scholarly journals The Assessment of Medical Recording Resources in Asembling Units with Workload Staffing Needs (WISN) Methods in Bendan General Hospital, Pekalongan

2020 ◽  
pp. 18-31
Author(s):  
Nisa Bela Aryana ◽  
Maulana Tomy Abiyasa ◽  
Hery Kurniawan ◽  
Slamet Isworo
Keyword(s):  
General Hospital ◽  
Medical Record ◽  
Medical Records ◽  
District General Hospital ◽  
City Government ◽  
Records Management ◽  
General Description ◽  
Inpatient Ward ◽  
Ongoing Training ◽  
Staffing Needs

Objective: Bendan district general hospital is a type C hospital owned by the Pekalongan City Government which is demanded to have good service performance. The assembling unit in the Medical Records department at the Hospital is a unit that influences the overall service process because in this unit all medical records management for patients from all wards is managed. Research Purposes:  This study aims to find a general description of the workload and the needs of assembling officers in the medical records department. Method: This research was conducted by assembling officers, from February to March 2020, with the type of descriptive research using the interview method based on the Workload Indicator Staffing Needs (WISN) Formula. The Results: The results of the study were based on the calculation of the WISN method so that the officers' needs were 2 people for 7 hours / day and with 6 working days / week. The effective working day in 1 year is 227 days with a standard workload of assembling medical record documents on the inpatient ward of 14887 documents and inputting data in a computer with a standard workload of 23820 documents. Conclusion: that the workload of the assembling officer in the medical record department is not appropriate, there is still a buildup of medical records in the assembling section. Suggestion: It is necessary to add assembling officers to the medical record unit and to provide ongoing training so that the performance of officers is compatible in performing their work.

scholarly journals ANALISIS FAKTOR – FAKTOR KONDISI KERJA YANG MELATARBELAKANGI KETERLAMBATAN PENYELESAIAN PENGISIAN DOKUMEN REKAM MEDIS OLEH DOKTER DI INSTALASI RAWAT INAP RUMAH SAKIT UMUM DAERAH KABUPATEN KLUNGKUNG

2020 ◽  
Vol 4 (2) ◽  
pp. 81
Author(s):  
I Gede Diki Sudarsana ◽  
Ketut Suarjana ◽  
Pande Putu Januraga
Keyword(s):  
General Hospital ◽  
Medical Record ◽  
Medical Records ◽  
Working Condition ◽  
Working Hours ◽  
Work Load ◽  
Records Management ◽  
Internal Working ◽  
Study Results ◽  
Depth Interviews

