Completeness Of Medication Information Research Articles

Hubungan Kelengkapan Informasi Medis Pada RM A-1, RM I-1 dan RM L-8 dengan Keakuratan Pengkodean Diagnosis Appendic Pada Rekam Medis Rawat Inap di RS. TK. III dr. Reksodiwiryo Padang Tahun 2021

Appendix is included in the 20 most diseases in Kindergarten Hospital. III Dr. Reksowidiryo Padang where there are problems in terms of completeness of medical information on RM A-1, RM I-1 and RM L-8 with the level of accuracy of coding disease diagnosis is still low. This study aims to determine the relationship between completeness of medical information and the accuracy of coding appendic diagnoses based on ICD-10 in medical records at the Kindergarten Hospital. III Dr. Reksowidiryo Padang in 2021. The type of research is correlational, the research is carried out at the Kindergarten Hospital. III Dr. Reksowidiryo Padang, the initial survey was carried out in February with field research on 18 to 22 June 2021, the total population in January-December 2021 was 110 along with a sample of 110 appendic medical record files, the study was conducted by direct observation, data analysis used namely bivariate and univariate. With the results of the study, it was found that the completeness of complete medical information was 42 (38.2%), the completeness of incomplete medical information was 68 (61.8%), the accuracy of the accurate diagnosis code was 45 (40.9%), the accuracy of the code was There were 65 (59.1%) inaccurate diagnoses, with p-value = 0.003 (p0.05), which means that there is a relationship between the completeness of medical information and the accuracy of coding for appendic diagnoses. With the results of the study, it is known that the completeness of medical information and the accuracy of the disease diagnosis code is still not good, the researchers suggest that health workers can fill in each item of the medical record sheet completely and write down the diagnosis code accurately and clearly in order to increase efforts to complete the diagnosis and completeness of the diagnosis medical information.

A Hybrid Framework based on IoT and Blockchain Network to Store the Patient Health Data

Healthcare industry constantly faces many issues such as patient data access, drug storage log, medical records, or logs these are only a few of the many problems hospitals and other medical institutions must deal with. Healthcare industry must balance patient care with information privacy, security. The healthcare industry faces major issues like, putting the patient at the center, privacy and access, completeness of medical information, cost, supply chain management, drug records. Medical record keeping has evolved into a science of itself, even though the traditional method of storing data over a centralized database can be harmful as mentioned in the sections above, it can be prone to hacking or even a single point failure. Another issue with storing medical data in these databases is that, when these databases need an update in software all the servers are temporally down until the updates are finished. This small window can lead to be very lethal as healthcare is a 24/7 work. Blockchain technology and cryptocurrencies are being touted as the “solution” to problems in many different, disparate sectors throughout multiple industries. In this paper the goal is to identify blockchain technology applications in healthcare industry by conduction a systematic literature based on which a framework will be proposed. The promise of blockchain extends into the healthcare industry allowing a transformation of the current system and its use of information technology.

The Relationship of Completeness of Medical Information with the Accuracy of Diabetes Mellitus Diagnosis Codes at X Kediri Hospital

Completeness of medical information is very supportive in determining the accuracy of the diagnosis code for each disease. The correct diagnosis code determines the value of the claim following the tariff pattern that has been determined by the insurance company. Diabetes mellitus is a disease that is in the top 10 diseases in Indonesia, so research in this field is important. The analysis of the relationship between the completeness of medical information and the accuracy of the diabetes mellitus diagnosis code is the purpose of this study. The research design used correlation analytics with the cross-sectional approach. The population consisted of 68 medical record documents with diabetes mellitus cases in January-August 2021. The research sample used the entire population, namely 68 inpatient medical record documents. The results showed that complete medical information was 39 medical record documents (57%) and incomplete was 29 medical record documents (43%). The accuracy of the correct diagnosis code for diabetes mellitus is 17 medical record documents (24%) and the incorrect code is 51 medical record documents (76%). Based on the results of the Chi-Square statistical test, the results obtained p-value = 0.023, which means p-value <0.05 so H0 is rejected, which means that there is a significant relationship between the completeness of medical information and the accuracy of the diabetes mellitus diagnosis code. As conclusion, the completeness of information in medical record influence the accuracy of diagnose, specifically in diabetes mellitus cases (p-value = 0.023) Therefore, medical record officer plays important roles for the completeness of the documents

Correlation Between Medical Information Completeness and Accuracy of The Diagnosis Code for Upper Respiratory Tract Infection and Hypertension Based on ICD-10 in Medical Record at Cibening Health Center

Background: Completeness of patient medical information in medical records is one indicator in assessing the quality of health services. Complete and accurate medical records contribute to the accuracy of medical staff in making a diagnosis so that they can determine the correct diagnosis code according to the ICD-10 guidelines. A good medical record shows that a doctor or other medical staff has carried out their duties by the demands of their profession as stated in the Medical Practice Law No.29 of 2004. Purposes: To find out there is or not a correlation between the medical information completeness and the accuracy of the diagnosis code for upper respiratory tract infection and hypertension based on the ICD-10 in the medical record documents of outpatients at the Cibening Health Center in 2019. Method: The method used in this study is observational analytic with a cross-sectional study design. The population of this study was outpatient medical records with a diagnosis of upper respiratory tract infection and hypertension at the Cibening Health Center in 2019. The sampling technique used a simple random sampling technique with a sample size of 100. Results: Out of obtained 71 complete medical record (71%) filling in medical records, 64 medical records (64%) were accurate in giving ICD-10 codes, 63 medical records (88.7%) with complete medical information had accurate diagnosis codes in comparison with 8 medical records (11.3%) which were complete but inaccurate diagnosis code. Conclusion: With a p-value of 0.000, there is a significant correlation between the completeness of medical information and the accuracy of the diagnosis code for Upper Respiratory Tract Infection and Hypertension based on ICD-10.

