Study of Incompleteness Medical Records of Inpatient in Appendicitis Cases at Dr. Reksodiwiryo Hospital Padang

Background: Incomplete filling of medical record files for inpatients at Dr. Reksodiwiryo hospital medical records will be describe health services and the quality of medical record services. Medical record quality services include the completeness of medical record files, accuracy in providing diagnosis and diagnosis codes, as well as speed in providing service information. The requirements for quality medical records must be accurate, complete, reliable, valid, timely, usable, common, comparable, guaranteed, and easy.Methods: This research method is a descriptive with a retrospective approach or looking at existing data. This study was carried out in September 2021. The population was 70 files cases of inpatient digestive surgery. Samples were taken from 27 files of inpatients with appendicitis cases.Results: From the research that has been done, the highest percentage of incomplete identification components is found on the gender item about 81.48%, the highest percentage of incomplete important report components is obtained on the medical resume and informed consent items about 11.1%. The highest percentage of incomplete authentication components was obtained in the nursing degree about 96.3%. The highest percentage of the components of the recording method was obtained by 59.3%, there are several blank sections about 16 files. The percentage of incomplete diagnostic codes and procedures is 100% Conclusions: the researcher suggested that the hospital can have an Operational Standart on filling out the completeness of medical records files

Electronic Medical Record as Literature Study

Background: Medical records can be created manually or electronically. In the world of health, the development of information and communication technology is currently affecting health care services as a whole, including the implementation of electronic medical records. The application of electronic medical records must go through a careful planning stage, this is because electronic medical records involve many parties in health facilities and and require a lot of costs. For this reason, a comprehensive study of electronic medical records is needed. One way is to conduct a literature study of several articles related to the electronic medical record.Methods: In conducting this research, the literature review method was used, where the search for articles was not carried out systematically, but the scientific journal articles reviewed were selected by the researcher on one research topic, and selected based on the knowledge and experience possessed by the researcher (traditional review).Results: In this study, 7 articles were reviewed related to electronic medical records. There are some similarities in terms of benefits or obstacles in the application of electronic medical records in health facilities. Among the benefits of electronic medical records are the efficiency of using paper/medical record files, efficiency in the use of space/storage media, time efficiency in searching data and distributing medical record data, efficiency of human resources in finding medical record files and being able to detect errors in data entry. While some of the common obstacles to implementing electronic medical records in health facilities are the unpreparedness of officers at health facilities, so it takes time for socialization and training of human resources, problems with the network, lack of IT resources at health facilities that specifically handle electronic medical records, high implementation costs. expensive (hardware software) and there is no legal umbrella.Conclusions: There is a need for comprehensive research using the semantic review method of articles related to electronic medical records, so that the results can be used as a reference for health facilities in implementing electronic medical records. Thus, it is hoped that the migration and implementation process from manual medical records to electronic medical records can be carried out as expected.

Accuracy and Validity Outpatient Diagnosis Code Base On ICD-10 at Imogiri I Health Center Bantul Yogyakarta

Background: Analysis of accuracy and validity fill code diagnosis on medical record document is very important because if diagnosis code is not appropriate with ICD-10, will cause decline in quality services health center, generated data have this validation data level is low, because accuracy code very important for health center such as index process and statistical report, as basis for making outpatient morbidity report and top ten diseases reports, as well as influencing policies will be taken by primary health center management. This study aims to analyze accuracy and validity diagnosis disease code based on ICD-10 fourth quarter in 2020 Imogiri I Health Center Bantul.Methods: Descriptive qualitative approach, case study design. Subject is a doctor, nurse, head record medical and staff. Object is outpatients medical record document in Imogiri I Health Center Bantul. Total sample 99 medical record file. Obtaining data from this study through interviews and observations.Results: Number of complete accurate diagnosis codes is 60 (60,6%), incomplete accurate diagnosis codes is 26 (26.3%) and inaccurate diagnosis codes is 13 (13.1%). Inaccuracies include errors in determining code, errors in determining 4th character ICD-10 code, not adding 4th and 5th characters, not including external cause, and multiple diseases.Conclusions: Inaccuracy factors are not competence medical record staff, incomplete diagnosis writing and no training, no evaluation or coding audit has been carried out, and standard operational procedure is not socialized.

Risk Factor Identification Occupational Health and Safety Medical Record Officer Filing Section in Hospital (Literature Review)

Background: Filing service is one of the medical record work units that responsible for the storage and maintenance of medical record files. Filing is one of the work units in medical records that are responsible for the storage and maintenance of medical record files. The work implementation process has risks that can threaten the safety and health of officers. Therefore, it can result in low quality of work. An attempt that can be performed to decrease the risk of accident is the implementation of good Occupational Health and Safety. Through several studies related to Occupational Health and Safety in Filing Unit, some of the factors causing work accidents are physical, chemical, biological, biomechanical factors related to ergonomics, individuals, and psychosocial, which causes the officers to feel unsafe and uncomfortable at work. Therefore, this study aims to identify what are the risk factors for occupational health and safety to medical record officers in the filing section at the hospital.Methods: The research method was qualitative research. The data collection used a literature study. The subjects of the study were medical record officers in the filing section, while the object of the study was occupational health and safety.Results: The results of the study, according to 10 journals reviewed, show that factors that become the risk to occupational health and safety of medical record officers in the filling section are lighting, air temperature, smells caused by old medical record files, virus exposure, medical record storage rack, awareness of using PPE, and work relationship between officers.Conclusions: It is expected that the hospital can improve work facilities and infrastructures, and the self-awareness of medical record officers to maintain safety and comfort at work is required so that a good and optimal working atmosphere can be created.

