Rancang Bangun Sistem Informasi Rekam Medis (Studi Kasus: Klinik PKU Muhammadiyah Gandrungmangu)

Health Services at the PKU Muhammadiyah Gandrungmangu Clinic have not made much use of information technology. Documentation of patient medical records still uses a manual recording system, causing various obstacles; for example, officers often find the same medical record number and difficulties making reports. Thus, creating a medical record information system is necessary to help manage medical record data electronically. The system was developed using the prototyping method. This system has several features: medical record management, user management, reporting system, input checking feature for vital sign results, uploading feature for supporting examination results, and patient queuing system for each poly. The results of the user convenience test using the SEQ method obtained an average value of 6 and 7. The usability test results using the SUS method also got a good response from the questionnaire questions given to the respondents, which got a total score of 90.6, meaning that the system has an excellent usability level.

The storm that was delayed: the deterioration of an in-hospital diabetes process-of-care metric during the COVID-19 pandemic

Background/Aims Networked glucose blood monitoring has been demonstrated as a useful process of care for improving glycaemia and clinical outcomes in hospital inpatients. However, these benefits are partly reliant on the accurate entry of patients' medical record numbers by healthcare staff. This study assessed the accuracy of such data entry, comparing the periods before and after the onset of the COVID-19 pandemic. Methods This retrospective observational study analysed glucose meter medical record number entries at a large hospital in Victoria, Australia. The study period spanned from September 2019, when the networked blood glucose monitoring system was introduced, to July 2020. The proportion of inaccurate entries were presented as a percentage of the total number of entries and comparisons were made between the pre-COVID-19 and post-COVID-19 onset periods. Data were analysed using an interrupted time series methodology and presented using a Quasipoisson distribution. Results A gradual decrease in the percentage of accurate medical record number entries was observed following the introduction of the networked blood glucose monitoring system. This decline in accuracy decreased further following the onset of COVID-19, despite the hospital serving a relatively low number of patients with the virus. Conclusions The ongoing decrease in accuracy of data entry into the networked blood glucose monitoring system is thought to be a result of insufficient training and time constraints, which were exacerbated by the COVID-19 pandemic because of protocol changes and furloughed staff. It is recommended that accurate use of the networked blood glucose monitoring system is allocated more regular training in hospital wards.

LITERATURE REVIEW : PERANCANGAN TRACER DALAM PENYIMPANAN DOKUMEN REKAM MEDIS

Tracer Medical recordis a tool used to control the use of medical record documents which are usually used to replace medical record documents that come out of storage shelves. Problems that occur in the storage system are misfiles and delays in returning medical record documents anddesigns tracer that are not up to standard. The method used is a literature review to determine thedesign tracer based on aspects of size, material and color, content, pouch and request slip. It was concluded that the size used was in accordance with the standard, which was equal to or larger than the medical record, the material used was strong and brightly colored so that it was easy to search, contained the contents of the patient's name, medical record number, the purpose of the medical record or borrower and the date of discharge and there was a pocket. and the request slip on the tracer . Keywords : tracer, design, medical record Abstrak Tracer rekam medis adalah sarana yang digunakan untuk mengontrol penggunaan dokumen rekam medis yang biasanya digunakan untuk menggantikan dokumen rekam medis yang keluar dari rak penyimpanan. Permasalah yang terjadi pada sistem penyimpanan yaitu misfile dan keterlambatan pengembalian dokumen rekam medis serta rancangan tracer yang tidak sesuai standar. Metode yang digunakan adalah literature review untuk mengetahui rancangan tracer berdasarkan aspek ukuran, bahan dan warna, isi, kantong dan slip permintaan. Didapatkan kesimpulan ukuran yang digunakan sudah sesuai standar yaitu sama atau lebih besar dari rekam medis, bahan yang digunakan kuat dan berwarna mencolok agar mudah dalam pencarian, memuat isi berupa nama pasien,nomor rekam medis,tujuan rekam medis atau peminjam dan tanggal keluar serta terdapat kantong dan slip permintaan pada tracer tersebut. Kata Kunci : tracer,perancangan,rekam medis

Improving ACGME Compliance for Obstetric Anesthesiology Fellows Using an Automated Email Notification System

