THE MANAGEMENT OF MEDICAL REPORT COMPLETENESS FOR THE LEGALITY OF MEDICAL RECORD DOCUMENTS AT RSUD KRMT WONGSONEGORO (RSWN) SEMARANG CITY

ABSTRACTBackground: Quality hospital services is reflected in the achieving of medical records. Improper medical record documentation would negatively affect the quality of service delivered to patients and it would disadvantage the hospital when medical disputes occur.Objective:Analyzing the management of medical record completeness at RSWN to guarantee the legality of medical record documents and its effect in supporting the completeness of medical record documents.Method:In this qualitative research, observation and interviews were conducted to 60 PJRM officers in the Arimbi ward, Banowati, Nakula I and Prabukresna. The obtained data were qualitatively and quantitatively analyzed based on several underlying theories.Results:The results showed that the completeness of some aspects includinghuman, money, method, material and machine elements was proper. The quantitative analysis showed 100%, while the qualitative analysis showed a percentage of 100% with the exception on the informed consent component with the potential for loss of 99%.Conclusions:The human element required periodic outreach to PPA. In the machine element, special computerswere needed for PJRM officers, and the importance of informed consent for patients undergoing hemodialysis to obtain medical records with strong legal force. Key Words :Management, Medical Record Completeness, Legality of Medical Records.

Impact of Patient Load on the Quality of Electronic Medical Record Documentation

Objective: American College of Graduate Medical Education (ACGME) recommends ongoing care of 10 patients per resident however its implication is unclear. We hypothesized EMR quality to vary based on patient load and call status. Methods: We conducted a double-blind, single-center, retrospective observational study between 2017 and 2019 to investigate the quality and accuracy of resident documentation using the Responsible Electronic Documentation (RED) Checklist, a validated scoring system. Results: A total of 234 independent charts were analyzed and 80 met scoring criteria. Average patients per residents was 4, 9.1, 7.2, and 5.5 on “call” day (D0), “post-call” day (D1), “mid-call” day (D2), and “pre-call” day (D3), respectively. Mean RED checklist scores were 68.1%, 57%, 68.6%, and 72.1% on the above call status. The difference in score between D3 and D1 was statistically significant ( P = .00042). There was a negative correlation between score and number of patients per resident ( r = −0.286, P = .010). Conclusion: EMR documentation quality is directly impacted by patient load and resident call status with the lowest documentation quality on post-call day, correlating with patient load.

Analysis of Nursing Documentation Implementation In Outpatient Room

The quality of nursing care is a key element of service quality in hospitals. To realize good quality nursing service and quality in the Outpatient Institution, qualified human resources are also needed and good nursing management skills are needed from a manager or head of the service unit. For the implementation of nursing care documentation in outpatient installations to be carried out optimally, it is necessary to carry out management activities in the form of supervision by carrying out nursing support activities in stages. The purpose of this analysis is to determine the implementation of outpatient nursing medical record documentation. The use of action methods in this analysis aims to develop new skills or new approaches and be applied directly and reviewed the results. From the results of the assessment found several nursing management problems and the priority is the completeness of outpatient nursing medical record documentation which is still low. The action taken is by providing refresher activities or material refreshing on nursing documentation, initial assessment of outpatients, simulations of filling out initial outpatient assessment documentation, making and disseminating supervision forms and techniques for tiered supervision using the supervision form. The activity was attended by 23 participants consisting of the head of the room, the team leader and the nurse executing from the polyclinic or outpatient installation. Evaluation after carrying out activities on the completeness of outpatient nursing medical record documentation was 70% (14 of 20 samples).

The Factors Militating Against Effective Medical Record Documentation. A Case Study of Ekiti State University Teaching Hospital Ado Ekiti

It has been recognized that effective medical record documentation is affected by prevailing factors militating against health institutions in Nigeria. The Ekiti State University teaching Hospital has track record of competent Health Information officers who utilize different documentation methods, the methods in use are assessed while also identifying the problems or factors militating effective documentation in the EKSUTH. . The sampling technique employed was a random sampling which is a sub-group of people chosen by chance in a way that everyone has the chance of being selected. Thirty questionnaires was distributed and retrieved personally. From the data collected it revealed that the Major factor militating against effective MRD in EKSUTH is inadequate resources, funding while also revealing complaints on non-legibility of physicians handwriting, lack of skilled personnel among others. Based on the findings of this research work, it was concluded that inadequate funding and resources is the main factor militating against effective MRD in EKSUTH. Government should make provision for more facilities and electronic medical record equipment to enhance efficient MRD while also making effort to employ more Health Information professionals to further boost effective MRD in EKSUTH.