ABSTRAKRSUD Kabupaten Klungkung merupakan salah satu rumah sakit yang belum dapat mencapai indikator mutu kelengkapan rekam medis 24 jam setelah selesai pelayanan. Kelengkapan, keakuratan, dan ketepatan rekam medis merupakan tanggungjawab utama dokter. Perilaku dokter dalam penyelesaian pengisian rekam medis salah satunya dapat dipengaruhi oleh kondisi kerja tempatnya bertugas. Penelitian ini bertujuan untuk mengetahui faktor-faktor kondisi kerja yang melatarbelakangi keterlambatan penyelesaian pengisian dokumen rekam medis oleh dokter di Instalasi Rawat Inap RSUD Kabupaten Klungkung. Penelitian ini menggunakan metode deskriptif kualitatif. Pengumpulan data menggunakan metode wawancara mendalam dan studi dokumentasi yang dilakukan di instalasi rawat inap RSUD Kabupaten Klungkung pada bulan April-Mei 2017. Informan pberjumlah delapan orang yang terdiri dari dokter spesialis dan manajemen rumah sakit. Hasil penelitian ini menunjukan bahwa beban kerja yang cukup tinggi, belum efektifnya supervisi, belum maksimal pengetahuan dokter terkait rekam medis, belum terbiasanya dokter menggunakan formulir rekam medis yang baru, serta belum efektifnya pelaksanaan sosialisasi melatarbelakangi keterlambatan penyelesaian pengisian rekam medis oleh dokter. Selain itu, faktor diluar kondisi kerja yang melatarbelakangi keterlambatan penyelesaian pengisian yaitu kebijakan hari libur dan kepulangan pasien diluar jam kerja dokter spesialis. Simpulan penelitian ini diketahui bahwa faktor kondisi kerja yang belum optimal di RSUD Kabupaten Klungkung melatarbelakangi terjadinya keterlambatan penyelesaian pengisian dokumen rekam medis oleh dokter spesialis di instalasi rawat inap. Maka perlu adanya perbaikan pada faktor kondisi kerja yang ada di RSUD Kabupaten Klungkung.Kata Kunci : Dokter, Kondisi Kerja, Rekam Medis. ABSTRACTKlungkung Public General Hospital has not able to achieve one of the quality indicators namely completeness of patients’ medical records after 24 hours of the patient care is finalized. The completeness and validity of the medical record is the responsibility of the physician. This study aimed at identifying factors related to the physicians’ performance in filling up the medical records. This study used a qualitative method with in-depth interviews conducted among eight specialized physician and administrative staff working at in-patient wards of Klungkung Public General Hospital from April to May 2017. The study results showed two groups of factors influencing the performance of physicians in filling up the medical records. The first was internal working condition factors consist of a high work-load, lack of socialization and supervision, lack of knowledge related to the medical records management, and problems with the new forms. The second was external factors such as off-day policy as well as the time difference between patients’ discharge and physician working hours. The study conclusion is that suboptimal working conditions influence the completeness of patients’ medical records. A human resources strategy to optimize working condition particularly for physicians, is needed.Keywords: Doctor, Work Condition, Medical Record

Risk Factor Of Substitution ARV First Line People Living With HIV/AIDS In General Hospital Buleleng Bali

2020 ◽  
Vol 9 (1) ◽  
pp. 190-197
Author(s):  
Luh Putu Desy Puspaningrat ◽  
Gusti Putu Candra ◽  
Putu Dian Prima Kusuma Dewi ◽  
I Made Sundayana ◽  
Indrie Lutfiana
Keyword(s):  
Risk Factor ◽  
General Hospital ◽  
Medical Records ◽  
Secondary Data ◽  
District General Hospital ◽  
People Living With Hiv ◽  
First Line ◽  
The Past ◽  
Factor Substitution ◽  
Living With Hiv

Substitution is still a threat to the failure of ARV therapy so that no matter how small it must be noted and monitored in ARV therapy. The aims  was analysis risk factor substitution ARV first line in therapy ARV. This study was an analytic longitudinal study with retrospective secondary data analysis in a cohort of patients receiving ARV therapy at the District General Hospital of Buleleng District for the period of 2006-2015 and secondary data from medical records of PLHA patients receiving ART.  Result in this study that the percentage of first-line ARV substitution events is 9.88% (119/1204) who received ARV therapy for the past 11 years. Risk factors that increase the risk of substitution in ARV therapy patients are zidovudine (aOR 4.29 CI 1.31 -2.65 p 0.01), nevirapine (aOR1.86 CI 2.15 - 8.59 p 0.01) and functional working status (aOR 1.46 CI 1.13 - 1.98 p 0.01). 

scholarly journals Completeness criteria and filling of medical records in dental clinic of Cianjur General Hospital (January - April 2011)

2012 ◽  
Vol 24 (2) ◽  
Author(s):  
Annisa Rosalina ◽  
Netty Suryanti ◽  
Riana Wardani
Keyword(s):  
General Hospital ◽  
Medical Record ◽  
Medical Records ◽  
Random Sampling ◽  
Sampling Technique ◽  
Patient Treatment ◽  
Dental Clinic ◽  
The Republic ◽  
Descriptive Method ◽  
Medical Record Documentation

