patient medical record
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2021 ◽  
Vol 5 (2) ◽  
pp. 157-166
Author(s):  
Muhammad Khairul Faridi ◽  
◽  
Imam Riadi ◽  
Yudi Prayudi ◽  
◽  
...  

The Hospital Management Information System (SIMRS) functions as a medium for hospital information and hospital management. There are patient medical record data, which is the result of interactions between doctors and sufferer. Medical records are sensitive data so that the security of the hospital management information system needs to be improved to convince users or patients that the data stored on SIMRS is safe at attackers. There are several ways to improve system security, one of which is by threat modeling. Threat modeling aims to identify vulnerabilities and threats that exist in SIMRS. In this paper, threat modeling will use the STRIDE-model. The recognition with the STRIDE-model will then be analyzed and sorted according to the modeling with the STRIDE method. After the analysis is complete, it will be calculated and given a rating based on the DREAD method's assessment. The STRIDE method's results show that there are several threats identified, such as there is one threat on the user side, the webserver is five threats, and the database is three threats. The level of the threat varies from the lowest-level (LowL) to the highest-level (HiL). Based on the threat level, it can be a guide and sequence in improving and improving the security system at SIMRS, starting from the LowL to the HiL.


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.


2021 ◽  
Vol 6 (2) ◽  
pp. 183-188
Author(s):  
Erlindai Purba ◽  
Hesty Afriani Sidabutar

The Imelda Workers General Hospital of Indonesia does not yet have specific routines regarding the release of medical record information to third parties. however, they have used regular procedures for providing information and borrowing medical records in general, This study aims to determine the number of requests for medical record information. This type of research is descriptive, namely the research method carried out with the aim of making an objective state. The population was 4 people and the sample size was 4 people as the total sampling with the research methodology using quantitative methods. How to collect data by interview and observation. The results showed that the services of the Imelda Hospital for Indonesian Workers in Medan according to legalized death certificates amounted to 34 percent (0.56%), claims for raharja services amounted to 56 percent (0.92%), audits and insurance claims were 69 percent (1.14%) , research or education as much as 54 percent (0.89), post mortem as much as 28 percent (0.46%), BPJS as much as 5,790 percent (99.00%). Based on the results of the study, it is known that knowing the data on the number of requests for medical record information in January-June 2020 is 6,224 with a percentage (99.97%). As well as the absence of a special SPO on procedures and utilization of medical record information of deceased patients, however, they have used the permanent procedure of providing information and borrowing medical records in general. It is recommended that hospitals and medical record officers provide regular training or coaching to officers. And to health workers, especially medical records, in order to maintain the confidentiality of patient medical record information and carry out the established procedures properly.                   


2021 ◽  
Vol 38 (4) ◽  
pp. 70-75
Author(s):  
A. A. Rykhlevich

Objective. To study the detection of potentially malignant diseases of the oral cavity in the provision of dental care in outpatient settings Methods. The analysis of the reporting form 039-2/y-88 for 20112020 and medical records of 2400 patients who received dental care on an outpatient basis was carried out. Results. Over the past 10 years, the proportion of people who underwent treatment of the oral mucosa has decreased, relative to the total number of admitted patients and the number of primary patients. Potentially malignant diseases of the oral cavity were diagnosed on an outpatient basis in 7.5 % of cases: leukoplakia 1.75 %, erythroplakia 0.4 %, lichen planus 1.25 %, candidiasis 4.7 %. In 65.5 % of the out-patient medical record issued for the treatment and extraction of teeth, there is no description of the oral mucosa, in 26.8 % a description of the normal state is given, in 7.7 % it is indicated that there are changes in the oral mucosa, of which 5.3 % of the changes are described with varying degrees of detail. At the same time, complaints of burning, pain in the mouth when eating and talking are present in 19.5 % of the out-patient medical record issued during the treatment and removal of teeth. Conclusions. The frequency of diagnosing potentially malignant diseases of the oral cavity in the provision of dental care in outpatient settings is lower than the data of Russian epidemiological studies. Dentists in outpatient settings do not pay due attention to the condition of the oral mucosa.


2021 ◽  
Vol 12 (03) ◽  
pp. 479-483
Author(s):  
Holly B. Ende ◽  
Michael G. Richardson ◽  
Brandon M. Lopez ◽  
Jonathan P. Wanderer

Abstract 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.


2021 ◽  
Vol 6 (1) ◽  
pp. 139
Author(s):  
Sudjiran Sudjiran ◽  
Akbar Syahbanta Limbong

Along with the development of technology, the speed of data processing is needed in order to compete with competitors. A company must have an advantage over other companies if it does not want to lose in the competition. MRCCC Siloam Semanggi is a company that provides health services for cancer patients. One of the transaction processes within the hospital is sensing data in the form of images of patient data. Image data processing activities at this hospital are not yet structured and require a database in order to assist in fast data processing. This study aims to create an image transfer system to transfer physical documents into digital documents. This system is useful for hospital employees to be able to find documents easily for certain purposes, the system is made web-based using XAMPP, using PHP language with MySQL database. The results of the analysis of research that has been done, there are problems that arise related to the retention system in hospital patient data. Retention data collection activities are usually carried out by sorting out patient medical record documents from those not recorded on a computer.


2021 ◽  
Vol 6 (01) ◽  
pp. 8-12
Author(s):  
Salasiah Salasiah ◽  
Afrinal Afrinal

The Puskesmas is a functional health organization which is the center for community health development and fostering community participation. Existing services at the puskesmas must be carried out properly and correctly in order to simplify and speed up the flow of services, a medical record data processing information system is very appropriate to simplify existing services at the puskesmas. This study aims to produce a patient medical record information system at Tambarangan Public Health Center. This system is built on a web-based basis using the CodeIgniter framework and will be developed using the waterfall medote.


Author(s):  
Zulham Andi Ritonga ◽  
Hasran Ependi Lubis

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


2021 ◽  
Vol 3 (2) ◽  
pp. 70-83
Author(s):  
Hendra Djuhendi ◽  
Popon Popon

Background: Individuals with aphasia experience speech, listening and writing disorders although they do not affect intelligence due to brain damage which contains language, usually on the left side of the left cerebral hemisphere. Aphasia cases can be handled by semantic divergent methods. Objective: This study aims to determine the treatment of adult aphasia patients who have impaired word discovery, compose sentences that sometimes express them not using the correct sentence structure, using the semantic divergent method. There were also some patients who experienced disturbances in the relationship between thought processes and language; the inability to turn thoughts into sentences. This study was conducted on a female patient with Global Aphasia Post Stroke aged 84 years at the Cibabat Regional General Hospital, Cimahi. Methods: The research method used is experimental case study research which aims to determine the condition of the subject before and after intervention or therapy. Data collection was carried out through the WOTS stage, namely interviews with the client's parents, direct observation of clients, conducting tests on clients, and study of patient medical record documents. Conclusion: The results showed that after 20 sessions of therapy, the ability to designate the patient's noun level increased where the initial test scored 0 points and the final test scored 8 points with a success percentage of 80% of the maximum 10 points get tested. Based on these results it can be concluded that the application of total communication methods in global aphasia patients is successful.


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