Background The Accreditation Council for Graduate Medical Education establishes minimum case requirements for trainees. In the subspecialty of obstetric anesthesiology, requirements for fellow participation in nonobstetric antenatal procedures pose a particular challenge due to the physical location remote from labor and delivery and frequent last-minute scheduling. Objectives In response to this challenge, we implemented an informatics-based notification system, with the aim of increasing fellow participation in nonobstetric antenatal surgeries. Methods In December 2014 an automated email notification system to inform obstetric anesthesiology fellows of scheduled nonobstetric surgeries in pregnant patients was initiated. Cases were identified via daily automated query of the preoperative evaluation database looking for structured documentation of current pregnancy. Information on flagged cases including patient medical record number, operating room location, and date and time of procedure were communicated to fellows via automated email daily. Median fellow participation in nonobstetric antenatal procedures per quarter before and after implementation were compared using an exact Wilcoxon-Mann-Whitney test due to low baseline absolute counts. The fraction of antenatal cases representing nonobstetric procedures completed by fellows before and after implementation was compared using a Fisher's exact test. Results The number of nonobstetric antenatal cases logged by fellows per quarter increased significantly following implementation, from median 0[0,1] to 3[1,6] cases/quarter (p = 0.007). Additionally, nonobstetric antenatal cases completed by fellows as a percentage of total antenatal cases completed increased from 14% in preimplementation years to 52% in postimplementation years (p < 0.001). Conclusion Through an automated email system to identify nonobstetric antenatal procedures in pregnant patients, we were able to increase the number of these cases completed by fellows during 3 years following implementation.

Abstract P118: Process Improvement for Stroke/EMS Run Sheets Available in Medical Record

Background and Purpose: When stroke patients arrive to the hospital, it is imperative to have a clear picture of what occurred during transport from home, scene or other facility. The stroke team encountered difficulties in obtaining emergency medical services (EMS) run sheets in real time. We also found that these records, even when obtained, were often not scanned into the electronic medical record (EMR). Methods: We created a plan of action with our ED Stroke Champions, which involved development of an automated system to streamline the process of the run sheet scanning into EMR. In December 2019 barcode scanning devices were purchased and placed in the ED to facilitate this process. Ongoing education of the new process was conducted via email to notify our EMS partners of these changes, as well as face to face discussions whenever possible. Laminated color copies of the visual aide were posted at the central scanner location and in the EMS room in the ED. The process was that the EMS partners would:•receive the patient’s medical record number with barcode•stop at a central scanner•send the EMS run sheet directly into the EMR This process began on December 16, 2019. Three days before, another email went out to all EMS partners describing the process with a visual aide. Laminated color copies of the visual aide were posted at the central scanner location and in the EMS room in the ED. Results: In November 2019, 20 eligible ground EMS run sheets were sent to the Medical Records department for EMR scanning. After review, 13 (65%) were found scanned into the EMR. A review of January-July 2020 showed the following eligible scanned run sheets into EMR.•January 2020, 1 out of 21 (4.5%)•February 2020, 4 out of 26 (1.5%)•March 2020, 2 out of 17 (12%)•April 2020, 5 out of 15 (33%)•May 2020, 12 out of 18 (67%)•June 2020, 7 out of 7 (100%) Conclusions: With implementation of an automated process, significant improvement has been seen in obtaining and scanning run sheets. This will lead to better decision making regarding acute treatments in stroke patients.

Charateristics of Gynecological Abnormalities and Types of Urine Diversion at Dr Soetomo Hospital, Surabaya, Indonesia, in Three-Year Period

In the case of advanced stage gynecological disorders, most patients have a disturbance in the upper urinary tract. Most patients with uterine cervical carcinoma are already in stage 3B and require urine diversion. The purpose of this study is to find and determine the profile of gynecological disorders that require urine diversion, the type of urine diversion, and urine diverted output in patients with cervical carcinoma. This descriptive analytical retrospective study was conducted at Dr. Soetomo Hospital, Surabaya, Indonesia, between 2012 and 2015. The samples of this study were all patients with gynecological disorders who underwent retrograde DJ stent procedures, underwent ureterocutaneostomy and nephrostomy at the Integrated Central Surgery Building, Dr. Soetomo Hospital, Surabaya, for three years between 2012 and 2015. Data was collected based on the medical record number of patients with gynecological disorders who underwent urine diversion procedures and were recorded in the book on the operation schedule. We find that the most common cause of gynecological abnormalities in kidney obstruction is cervical carcinoma. There are three types of urine diversions used, namely DJ stent, percutaneous nefropyelostomy, and ureterocutaneostomy, with DJ as the most commonly performed. Urine diversion can improve creatinine without being influenced by the type of diversity.

