Medical Record Management Research Articles

\u201cWhat do you mean I can\u2019t have a doctor? this is Canada!\u201d \u2013 a qualitative study of the myriad consequences for unattached patients awaiting primary care attachment

BackgroundPatient access to primary healthcare (PHC) is the foundation of a strong healthcare system and healthy populations. Attachment to a regular PHC provider, a key to healthcare access, has seen a decline in some jurisdictions. This study explored the consequences of unattachment from a patient perspective, an under-studied phenomenon to date.MethodsA realist-informed qualitative study was conducted with unattached patients in Nova Scotia, Canada. Semi-structured interviews with nine participants were conducted and transcribed for analysis. The framework method was used to carry out analysis, which was guided by Donabedian’s model of assessing healthcare access and quality.ResultsFive key findings were noted in this study: 1) Participants experienced a range of consequences from not having a regular PHC provider. Participants used creative strategies to 2) attempt to gain attachment to a regular PHC provider, and, to 3) address their health needs in the absence of a regular PHC provider. 4) Participants experienced negative feelings about themselves and the healthcare system, and 5) stress related to the consequences and added work of being unattached and lost care.ConclusionsUnattached patients experienced a burden of care related to lost care and managing their own health and related information, due to the download of medical record management and system navigation to them. These findings may underestimate the consequences for further at-risk populations who would not have been included in our recruitment. This may result in poorer health outcomes, which could be mitigated by interventions at the structural level, such as enhanced centralized waitlists to promote attachment. Such waitlists may benefit from a triage approach to appropriately attach patients based on need.

Studying Students' Knowledge of the Benefits, Challenges, and Applications of Big Data Analytics in Healthcare

The purpose of this study was to evaluate the students' familiarity from different universities of Mashhad with the benefits, applications and challenges of Big Data analysis. This is a cross-sectional study that was conducted on students of different fields, including Medical Engineering, Medical Informatics, Medical Records and Health Information Management in Mashhad-Iran. A questionnaire was designed. The designed questionnaire evaluated the opinion of students regarding benefits, challenges and applications of Big Data analytics. 200 students participated and participants' opinions were evaluated descriptively and analytically. Most students were between 20 and 30 years old. 43.5% had no work experience. Current and previous field of study of most of the students were HIT, HIM, and Medical Records. Most of the participants in this study were undergraduates. 61.5% were economically active, 54.5% were exposed to Big Data. The mean scores of participants in benefits, applications, and challenges section were 3.71, 3.68, and 3.71, respectively, and process management was significant in different age groups (p=0.046), information, modelling, research, and health informatics across different fields of studies were significant (p=0.015, 0.033, 0.001, 0.024) Information and research were significantly different between groups (p=0.043 and 0.019), research in groups with / without economic activity was significant (p= 0.017) and information in exposed / non-exposed to Big Data groups was significant (p=0.02). Despite the importance and benefits of Big Data analytics, students' lack of familiarity with the necessity and importance is significant. The field of study and level of study does not appear to have an effect on the degree of knowledge of individuals regarding Big Data analysis. The design of technical training courses in this field may increase the level of knowledge of individuals regarding Big Data analysis.

Analysis of Prescription Medication Rules of Traditional Chinese Medicine for Diabetes Treatment Based on Data Mining.