Introduction: The medical record documentation of patient treatment Provides the which in turn, must be maintained Clearly, concisely, comprehensively and accurately. Medical record and its filling criteria must be based on the regulation of the Minister of Health of The Republic of Indonesia No. 269/Menkes/Per/III / 2008 regarding to the medical record. The research was Aimed to unveil the completeness of both criteria and filling on medical records at the General Hospital’s Dental Polyclinic of Cianjur District. Methods: Survey-based descriptive method was applied within the research. Its Data was acquired through the examination on medical records and interviews. Random sampling was conducted to run the sampling technique. 89 pieces of outpatient’s medical records were embodied as samples. Results: Based on the research results, it is discovered that 6 out of 12 criteria (50%) are not listed within the medical record. Thus, the filling on medical records of 100% is found incomplete. Conclusion: Medical records Dental Clinic Regional General Hospital Cianjur according to standards Permenkes No. 269/2008 not inlude on complete criteria according to standards Permenkes No. 269/2008.

scholarly journals TINJAUAN PELAKSANAAN NILAI GUNA REKAM MEDIS BAGI PASIEN DI RUMAH SAKIT UMUM IMELDA PEKERJA INDONESIA (RSU IPI) MEDAN TAHUN 2018

2020 ◽  
Vol 5 (1) ◽  
pp. 80-84
Author(s):  
Johanna Christy ◽  
Afni Efani Putri S
Keyword(s):  
Health Care ◽  
Medical Care ◽  
General Hospital ◽  
Medical Record ◽  
Medical Records ◽  
Health Care Facilities ◽  
Use Value ◽  
Care Facilities ◽  
Conducting Research

ABSTRAK Rekam medis adalah berkas yang berisi catatan dan dokumen tentang identitas pasien, pemeriksaan, pengobatan, tindakan dan pelayanan lain kepada pasien pada sarana pelayanan kesehatan. Tujuan penelitian ini adalah untuk mengetahui bagaimana pelaksanan nilai guna rekam medis bagi pasien. Jenis penelitian ini adalah deskriptif bertujuan menggambarkan secara sistematis fakta dan karakteristik objek dan subjek secara tepat. Waktu penelitian ini dilakukan pada bulan Juli di Rumah Sakit Umum Pekerja Indonesia Medan (RSU IPI) Tahun 2018. Populasi dalam penelitian adalah 440 berkas rekam medis. Dalam melakukan penelitian, peneliti mengambil sampel sebanyak 81 berkas rekam medis. Berdasarkan hasil penelitian yang dilakukan di RSU IPI pelaksanaan nilai guna rekam medis sudah terlaksana dengan baik, dilihat dari tersedianya ringkasan masuk dan keluar, resume, lembar operasi, identifikasi bayi, lembar persetujuan tindakan, lembar kematian pada setiapberkas pasien pulang meninggal, asuhan keperawatan didalam berkas rekam medis. Tetapi dalam pengisian berkas rekam medis petugas rekam medis belum mengimplementasikan nilai guna rekam medis dengan baik. Kesimpulannya pelaksanaan nilai guna rekam medis sudah baik namun dalam pengisian berkas rekam medis lebih di perhatikan sesuai Permenkes 269 Tahun 2008 Tentang rekam Medis sehingga pelaksaaan nilai guna rekam medis dan pengisisan berkas rekam medis berjalan lebih baik.   Kata Kunci: Rekam Medis, Nilai Guna Rekam Medis, Berkas Rekam Medis                                             ABSTRACT   Medical record is a document that contains records and documents about patient identity, examination, treatment, care and other services for patients in health care facilities. The purpose of this study was to study how the implementation of the use of medical records for patients. This type of research is descriptive which addresses the systematic problem and the appropriate characteristics of objects and subjects. When this study was conducted in July at the Medan Indonesian Workers General Hospital (RSU IPI) in 2018. The population in this study was 440 medical record documents. In conducting research, researchers took 81 samples of medical records. Based on the results of research conducted at the IPI General Hospital, the implementation of the use value of medical records has been carried out well, seen from the availability of incoming and outgoing assessments, proceeding, surgery sheets, accessing infants, action approval sheets, consent sheets on each patient's return documents, medical care care. However, in applying medical records, medical record officers have not applied the use value of medical records properly. Conclusion the reclamation of the value of the medical record has been better in the reclamation of the medical record is better with the approval in accordance with Minister of Health Regulation 269 of 2008 About the Medical Record requires the implementation of the value of the medical record and the filling of the medical record better.