The satisfaction regarding handovers between ambulance and emergency department nurses: an observational study

BackgroundA thorough handover in the emergency department (ED) is of great importance for improving the quality and safety in the chain of care. The satisfaction of handover may reflect the quality of handover. Research to discover the variables influencing the satisfaction of handovers is scarce. The goal of this study was to determine the factors influencing the satisfaction regarding handovers from ambulance and ED nurses.MethodsWe performed a prospective observational study in the University Medical Center of Groningen. Data regarding prehospital-hospital handovers has been collected by observing handovers and assessing patient chart information. Data regarding the satisfaction has been collected with a questionnaire including a 5-point scale for the level of satisfaction.ResultsIn total, 97 handovers were observed and 97 ambulance nurses and 89 ED nurses completed the questionnaire. The satisfaction of ambulance nurses showed a negative correlation with the waiting time prior to handover (r = −.287, p = .004) and a positive correlation with the presence of a physician in the receiving team (r = .224, p = .028). The satisfaction of ED nurses showed a positive correlation with the use of the ABCDE (r = .288, p = .006) and AMPLE instrument (r = .208, p = .050).ConclusionThe satisfaction of ambulance and ED nurses as sender or receiver of the handover is determined by different factors. The satisfaction of ambulance nurses is mainly affected by the waiting time and presence of a physician, while the satisfaction of ED nurses is affected by the use of handover instruments and the completeness of medical information.

Do electronic discharge summaries contain more complete medication information? A retrospective analysis of paper versus electronic discharge summaries.

Complete, accurate and timely hospital discharge summaries are important for continuity of care. The aim of this study was to evaluate the effectiveness of an electronic discharge summary system in improving the medication information provided compared to the information in paper discharge summaries. We conducted a retrospective audit of 199 paper and 200 electronic discharge summaries from a 350-bed teaching hospital in Sydney, Australia. The completeness of medication information, and whether medication changes during the admission were explained, were assessed. Further, the likelihood of any incomplete information having an impact on continuity of care was assessed. There were 1352 and 1771 medication orders assessed in paper and electronic discharge summaries, respectively. Of these, 90.9% and 93.4% were complete in paper and electronic discharge summaries, respectively. The dose (OR 25.24, 95%CI: 3.41-186.9) and route (OR 8.65, 95%CI: 3.46-21.59) fields of medication orders, were more likely to be complete in electronic as compared with paper discharge summaries. There was no difference for drug frequency (OR 1.09, 95%CI: 0.77-1.55). There was no significant improvement in the proportion of incomplete medication orders rated as unclear and likely to impede continuity of care in paper compared with electronic discharge summaries (7.3% vs. 6.5%). Of changes to medication regimen, only medication additions were more likely to be explained in the electronic (n=253, 37.2%) compared to paper (n=104, 14.3%) discharge summaries (OR 3.14; 95%CI: 2.20-4.18). In summary, electronic discharge summaries offer some improvements over paper discharge summaries in terms of the quality of medication information documented. However, explanations of changes to medication regimens remained low, despite this being crucial information. Future efforts should focus on including the rationale for changes to medication regimens in discharge summaries.

Staff Burnout and Patient Satisfaction With the Quality of Dialysis Care

Although there has been increasing interest in assessing patient satisfaction with health care during the past year, relatively few studies investigated hemodialyzed patient satisfaction. Cross-sectional study of the relationship between burnout in nephrologists and nurses and patient satisfaction with their care. Nephrologists (n = 68), nurses (n = 334), and hemodialyzed patients (n = 695) from 10 dialysis centers across northern Italy. Staff burnout was assessed using the Maslach Burnout Inventory. Three staff burnout subscales were developed by using factor analysis: Emotional Exhaustion, Depersonalization, and Personal Accomplishment. Patient satisfaction was assessed by means of a multichoice questionnaire that incorporated 4 patient satisfaction dimensions: (1) completeness of medical information, (2) emotional relationship with health care staff, (3) performance of dialysis center staff, and (4) organizational aspects of health care service. Each item was scored on a 4-point scale ranging from 1 (very dissatisfied) to 4 (very satisfied). Spearman rank-order correlation was used to examine relationships between patient satisfaction and each of the 3 staff burnout subscales for each dialysis center. Overall, burnout scores were lower than the Italian normative sample, with no significant differences between physicians and nurses. However, considering each dialysis center separately, in 2 centers, nurses registered higher emotional exhaustion levels compared with physicians, with statistically significant differences (P = 0.004 and P = 0.003, respectively). Analysis of patient overall satisfaction assessments showed general appreciation for the "courtesy" and "kindness" of staff, but evidence of problems regarding organizational aspects and structural factors. However, the most critical dimension was for "information." There was a significant positive correlation between staff personal accomplishment and client satisfaction (P < 0.01) and a significant negative correlation between staff emotional exhaustion and patient satisfaction (P < 0.01). No significant correlation was found between staff depersonalization and patient satisfaction level. Factor analysis should be considered exploratory and confirmed in future use of the questionnaire. Our results suggest that high levels of burnout in physicians and nurses are associated with poor patient satisfaction in dialysis units. Identifying and preventing staff burnout may increase patient satisfaction with health care.