In this study, we have used TCM medical record management platform and SAS statistical software to analyze the cases of a professor in the treatment of type 2 diabetes, in order to explore the medication rules for the treatment of type 2 diabetes, so as to enrich and optimize the diagnosis and treatment plan for type 2 diabetes based on the experience of famous doctors. Chinese medicine treatment provides more diagnosis and treatment ideas. We have collected the professor's treatment of type 2 diabetes, screened out 100 patients, from a total of 285 prescriptions, and entered them into the TCM medical record management platform. We used the TCM medical record management platform and SAS statistical software to analyze his professor's experience in the treatment of type 2 diabetes. The medication analysis is as follows: (1) frequency of medication: 285 cases that met the inclusion criteria used a total of 187 traditional Chinese medicines. Among them, Salvia miltiorrhiza was used most frequently; (2) drug frequency analysis: 285 cases met the inclusion criteria, and the four Qi were mainly cold and warm medicines. The five flavors are mainly sweet, bitter, and pungent drugs. The main meridians are the liver, spleen, and kidney; (3) drug efficacy and classification analysis: 285 cases met the inclusion criteria, and 285 cases met the inclusion criteria and the Chinese medicines involved are the most common medicines used for tonic, heat clearing, blood circulation, and stasis; (4) clustering of medications: 35 Chinese medicines with medication frequency ≥20% are divided into 11 categories. (5) Using the improved Apriori algorithm, the minimum confidence level is selected to be 0.5, data mining is conducted on all type 2 diabetes cases, and a total of 21 recipes are dug out involving 10 Chinese medicines. In this study, with the aid of the TCM medical record management platform and SAS statistical software, cluster analysis, improved Apriori algorithm, and other data mining methods were used to systematically and objectively analyze the professor's treatment of type 2 diabetes cases. The results have clinical significance and can be used for traditional Chinese medicine treatment of type 2 diabetes, which provides an objective basis and provides a certain reference for the current inheritance of traditional Chinese medical experience and summary research.

Analisi Kinerja Pegawai di Bagian Rekam Medis Rumah Sakit Umum Haji Medan

Management of medical record s in hospitals is to support the achievement of orderly administration in order to achieve the hospitals goals, namely improving the quality of health services that are affective and efficient in hopitals. Therefore, in the organization of medical records in every hospital. The sick must be admitted to the new general issued by the ministry of health and management. Medical records technically created by the hospital. The purpose of this research is to see. Employe performance in the medical records secition of the General Hospita Haji Medan. This research method used with indepth interviews, observation, documentation and data triangulations. Interview informants consist of medical record officers, doctors and nurses. From the research results, several files the medical records is not completely files in by the doctor, this causes the medical record file to the medical record unit.

Penerimaan Pengguna Terhadap Sistem Informasi Manajemen Rekam Medis (SIMRM) Di RSUD Tebet Jakarta Selatan Tahun 2021

Rumah Sakit Umum Daerah Tebet, South Jakarta, has been using a computerized management information system for medical record services called the Hospital Information System (HIS) since 2017. The presence of the Medical Record Management Information System (SIMRM) at the Rumah Sakit Umum Daerah Tebet, has brought many influences to services. Along with the implementation of SIMRM, it is necessary to assess whether the system is running properly and has been accepted by its users, in this case the medical record officer. The research method used The research method that the researcher uses is a quantitative descriptive method using the Technology Acceptance Model (TAM) to assess the perception of technology users as seen from 5 constructs, namely perceived ease of use, perceived usefulness. , perceptions of attitudes toward using, behavioral intention to use and actual usage by distributing questionnaires to 16 respondents consisting of 7 medical record unit officers and 9 registration unit officers. The results showed that the average user acceptance of SIMRM in South Jakarta Hospital as seen from the 5 TAM constructs was 75% received and 25% did not receive which means SIMRM was received by the user. It is recommended for the hospital to conduct socialization and training in accordance with the needs of officers.

The development of Future Health Today: piloting a new platform for identification and management of chronic disease in general practice.

Chronic disease identification and management is a significant issue in Australia, with general practice being the primary contact point for those at risk of, or living with, chronic disease. However, there is a well-described gap between guideline recommendations for chronic disease management and translation in the general practice setting. In 2018, a group of researchers, clinicians and software developers collaborated to develop a tool to support the identification and management of chronic disease in general practice, with the aim to create a platform that met the needs of general practice. The co-design process drew together core principles and expectations for the establishment of a technological platform, called Future Health Today (FHT), which would sit alongside the electronic medical record (EMR) management system within general practice. FHT used algorithms applied to EMR data to identify patients with, or at risk of, chronic disease and requiring review. Using chronic kidney disease as a clinical focus, the FHT prototype was piloted in a large, metropolitan general practice, and a large regional general practice. Based on user feedback, the prototype was further developed and improved. This paper provides a report on the key features and functionalities that participants identified and implemented in practice.