scholarly journals Characteristic of Patients with Gastric Perforation due to Peptic Ulcer in Dr. Soetomo General Hospital Surabaya in the Period of January - December 2016

2019 ◽  
Vol 3 (2) ◽  
pp. 45
Author(s):  
Esthiningrum Dewi Agustin ◽  
Mamiek Dwi Putro ◽  
Herry Purbayu
Keyword(s):  
Peptic Ulcer ◽  
Retrospective Study ◽  
Traditional Medicine ◽  
General Hospital ◽  
Medical Record ◽  
Medical Records ◽  
Gastric Perforation ◽  
Pathological Examination ◽  
Lack Of Information

Aim: This study aims to study the profile of patients with gastric perforation caused by peptic ulcer. Method: This is a retrospective study by obtaining patients data from medical records in the Medical Record Centre of Dr. Soetomo General Hospital during the period of January - December 2016 and analyzed descriptively. Result: 66 patients were identified (45 male and 21 female), most of them were between age 60 - 69 years old, and live in Surabaya (45.45%). 30.3% of patients No malignancy was found during the anatomic-pathological examination. 30.3% of patients have a long term NSAID taking, while 53.03% of patients came with a habit of traditional medicine consumption. Perforations were mostly located 1 - 5 cm pre-pyloric and between the range 0.5 - 1 cm in diameter (56.6% and 69.7%, respectively). Conclusion: With the lack of information, it still needs further studies with more completed data for better accuracy.

scholarly journals COMPARISON OF CLOPIDOGREL AND ACETOSAL IN THE PREVENTION OF RECCURENT ISCHEMIC STROKE AT DR. MOEWARDI REGIONAL GENERAL HOSPITAL

2017 ◽  
Vol 10 (10) ◽  
pp. 145
Author(s):  
Anis Dwi Kristiyowati ◽  
Retnosari Andrajati ◽  
Anton Bahtiar
Keyword(s):  
Ischemic Stroke ◽  
General Hospital ◽  
Medical Record ◽  
Medical Records ◽  
Recurrent Stroke ◽  
Control Group ◽  
Medical Record Data ◽  
Record Data ◽  
History Of ◽  
Almost All

  Objective: This study was conducted to determine the effect of clopidogrel on the prevention of recurrent stroke.Methods: This study used case–control study; data were taken from patient’s medical record of DR. Moewardi Regional General Hospital in the period of January 2013 – February 2017. Case group is a recurrent stroke patient receiving an acetosal or clopidogrel. The control group is a nonrecurrent stroke patient who receives an acetosal or clopidogrel.Results: During the period of study, the number of medical sample record data are 177 samples from the entire study subjects that met the inclusion and exclusion criteria, 50 medical records entered as subject of case study, 32 medical record samples was excluded because medical record data at the first stroke was gone (obselete), 35 medical record was excluded because medical record data at first stroke was not at of DR. Moewardi Regional General Hospital, 4 samples of medical records was excluded for using a combination of acetosal and clopidogrel, 55 samples of medical records as control subjects. Patients who use clopidogrel have a tendency to prevent recurrent stroke, but statistically not significantly different. This study shows that men tend to suffer more recurrent ischemic stroke (64.0%) than women. While in the control group of recurrent ischemic stroke of women (56.4%) more experienced the first stroke than men. Patients who had a stroke almost all had a history of hypertension (90.2%). Recurrent stroke patients in this study almost all had a history of hypertension. Bivariate analysis was showed that gender, history of diabetes mellitus (DM) and history of hypertension had an effect on recurrent stroke events. From the multivariate analysis, it was found that men had a risk of 2.328 for recurrent stroke (p=0.047), the history of DM had a risk of 3.975 times for recurrent stroke (p=0.016) and history of hypertension was 4.021 times for recurrent stroke (p=0.03)

scholarly journals 715 A Re-Audit of Compliance with Documentation Standards in General Surgery Operation Notes at A District General Hospital