Kelebihan dan Kekurangan Penerapan Family Numbering System di Puskesmas Dinas Kesehatan Kota Surakarta

The numbering system is one of the identification systems used to distinguish one patient's medical record file from another patient. Numbering system in the Surakarta Family Health Service Area Region Health Center Region. The implementation of the numbering system is experiencing problems, if there are patients who move or live separately the Head of the Family takes longer to register the patient, because the Officer will provide a new medical record number, create a new medical record document and a new folder for the patient. The research objective is to identify the strengths and weaknesses of the implementation of the Family Numbering System. A qualitative analysis research method with a case study approach. Sample 16 health centers with saturated sampling techniques. Data collection is done by observation, interview and FGD. The results of the study are the advantages of saving storage space, ease of retrieval and return of documents, ease of access to family-based documents while the weakness of the registration time is longer in the event of separation of the head of the family or moving residence. It is recommended that policies be made for all Puskesmas if there are patients who move house or separate families, maximizing the use of tracers by adding information to the tracer including name, medical record number, date and borrower unit.AbstrakSistem penomoran merupakan salah satu sistem identifikasi yang digunakan untuk membedakan berkas rekam medis satu pasien dengan pasien yang lain. Sistem penomoran di Puskesmas Wilayah Dinas Kesehatan Surakarta Family Numbering System. Pelaksanaan sistem penomoran ini mengalami kendala yaitu jika ada pasien yang pindah tempat tinggal ataupun pisah Kepala Keluarga membutuhkan waktu yang lebih lama dalam mendaftar pasien, dikarenakan Petugas akan memberikan nomor rekam medis baru, membuat dokumen rekam medis baru dan folder yang baru untuk Pasien. Tujuan penelitian untuk mengidentifikasi kelebihan dan kelemahan penerapan Family Numbering System. Metode penelitian analisis kualitatif dengan pendekatan studi kasus. Sampel 16 puskesmas dengan tehnik sampling jenuh. Pengumpulan data dilakukan dengan observasi, wawancara dan FGD. Hasil penelitian yaitu kelebihan hemat tempat penyimpanan, kemudahan pengambilan dan pengembalian dokumen, kemudahan akses dokumen berbasis keluarga sedangkan kelemahan waktu pendaftaran lebih lama jika terjadi pisah Kepala Keluarga atau pindah tempat tinggal. Disarankan adanya penentuan kebijakan untuk semua Puskesmas jika ada pasien yang pindah rumah atau pisah KK, memaksimalkan penggunaan tracer dengan menambahkan informasi pada tracer meliputi nama, nomor rekam medis, tanggal dan unit peminjam.