Blockchain technology for efficient data management in healthcare system: Opportunity, challenges and future perspectives

The healthcare data management system faces critical challenges related to data transparency, traceability, immutability, auditing, secure data provenance, and trust. This study aimed to provide a prospective overview of how blockchain technology can efficiently improve medical record management. Blockchain technology, an emerging and disruptive decentralized technology, is poised to impact the way data is handled in the healthcare industry significantly. As a result of this technology, we can fill out a patient's medical record efficiently and validated. Blockchain helps form a single network in which different organizations can safely share their records by forming a chain by linking it privately to store records like radiographic or different images. Blockchain-based digital platforms allow patients to interact with their data providers, including healthcare providers, in a seamless, fast and simple way. Numerous open research challenges, which we identify and explore, are inhibiting the successful implementation of blockchain in the healthcare sector. In this chapter, we have discussed the way that Electronic Medical Records is managed by blockchain, and this novel technology can be used in creating an efficient as well as interoperation infrastructure that helps in maintaining the record of patients that deals in improving the healthcare outcomes at the same time it also maintains its integrity and privacy of the essential data. We also discuss both existing and recent developments of management data in healthcare based on the blockchain model. We highlight the primary benefits of implementing blockchain technology, as well as the potential for healthcare companies. We highlight a range of healthcare applications have been demonstrated using recent research and case studies. The present study identifies and explains several outstanding issues that slow the adoption of blockchain technology in health care. Finally, we propose many more research topics for discussion and investigation.

AN APPROACH TOWARD STANDARDIZATION OF EMR WITH EFFICIENT ACCESSIBILITY OF DATA ON DEMAND

Among the most often discussed topics in the healthcare industry are medical terminology standardization and the establishment of a centralized electronic medical record (EMR). There is a wide range of information in patient master records and treatment statistics records, as well as a dynamic data structure. Over time, the number of records has increased at a rapid rate, resulting in a large volume of data that necessitated the implementation of a structured data base management system. Even while data science and analytics have the potential to alleviate the problem of data management, the lack of confidence in cloud-based data storage may become a big issue in the future. For improved storage management, these records may be preserved, and they may be replicated over different clouds or maintained in a distributed way for increased security and reliability. Medical data generated by wearable medical devices or portable devices used by home care patients, on the other hand, may be connected to several cloud servers in order to improve accessibility and security. For data accessibility and security, the proposed system will build a generic medical record management system that will be deployed across various clouds. It will also design a Body Area Network (BAN) architecture that will be connected to a distributed cloud

Tata Letak Ruang Unit Kerja Rekam Medis Di RSUD Dr.H.Moch Ansari Saleh Banjarmasin

Spatial planning is the arrangement of tools in the right location and workplace arrangements that create satisfaction for employees. The arrangement of the workspace in the medical record unit affects the service activities provided to patients, so that the workspace arrangement in the medical record unit needs to be considered so that the services provided by the medical record unit can run smoothly. Based on a preliminary study at RSUD dr. H. Moch Ansari Saleh through observation, researchers found the fact that the medical record management room was narrow, this made the officers jostling and when they passed each other they had to take turns, and the placement of facilities or facilities that were less needed made the room narrower. . And the results of interviews with medical records officers that he said officers work by walking back and forth from one table to another at a distance apart because the layout does not match the medical record workflow, this has an impact on the smoothness of service and reduces work speed. The purpose of this study Describes the layout of the medical record work unit at RSUD dr.H.Moch Ansari Saleh. This type of research method used is descriptive qualitative. Methods of data collection using interviews and observation. Based on the results of the research, the medical record unit room was not neatly arranged, the work desk was not in accordance with the medical record data processing flow, there were several work desks between officers who did not have distance, and for the filing room the layout was appropriate and did not hinder access. The area of ​​​​the medical record work unit is narrow, it is necessary to expand the room which has an impact on the comfort of the officer in working and for the filing room, it is sufficient in terms of the area of ​​​​the room. The facilities in data processing are still not suitable, it is necessary to add a work desk because there are officers who do not have a work desk

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.