2021 ◽  
Vol 108 (Supplement_2) ◽  
Author(s):  
O Ogundeji ◽  
S Hornby ◽  
S Dwerryhouse
Keyword(s):  
General Hospital ◽  
Medical Record ◽  
Continuity Of Care ◽  
Royal College ◽  
General Surgery ◽  
District General Hospital ◽  
Slight Improvement ◽  
Legal Document ◽  
Current Operation ◽  
Operation Note

Abstract Introduction The operation note is an important document in patient care. It is an essential part of a patient’s medical record. Apart from helping to ease the continuity of care, it is also a crucial medico-legal document. The aim of this audit was to re-assess the compliance of current operation note documentation in the department with the guidelines set out by the Royal College of Surgeons (RCS) of England. Method We carried out the re-audit 4 months after presenting the initial findings. 40 operation notes, randomly selected, were used for this audit over 6 weeks. Only operations conducted by General Surgery consultants (24) or registrars (16) were audited. Both Emergency and Elective procedures were audited (13 Emergency; 27 Elective). Results Time was still inconsistently documented in operation notes although there was a slight improvement (37%; 47.5%). Operative diagnosis was present in 82.5% of notes, compared with 78% in the first audit. 100% of notes had the signature of operating or assisting surgeon. Detailed post-operative plans were present in 95%, an improvement of 17% from the previous audit. Conclusions The quality and compliance with standards of the operation notes improved generally but there is still room for further improvement.

scholarly journals Analysis The Level of Compliance of Hospital Human Resources in Writing The Status of Inpatient Medical Record Dr Sayidiman Hospital and The Influences Factors

2020 ◽  
Vol 3 (2) ◽  
pp. 423-433
Author(s):  
Ratnawati Ratnawati
Keyword(s):  
Linear Regression ◽  
Human Resources ◽  
General Hospital ◽  
Medical Record ◽  
Health Professionals ◽  
Medical Records ◽  
Regional Hospital ◽  
P Value ◽  
The Status

The quality of medical records in hospitals also determines the quality of service, completeness of writing Medical Records documents correctly and correctly is very important. The purpose of this study was to analyze the level of compliance of hospital human resources in writing the status of the inpatient Medical Record Dr. Sayidiman Magetan Regional Hospital and the factors that influence it. The design of this study was an observational quantitative study with a cross section approach with the focus of the research directed to be analyzing the level of compliance of hospital human resources in writing the status of the inpatient Medical Record Dr Sayidiman Magetan Regional Hospital and the factors that influenced it with a sample of 192 respondents taken with the Simple Random Sampling technique. The findings found that most of the respondents have high motivation that is 144 respondents (75%). Most of the respondents care to write in the medical record that is 160 respondents (83.3%). Most of the respondents have a high appreciation of 136 respondents (70.8%). Most of the respondents did not comply doing medical record writing of 107 respondents (55.7%). Based on the Linear Regression analysis the motivation variable on compliance p-value 0.015 <0.05, the variable concern for compliance p-value 0.025 <0.05 then H0 is rejected so there is the influence of motivation and concern for compliance with medical record writing by health professionals in Regional General Hospital Dr. Sayidiman Magetan. Linear regression variable rewards for compliance shows that the p-value of 0.665> 0.05 then H0 is accepted so it is concluded that there is no effect of rewards on compliance with writing medical records by health professionals at the Dr Sayidiman Magetan Regional General Hospital. It is expected that respondents can comply to fill out medical records so that the delivery of care to passion can be well integrated

scholarly journals ANALISIS LUAS RUANGAN BERDASARKAN KEBUTUHAN RAK DI RUANG PENYIMPANAN BERKAS REKAM MEDIS RAWAT JALAN DI RUMAH SAKIT UMUM MADANI MEDAN TAHUN 2019

