik ABSTRACT Corresponding author: * [email protected]   Maintenance and retrieval of medical record data is an important function of service in every health care facility. This increasing demand for health information requires facilities to maintain effective and efficient information systems. Regarding the numbering, storage and retention systems of medical record management in Indonesia, there are many types. The form of a good numbering and storage system is the initial stage in providing services to patients. Proper collection and storage of medical records is an important element in the delivery of services. Care needs to be taken in planning the numbering and storage system. The main purpose in numbering is to identify patient data. The author believes that by using any method of giving numbers the patient's secret can be kept. Giving this number is done when the patient registers or contacts with health care facilities. The main goal in making numbering is to identify patient data. The number is given when the patient registers or contacts with health care facilities. In this activity we are trying to optimize the health service system at Puri Medical Clinic through counseling about the numbering system and storing good Medical Record data and facilitate the officers in retrieving and storing the Medical Record data. This Community Service Implementation describes the management of medical record data through the procedure for numbering and storing medical record data. The method is done by providing material and presented and discussed with the staff present at the Service with several stages, including the presentation of material about the numbering and storage system that was delivered to the staff / officers of the Medical Record section who attended the Community Service event, after it is continued with field practice, if there are things that are not understood in the implementation it will be continued with the guidance and consultation phase between the medical record staff and the Community Service Team, the final stage within a period of several weeks will be carried out monitoring and evaluation whether the knowledge provided has been applied well in the clinic. Keywords: Medical Record, Numbering, Archiving, Clinic


2021 ◽  
Vol 3 (1) ◽  
pp. 51-59
Author(s):  
Nurul Maulidya ◽  
Dian Oktianti

Diabetes Mellitus (DM) is a long-term or chronic disease which continues to increase every year. Indonesia itself is ranked 7th for the most DM sufferers in the world. The purpose of this study was to determine the profile of the use of antidiabetic drugs in DM patients at the Grabag Public Health Center. The method used in this research is descriptive method, with retrospective data collection. The population of DM sufferers at the Grabag Public Health Center was 50 patients, with the sampling technique using the total sampling method. The inclusion criteria were medical record data for outpatient type 2 diabetes mellitus, and the exclusion criteria incomplete medical record data. The results of this study were the use of oral antidiabetic drugs (OAD) with single therapy, metformin 32% and acarbose 2%, and with combination therapy are metformin + glimepirid 58%, acarbose + glimepiride 2%, and metformin + glimepiride+acarbose 6%. Based on the duration of suffering from diabetes, for 1 year the most people used metformin by 26%, for 2 and 3 years the most used metformin + glimepiride by 38% and 8%, while for 4 years using a combination of metformin + glimepiride + acarbose by 2%. Most of the patients are accompanied by hypertension complications. The most widely used single therapy oral OAD is metformin and the combination therapy is metformin + glimepiride. Patients suffering from diabetes for 1 year of treatment used metformin single therapy, for 2 and 3 years the most treatment used 2 combination therapy, glimepiride + metformin, while for 4 years of treatment using 3 combination therapy metformin + glimepiride + acarbose. Abstrak Diabetes Mellitus (DM) merupakan penyakit jangka panjang atau kronis yang pada setiap tahunnya terus mengalami peningkatan. Indonesia sendiri menduduki peringkat ke-7 untuk penderita DM terbanyak didiunia. Tujuan penelitian ini adalah untuk mengetahui profil penggunaan obat antidiabetes pada pasien DM di Puskesmas Grabag. Metode yang digunakan pada penelitian ini adalah metode deskriptif, dengan pengambilan data secara retrospektif. Populasi penderita DM di puskesmas Grabag sebanyak 50 pasien dengan teknik pengambilan sampel menggunakan metode total sampling. Kriteria inklusi berupa data rekam medik pasien DM tipe 2 rawat jalan, dan kriteria eksklusi berupa data rekam medik yang tidak lengkap. Hasil dari penelitian ini adalah penggunaan obat antidiabetes (OAD) oral dengan terapi tunggal yaitu metformin 32% dan acarbose 2%, dan dengan terapi kombinasi adalah metformin + glimepirid 58%, acarbose + glimepiride 2%, dan metformin+glimepiride + acarbose 6%. Berdasarkan lamanya menderita DM, selama 1 tahun terbanyak menggunakan metformin sebesar 26%, selama 2 dan 3 tahun terbanyak menggunakan metformin + glimepiride sebesar 38% dan 8%, sedangkan selama 4 tahun menggunakan kombinasi metformin + glimepiride + acarbose sebesar 2%. Sebagian besar pasien disertai dengan komplikasi hipertensi. Penggunaan OAD oral terapi tunggal terbanyak adalah metformin dan terapi kombinasi adalah metformin+glimepiride. Pasien yang menderita DM selama 1 tahun pengobatan terbanyak menggunakan terapi tunggal metformin, selama 2 dan 3 tahun pengobatan terbanyak menggunakan terapi 2 kombinasi yaitu glimepiride + metformin, sedangkan selama 4 tahun pengobatannya menggunakan terapi 3 kombinasi yaitu metformin + glimepiride + acarbose.