Hyperledger blockchain enabled secure medical record management with deep learning-based diagnosis model

In recent times, advanced developments in healthcare sector result in the generation of massive amounts of electronic health records (EHRs). EHR system enables the data owner to control his/her data and share it with designated people. The vast volume of data in the healthcare system makes it difficult for data to ensure security and diagnostic processes. To resolve these issues, this paper develops a new hyperledger blockchain enabled secure medical data management with deep learning (DL)-based diagnosis (HBESDM-DLD) model. The presented model involves distinct stages of operations such as encryption, optimal key generation, hyperledger blockchain-based secure data management, and diagnosis. The presented model allows the user to control access to data, permit the hospital authorities to read/write data, and alert emergency contacts. For encryption, SIMON block cipher technique is applied. At the same time, to improve the efficiency of the SIMON technique, a group teaching optimization algorithm (GTOA) is applied for the optimal key generation of the SIMON technique. Moreover, the sharing of medical data takes place using multi-channel hyperledger blockchain that utilizes a blockchain for storing patient visit data and for the medical institutions to record links for the EHRs saved in external databases. Once the data are decrypted at the receiving end, finally, variational autoencoder (VAE)-based diagnostic model is applied to detect the existence of the diseases. The performance validation of the HBESDM-DLD model takes place on benchmark medical dataset and the results are inspected under various performance measures. The experimental results proves that the HBESDM-DLD methodology is superior to state-of-the-art methods.

The Application of Modern Information Technology in Medical Record Management

The Application of Modern Information Technology in Medical Record Management

Analisis Kinerja Petugas Rekam Medis di Rumah Sakit Umum Daerah Besemah Kota Pagar Alam

The medical record is a permanent legal document that must contain sufficient information to identify the patient, justify the diagnosis and treatment, and record the results. Research Objectives to test the performance of medical records officers with compliance with procedures, storage room standards, the number of medical record personnel, and medical record management training simultaneously with the performance of medical record officers at Besemah Hospital Pagar Alam City. This study is a quantitative study with a cross-sectional research design to determine the independent and dependent variables. Data analysis was carried out univariate, bivariate, and multivariate. The sample in this study were all 62 medical record officers at Besemah Pagar Alam Hospital, and the sample was taken by purposive sampling. Data were collected using a questionnaire and processed using the Chi-Square statistical test. The results showed that medical record officers with high performance were 62.9%, compliance with reasonable procedures was 53.2%, and standard medical record file storage space was adequate, namely 33.9%, the number of medical record personnel was sufficient, namely 54.8%, training good medical record that is 62.9%. The most dominant variable is adherence to standard operating procedures, whose value is less than 0.05 with an OR value of 5.100. Based on the results of the study, it is recommended that the Besemah Hospital, Pagar Alam City, especially the hospital management, need to focus on the aspect of compliance with the fixed procedures that have been set by the hospital and conduct medical record management training to improve the performance of medical record officers.

Tinjauan Sistem Penyelenggaraan Rekam Medis Menurut Standart Akreditasi Puskesmas di Puskesmas Pangakalan Berandan Tahun 2020

Puskesmas are required to maintain medical records containing data and information on patient care. Implementation according to accreditation standards, namely criteria 3.2 Registration Process and 3.8 Administration of medical records which are divided into 3.8.1 Coding, 3.8.2 Medical Record Access Rights 3.8.3 Clinical Information Filling and 3.8.4 Storage. The purpose of the study was to find out the implementation of the medical record management system according to the Puskesmas accreditation standards at the Pangkalan Berandan Health Center in 2020. This type of research was qualitative with a Phenomenology approach. The place of research was conducted at the Pangkalan Berandan Health Center. Time of study in July 2020. Research population is all medical record officers at the Pangkalan Berandan Health Center. The research sample is 5 officers. The research instrument was interview guide and check list sheet for observation. The results of the study revealed that the outpatient registration process had been carried out according to criteria 3.2 but there was no inpatient numbering of medical records. Coding was not carried out according to criteria 3.8.1, namely the absence of coding SOPs carried out by doctors using ICD 10, Medical Record Access Rights were carried out according to criteria 3.8. 2 but the implementation is not fully carried out in accordance with the SOP, the lending process is not recorded in the expedition book, Assembling is in accordance with criteria 3.8.3 but recording corrections are carried out using stip-ex and the storage process has been carried out according to criteria 3.8.4 but retention is not carried out according to the guidelines legislation. It is recommended for registration to give medical record numbers to inpatients, coding to make SOPs and given coding training, access rights to medical records to record loans in expedition books, assembling to be given socialization in terms of correcting recording of medical record files and storing tracers as well as in the retention process. given socialization about the implementation of retention.