2020 ◽  
Vol 5 (1) ◽  
pp. 20-29
Author(s):  
Puput Melati Hutauruk ◽  
Fince Rahmat Zega
Keyword(s):  
General Hospital ◽  
Medical Record ◽  
Medical Records ◽  
Patient Medical Record ◽  
File Storage ◽  
Storage Room ◽  
Quantitative Descriptive ◽  
Storage Racks ◽  
Descriptive Method

ABSTRAK Rekam medis disimpan dalam rak penyimpanan agar terjaga kerahasiaanya, terhindar dari kerusakan dan mempermudah petugas dalam pengambilan dan pengembalian rekam medis. Agar pelayanan menjadi efektif dan efesien, selain memerlukan rak penyimpanan yang cukup, juga perlu ruangan penyimpanan yang bisa memuat rak penyimpanan tersebut agar dapat menyimpan berkas rekam medis pasien dalam jangka waktu tertentu guna pemeriksaan diwaktu yang akan datang dan memudahkan pengambilan kembali oleh petugas. Maka dari itu peneliti bertujuan untuk menegetahui luas ruangan berdasarkan kebutuhan rak saat ini di Rumah Sakit Umum Madani Medan tahun 2019. Penelitian ini menggunakan  metode deskriptif kuantitatif yaitu dengan memaparkan hasil penelitian apa adanya dan membandingkan dengan teori kemudian diambil kesimpulan. Subjek dalam penelitian ini adalah ruang penyimpanan berkas rekam medis rawat jalan, dan objek dalam penelitian ini adalah berkas rekam medis dan rak penyimpanan rawat jalan. Hasil penelitian ini menunjukkan bahwa jumlah rak penyimpanan berkas rekam medis rawat jalan di RSU Madani medan adalah 8 rak dengan luas ruangan 18,99 m2. Jika saat ini rumah sakit memiliki 8 rak, maka rumah sakit perlu menyediakan 10 rak lagi sehingga luas ruangan menjadi 48,82 m2 agar luas ruangan dapat tercukupi dan dapat memuat rak sesuai kebutuhan rumah sakit  sehingga tidak menyulitkan petugas penyimpanan dalam pengambilan maupun pengembalian rekam medis pasien.   Kata Kunci    :  Rekam Medis, Rak Penyimpanan, Luas Ruangan   ABSTRACT Medical records are stored in a storage rack to maintain confidentiality, avoid damage and make it easier for officers to retrieve and return medical records. In order for the service to be effective and efficient, in addition to requiring adequate storage shelves, storage rooms that can also contain storage shelves are needed so that they can store patient medical record files for a certain period of time for future examinations and facilitate retrieval by officers. Therefore the researcher aims to determine the area of ​​the room based on the needs of the current shelves at the Medan Madani General Hospital in 2019. This research uses a quantitative descriptive method by describing the results of the research as it is and comparing with the theory then conclusions are drawn. The subjects in this study were the outpatient medical record file storage room, and the object in this study was the medical record file and outpatient storage rack. The results of this study indicate that the number of outpatient medical record file storage racks in Medan Madani General Hospital is 8 shelves with an area of ​​18.99 m2. If the hospital currently has 8 shelves, the hospital needs to provide 10 more shelves so the room area becomes 48.82 m2 so that the room area can be fulfilled and can load the shelves according to the hospital's needs so that it does not make it difficult for the storage staff to retrieve or return the patient's medical record .

Sign in / Sign up

Export Citation Format

Share Document