FAKTOR-FAKTOR YANG MEMPENGARUHI DUPLIKASI PENOMORAN BERKAS REKAM MEDIS DI RUMAH SAKIT ADVENT MEDAN

Abstrak Rekam medis adalah berisikan cactatan dan dokumen tentang idetitas pasien , pemeriksaan, pengobatan, tindakan, dan pelayanan lain yang telah diberikan kepada pasien. Rekam medis adalah keteranan baik yang tertulis maupun yang terekam tentang identitas, anamases, pemeriksaan laboratorium, diagnosa, segala pelyanan dan tindakan medik yang di berikan kepada pasien. Penomoran berkas rekam medis yang baik merupakan salah satu kunci keberhsilan atau kebaikan suatu manajemen rekam medis dari suatu pelayanan kesehatan, tentunya didukung dengan sistem yang baik. Tujuan dari penelitian ini adalah untuk mengetahui faktor-faktor yang mempengaruhi duplikasi penomoran rekam medis di Rumah Sakit Advent Medan. Jenis penelitian ini adalah deskriptif kuantitatif dengan menggunakan metode cross sectional yang dilakukan di Rumah Sakit Advent Medan pada bulan juli 2018, Populasi dalam penelitian ini adalah 11 petugas rekam medis yang terdiri dari 7 orang petugas pendaftaran dan rawat jalan 4 orang petugas pendaftaran rawat inap, Sampel dalam penelitian ini Menggunakan total sampel, instumen penelitian yang digunakan observasi dan kuisoner, berdasarkan hasil penelitan yang dilakukan faktor yang mempengaruhi duplikasi nomor rekam medis mayoritas Pengetahuan diperoleh 54,5% dari 11 petugas rekam medis dan dengan hasil uji statistik diperoleh p=0.015<0.05. sehingga Ho ditolak artinya adanya pengaruh antara pengetahuan petugas rekam medis dengan duplikasi penomoran di Rumah Sakit Advent Medan. Minoritas sikap diperoleh 63,6% dan dengan hasil uji statistik diperoleh p=0,545%<0.05 sehingga Ho diterima artinya tidak ada pengaruh antara sikap dengan duplikasi penomoran. Dari hasil uji statistik antara pengetahuan dan sikap, terdapat pengaruh pengetahuan dengan duplikasi penomoaran di Rumah Sakit Advent, Sedangkan sikap tidak ada pengaruh dengan duplikasi penomoran di Rumah Sakit Advent. Diharapkan kepada Rumah Sakit untuk memberikan evaluasi atau pelatihan kepada petugas rekam medis dibagian pendaftaran secara berkesinambungan. Kata Kunci: Rekam medis, Faktor- faktor duplikasi No rekam medis, Sistem penomoran Abstrack Medical record is containing records and documents about patient identity, examination, treatment, actions, and other services that have been provided to patients. Medical records are written and recorded safety regarding identities, anamases, laboratory tests, diagnoses, all services and medical actions given to patients. Numbering a good medical record file is one of the keys to the success or goodness of a medical record management of a health service, of course, supported by a good system. The purpose of this study was to determine the factors that influence the duplication of medical record numbering in Medan Adventist Hospital. This type of research is quantitative descriptive using a cross sectional method conducted at Medan Adventist Hospital in July 2018, the population in this study were 11 medical record officers consisting of 7 registration and outpatient officers 4 inpatient registration officers, samples in this study Using the total sample, the research instrument used observation and questionnaire, based on the results of research conducted by factors that influence the duplication of the majority medical record number . so Ho is rejected, meaning that there is an influence between the knowledge of the medical record officer with the numbering duplication in Medan Adventist Hospital. Minority attitudes were obtained 63.6% and with statistical test results obtained p = 0.545% <0.05 so that Ho was accepted meaning that there was no influence between attitude and numbering duplication. From the results of statistical tests between knowledge and attitude, there is an influence of knowledge with duplication of numbers in Adventist Hospitals, whereas attitude has no influence with duplication of numbers in Adventist Hospitals. It is expected that hospitals will provide evaluation or training to medical records officers in the registration section on an ongoing basis.

Charateristics of Gynecological Abnormalities and Types of Urine Diversion at Dr Soetomo Hospital, Surabaya, Indonesia, in Three-Year Period

In the case of advanced stage gynecological disorders, most patients have a disturbance in the upper urinary tract. Most patients with uterine cervical carcinoma are already in stage 3B and require urine diversion. The purpose of this study is to find and determine the profile of gynecological disorders that require urine diversion, the type of urine diversion, and urine diverted output in patients with cervical carcinoma. This descriptive analytical retrospective study was conducted at Dr. Soetomo Hospital, Surabaya, Indonesia, between 2012 and 2015. The samples of this study were all patients with gynecological disorders who underwent retrograde DJ stent procedures, underwent ureterocutaneostomy and nephrostomy at the Integrated Central Surgery Building, Dr. Soetomo Hospital, Surabaya, for three years between 2012 and 2015. Data was collected based on the medical record number of patients with gynecological disorders who underwent urine diversion procedures and were recorded in the book on the operation schedule. We find that the most common cause of gynecological abnormalities in kidney obstruction is cervical carcinoma. There are three types of urine diversions used, namely DJ stent, percutaneous nefropyelostomy, and ureterocutaneostomy, with DJ as the most commonly performed. Urine diversion can improve creatinine without being influenced by the type of diversity.