Tinjauan Sistem Penyelenggaraan Rekam Medis Menurut Standart Akreditasi Puskesmas di Puskesmas Pangakalan Berandan Tahun 2020

Puskesmas are required to maintain medical records containing data and information on patient care. Implementation according to accreditation standards, namely criteria 3.2 Registration Process and 3.8 Administration of medical records which are divided into 3.8.1 Coding, 3.8.2 Medical Record Access Rights 3.8.3 Clinical Information Filling and 3.8.4 Storage. The purpose of the study was to find out the implementation of the medical record management system according to the Puskesmas accreditation standards at the Pangkalan Berandan Health Center in 2020. This type of research was qualitative with a Phenomenology approach. The place of research was conducted at the Pangkalan Berandan Health Center. Time of study in July 2020. Research population is all medical record officers at the Pangkalan Berandan Health Center. The research sample is 5 officers. The research instrument was interview guide and check list sheet for observation. The results of the study revealed that the outpatient registration process had been carried out according to criteria 3.2 but there was no inpatient numbering of medical records. Coding was not carried out according to criteria 3.8.1, namely the absence of coding SOPs carried out by doctors using ICD 10, Medical Record Access Rights were carried out according to criteria 3.8. 2 but the implementation is not fully carried out in accordance with the SOP, the lending process is not recorded in the expedition book, Assembling is in accordance with criteria 3.8.3 but recording corrections are carried out using stip-ex and the storage process has been carried out according to criteria 3.8.4 but retention is not carried out according to the guidelines legislation. It is recommended for registration to give medical record numbers to inpatients, coding to make SOPs and given coding training, access rights to medical records to record loans in expedition books, assembling to be given socialization in terms of correcting recording of medical record files and storing tracers as well as in the retention process. given socialization about the implementation of retention.

Medical Records Management with Decentralized Framework

The mystery between the emotional improvement of medical information protection interest and long periods of administrative guideline has eased back advancement for electronic medical records (EMRs). In this paper, we propose a efficient, secure and decentralized Blockchain system for data privacy preserving and sharing. This manages confidentiality, authentication, data preserving and data sharing when handling sensitive information. We exploit consortium Blockchain and smart contracts to accomplish secure information storage and sharing, which forestalls information sharing without consent. The patient’s historical data, medical record, patient’s private information is very critical and needs to be stored and maintained securely. The proposed framework builds information security and eliminates the cost, time, and assets needed to deal with the medical care information records.

Application of Blockchain and Internet of Things in Healthcare and Medical Sector: Applications, Challenges, and Future Perspectives

Internet of Things (IoT) is one of the recent innovations in Information Technology, which intends to interconnect the physical and digital worlds. It introduces a vision of smartness by enabling communication between objects and humans through the Internet. IoT has diverse applications in almost all sectors like Smart Health, Smart Transportation, and Smart Cities, etc. In healthcare applications, IoT eases communication between doctors and patients as the latter can be diagnosed remotely in emergency scenarios through body sensor networks and wearable sensors. However, using IoT in healthcare systems can lead to violation of the privacy of patients. Thus, security should be taken into consideration. Blockchain is one of the trending research topics nowadays and can be applied to the majority of IoT scenarios. Few major reasons for using the Blockchain in healthcare systems are its prominent features, i.e., Decentralization, Immutability, Security and Privacy, and Transparency. This paper’s main objective was to enhance the functionality of healthcare systems using emerging and innovative computer technologies like IoT and Blockchain. So, initially, a brief introduction to the basic concepts of IoT and Blockchain is provided. After this, the applicability of IoT and Blockchain in the medical sector is explored in three major areas—drug traceability, remote patient-monitoring, and medical record management. At last, the challenges of deploying IoT and Blockchain in healthcare systems are discussed.