2018 ◽  
Vol 4 (1) ◽  
Author(s):  
Dewa Made Andika Dwi Prawiradirjo ◽  
Bambang Hadi Kartiko ◽  
Gerson Feoh

ABSTRACT<br />The medical record officer at Bright Smiles Bali Clinic is still having difficulty in the process of<br />managing the data of outpatients because the clinic still using manual system that has not been<br />computerized. So it is necessary to design a web-based electronic medical record information system<br />that can help medical record officer in patient data management process. The method used in the<br />design of this system is the system development life cycle (SDLC) which consists of the planning,<br />analysis, design, implementation, and usage phases. The purpose and benefits of this information<br />system design is to produce a web based outpatient medical record information system at Bright<br />Smiles Bali Clinic.This information system facilitate medical record officer in carrying out patient<br />data management covering patient registration process, recording of patient medical record, doctors<br />data recording, code search on ICD 9 CM, code search on ICD 10. Besides, this information system<br />produces various reports as well as patient medical record information that management needs for<br />decision making.<br />Keywords: Information System, Electronic Medical Record, Outpatient, Web.<br />ABSTRAK<br />Petugas rekam medis di Klinik Gigi Bright Smiles Bali masih kesulitan dalam proses pengelolaan data<br />pasien rawat jalan karena masih menggunakan sistem manual yang belum terkomputerisasi. Maka<br />diperlukan sebuah sistem informasi rekam medis elektronik berbasis web yang dapat membantu<br />petugas rekam medis dalam proses pengelolaan data pasien tersebut. Metode perancangan sistem ini<br />menggunakan siklus hidup pengembangan sistem (Systems Development Life Cycle-SDLC) yang<br />terdiri dari tahap perencanaan, analisis, desain, implementasi, dan penggunaan. Sedangkan tujuan dan<br />manfaat dari perancangan sistem informasi ini yaitu menghasilkan sistem informasi rekam medis<br />elektronik rawat jalan berbasis web di Klinik Gigi Bright Smiles Bali. Dengan adanya sistem informasi<br />ini, dapat memudahkan petugas rekam medis dalam pengelolaan data pasien yang meliputi proses<br />pendaftaran pasien, pencatatan rekam medis pasien rawat jalan, pencatatan data dokter, pencarian kode<br />ICD 9 CM, pencarian kode ICD 10. Selain itu sistem informasi ini menghasilkan berbagai laporanlaporan<br />serta informasi rekam medis pasien yang dibutuhkan pihak manajemen untuk pengambilan<br />keputusan.<br />Kata Kunci : Sistem Informasi, Rekam Medis Elektronik, Rawat Jalan, Web.


2020 ◽  
Vol 6 (4) ◽  
Author(s):  
Nur Rokhman ◽  
Annisa Maulida Ningtyas ◽  
Marko Ferdian Salim ◽  
Dian Budi Santoso

Health Information System is a system that integrates the collection, processing, reporting of data, and use of information needed to increase the effectiveness and efficiency of health services through better management at all levels of health services. Kulon Progo Health Office is one of the Health Services that has utilized the Health Information System in organizing its health transactions. However, the implementation of the Health Information System still has shortcomings, namely that it was found that a patient has many medical record numbers or often referred to as duplicated medical record data. Community service activities are carried out through the use of appropriate technology at the Kulon Progo Health Office. This activity aims to implement data cleansing techniques using the "RESIK" framework  to help prevent and detect duplication of medical records and provide training to medical recorders in cleaning data. The training was attended by 105 participants, each of whom was a representative of the Puskesmas staff in the Kulon Progo Health Office area. The “RESIK” framework  was then piloted at Puskesmas Sentolo 2 as the location for the implementation of the system. From this activity, duplicate medical record data can be found at Puskesmas Sentolo 2, and then cleaning is carried out. Kulon Progo Health Office is advised to implement data cleansing using the "RESIK" framework  at all Puskesmas in the Kulon Progo area.


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