The Completeness and Accuracy of Hepatoma Coding for Medical Procedure Based on ICD-9 CM at Public Hospital in Padang

Background: Hepatoma or hepatocellular carcinoma (KHS) is a primary malignant tumor of the liver originating from hepatocytes and the 3rd cause of death from cancer in the world. The history of a hepatoma patient can be seen based on the patient's medical record. The filling of medical record is done by doctors, nurses and medical record personel. However, in medical record filling, incompleteness is often found and cause inaccurate information. Accuracy coding important for financial of hospital.Methods: Type of research is quantitative descriptive, which is to determine the completeness and accuracy of the medical records for hepatoma cases and procedure code using criteria for document quantitative analysis in a public hospital, Padang. The study design used a retrospective analytical approach. The variables in the study were completeness of discharge summary and accuracy of hepatoma procedure based on ICD-9 CM. The population in this study were inpatient medical record documents for Hepatoma cases at a public hospital, Padang from June to August 2019, which were 45 medical record documents (discharge summary form) of hepatoma inpatients.Results: From 45 hepatoma patient medical record documents, filling of item name, medical record number, date of admission, indication of the patient being treated, history, physical examination, diagnostic examination, procedures, medications given, medicines used at home, PPBS doctor's signature, DPJP doctor's hand is complete 100% . Highest incompleteness of filling was found at code ICD (47%) and address item (43%). From 45 discharge summary , accuracy procedure code at hepatome case shows 100 % accurate in ultrasonoggrafi abdomen and ultrasonografi thorax. While that EKG 98% accurate and 95 % rontgen thorax.Conclusions: In general, item data of discahrege summary for hepatoma medical record are completenes; highest incompleteness of filling was found at code ICD (47%) and address item (43%); Accuracy of code procedure more than 90% in each code procedure.

PREVALENCE OF DIABETES MELLITUS WITH PULMONARY TUBERCULOSIS IN DR. SOETOMO GENERAL ACADEMIC HOSPITAL, SURABAYA, INDONESIA 2016

Highlight:1. The signs and symptoms of patients with pulmonary tuberculosis and those of diabetes mellitus were similar.2. Male, aged 51-75 years old, and working in private sector are characteristics of most of the diabetic patients with pulmonary tuberculosis.Abstract:Background: Diabetes Mellitus is a type of disorder where the patients’ blood sugar is above average. Diabetes Mellitus can cause an abundance of comorbidities, from viral infection until metabolic abnormalities. The increased risk of infections is mostly because diabetes mellitus changes how the body works. The changes range from changes in mechanical barriers (humoral immunity) and cellular changes (cellular immunity), the changes of the humoral immunity that can increase the chance of protracting pulmonary tuberculosis. Objective: The purpose of this study was to describe the characteristics of diabetes mellitus in pulmonary tuberculosis in Dr. Soetomo General Academic Hospital, Surabaya, Indonesia from January to December 2016. Materials and Methods: The research method used was an observational study using a cross-sectional design conducted in Central Medical Record for hospitalized patients, Dr. Soetomo General Academic Hospital, Surabaya, Indonesia. The diabetes mellitus patients’ data collected from the medical records of Dr. Soetomo General Academic Hospital, Surabaya, Indonesia in 2016 were 1,410 and 11 of them were also diagnosed with pulmonary tuberculosis. The final data taken were from 67 out of 115 patients due to the incomplete medical record. Results: According to the data, the most of the diabetic patients with pulmonary tuberculosis were male, age of 51-75 years old, and worked in private sector. Conclusion: There was a significantly higher number of diabetes mellitus with pulmonary tuberculosis patients in older age, males, and private-sector workers. Diabetic patients with pulmonary t

A Metaphoric Design of Electronic Medical Record (EMR) for Periodic Health Examination Reports

The exponential growth of big data demands an efficient knowledge discovery. The electronic medical records of patients on medical data Clouds contain implicit medical information. Although the periodic health examination (PHE) reports describing a set of screening tests for healthy individuals performed periodically, common individuals require the assistance of an expert to interpret the results for a medical opinion. This research study proposes a metaphoric design of Electronic Medical Record (EMR) for PHE reports of patients. The outcomes of this study glimpses useful findings for the common people in the self-interpretation of their medical reports. Besides, among a variety of solutions, the study uses the metaphoric representation to convert the numerical data and medical terminology to familiar graphic representations from real life. The study identifies the detailed requirements to propose a conceptual architecture for metaphoric EMR reports. The future work will result in a prototype design, evaluation, and refinement of metaphors based on stakeholders' feedback.