EVALUASI MANAJEMEN DOKUMEN REKAM MEDIS DI FILING AKTIF RUMAH SAKIT SWASTA KABUPATEN SEMARANG

Missfile can inhibit medical services provided to patients without information about history. From the initial survey, it found 90 missile incidents (4.7%) from 2000 medical record documents, the second survey found 578 incidents from 7000 medical record documents with 9.0% missfile. This study aims to identify the medical records management in the outpatient filing section of The Private Hospital, Semarang Regency in 2019. This research is a mix methode study. Data collection by observation and interview methods with a cross-sectional approach. The research subjects were 3 filing officers. The research objects to the management of medical record documents in the outpatient filing section. The research instrument used in this research were interview and observation guidelines.The number of polyclinics at The Private Hospital in Semarang Regency is 20 polyclinics. There should be a submission terminal so staff will not be tired. The hospital management facilities were adequate but have not been properly utilized by the officers, the officers should use these facilities to facilitate document tracking. The Hospital should make a policy regarding the management of medical record documents and use colour codes on the documents so that the staff can understand and carry out their duties properly.Key Word : medical record management, storage systems, management standards

Introduction Study Of Business Intelligence Hospital Medical Recording Data

In every health service facility in a hospital, it is obligatory to make medical records made by doctors and health workers related to the services provided by doctors and other health workers. Medical records made, both outpatient medical records and inpatient medical records, are stored in a medical record file storage area (filling).. Phe management of medical records with the standard Medical Record Information Management (MIRM) is to support orderly administration in the context of efforts to improve health services in hospitals which are supported by a medical record management system that is fast, precise, valuable, accountable, and focuses on patients and safety patients in an integrated manner. The purpose of this system plan is to make it easier for management and leaders to get a visual summary of information for decision making.

Lopinavir-ritonavir alone or combined with arbidol in the treatment of 73 hospitalized patients with COVID-19: A pilot retrospective study.

This study aimed to evaluate the antiviral efficacy of lopinavir-ritonavir alone or combined with arbidol in the treatment of hospitalized patients with common coronavirus disease-19 (COVID-19). In this retrospective observational study, hospitalized COVID-19 patients were identified and divided into two groups based on the antiviral agents during their hospitalization. Patients in group LR were treated with lopinavir-ritonavir 400mg/100mg, twice a day, while patients in group LR+Ar were treated with lopinavir-ritonavir 400mg/100mg twice a day and arbidol 200mg three times a day for at least 3 days. Data from these patients were collected from electronic medical record management system. 73 patients were divided into two groups: group LR (34 cases) and group LR+Ar (39 cases), according to the antiviral agents. The overall cure rate of COVID-19 in group LR+Ar and group LR were 92.3% and 97.1%, respectively, with no significant difference (p=0.62). In a modified intention-to-treat analysis, lopinavir-ritonavir combined with arbidol led to a median time of hospital stay that was shorter by 1.5 days than in group LR (12.5 days vs. 14 days). The percentages of -COVID-19 RNA clearance was 92.3 in group LR and 97.1 in group LR+Ar which was similar to the cure rate. The median time to nucleic acid turning negative = (date of first negative PCR test) - (date of last positive PCR test) was 8.0 days in both groups with no significant difference (p=0.59). Treatment of lopinavir-ritonavir combined with arbidol did not significantly accelerate main symptom improvement and promote the image absorption of pulmonary inflammation. No benefit was observed in the antiviral effect of lopinavir-ritonavir combined with arbidol compared with lopinavir-ritonavir alone in the hospitalized patients with COVID-19. More clinical observations in COVID-19 patients may help to confirm or exclude the effect of antiviral agents.