Medical Record Files Research Articles

Evaluation Analysis of Using Tracer on Medical Record Storage

Tracer is one of the facilities in the medical record filing room that can be used as medical record storage to facilitate the detection of its existence. Several studies show that there are still missfiles in medical record files. This can make services to patients often delayed and not timely because medical records are very important for patients. The purpose of this study will be to analyze the importance of evaluating the use of tracers in order to achieve the best quality of health institutions. The research method used is qualitative research with a literature review. The secondary data used for the literature review are15 peer-reviewed journal articles published between 2019-2021 on evaluation of the use of tracers of health agencies spread throughout Indonesia. The findings indicate that there is a need for a good medical record document storage system in the form of a tracer to maximize the service quality of health agencies, both puskesmas and hospitals throughout Indonesia.

Review Of Returning Medical Records In Outpatient Medical Record

In returning the outpatient medical record file to thesection of the Medical Record Unit, Assembling there was a delay. This is because the return of medical record files has not been carried out according to Standard Operating Procedures, as a result, causing delays in the reporting system. The method used is qualitative using a descriptive approach. Data collection techniques by observation, interviews and literature study. This study aims to determine the return of former medical records of outpatients at Dayeuhkolot Health Center. The results of the study prove that the delay in returning outpatient medical record files at the Dayeuhkolot Health Center with presentations during the 1 week study amounted to 63 or 22% of 285 medical record files. Efforts have been made to disseminate information to all officers related to the efforts made by the person in charge of COVID-19 patients in returning medical record files on time.

Analysis Of Time Analysis Of Outstanding Medical Records To Improve The Quality Of Services At Dustira Hospital, Cimahi

The provision of medical record files depends on the availability of data, clear and accurate information. The speed of providing medical record files is one indicator of the quality of service in medical records. The purpose of the study was to determine the achievement of the Minimum Service Standards in the medical record unit in providing medical record files. The research method uses descriptive methods with a qualitative approach. Data collection was carried out for 5 days by recording the hours the patient registered in the outpatient registration section until the time the medical record file was found, located at the hospital. Dustira Cimahi. The result is as many as 2090 or 86,1% of medical record files with a provisioning time of ? 10 minutes, 340 or 13,9% of medical record files requiring a provisioning time of> 10 minutes. The conclusion is based on the provision of medical record files at the hospital. Dustira has met the minimum service standards with the set waiting time standards for outpatient services which is an average of <60 minutes, it is recommended to maintain and improve the quality of service.

Medical Record Storage System Analysis On The Effectiveness Of Patient Services

This study aims to determine and analyze the medical record storage system on the effectiveness of patient care at the Cikole Public Health Center. The research method used is quantitative with inferential statistical analysis techniques. Data collection techniques by means of observation, interviews and questionnaires. Cikole Lembang Public Health Center is one of the first level health care facilities. Based on observations, the storage system used is a regional storage system in which each region starts from the first digit. There are 2 officers who work in the medical records section of the Cikole Public Health Center. With the storage system used, there are several shortcomings, namely the occurrence of misfiles and duplication. To find out whether there is an analysis of the medical record storage system on the effectiveness of the service, the author gives a questionnaire to the Cikole Public Health Center officers. The results of the questionnaire also show that the highest percentage level is found in item no.7, namely the decentralized storage system is in accordance with the target of 71%. Then the second is item no. 8, namely a decentralized storage system that allows the provision of medical record files on time by 61%. From the results of interviews with medical records officers, suggestions and input were given: (1). The storage system used was changed to centralization so that the alignment system was not duplicated; (2). The use of bindex as an additional tool to make storage neater and easier.

Contemporary treatment patterns and survival of cervical cancer patients in Ethiopia

BackgroundCervical cancer is the second commonly diagnosed cancer and the second leading cause of cancer death in women in Ethiopia, with rates among the highest worldwide. However, there are limited data on cervical cancer treatment patterns and survival in the country. Herein, we examine treatment patterns and survival of cervical cancer patients treated in Tikur Anbessa Hospital Radiotherapy Center (TAHRC), the only hospital with radiotherapy facility in the country.MethodsWomen with histologically verified cervical cancer who were seen in 2014 (January 1, 2014 to December 31, 2014) at TAHRC were included. Information about clinical characteristics and treatments were extracted from the patients’ medical record files. The information on vital status was obtained from medical chart and through telephone calls.ResultAmong 242 patients included in the study, the median age at diagnosis was 48 years. The median waiting time for radiotherapy was 5.6 months (range 2 to 9 months). Stage migration occurred in 13% of patients while waiting for radiotherapy. Consequently, the proportion of patients with stage III or IV disease increased from 66% at first consultation to 74% at the initiation of radiotherapy. Among 151 patients treated with curative intent, only 34 (22.5%) of the patients received concurrent chemotherapy while the reaming patients received radiotherapy alone. The 5-year overall survival rate was 28.4% (20.5% in the worst-case scenario). As expected, survival was lower in patients with advanced stage at initiation of radiotherapy and in those treated as palliative care.ConclusionThe survival of cervical cancer patients remains low in Ethiopia because of late presentation and delay in receipt of radiotherapy, leading to stage migration in substantial proportion of the cases. Concerted and coordinated multisectoral efforts are needed to promote early presentation of cervical cancer and to shorten the unacceptable, long waiting time for radiotherapy.

ANALISA PENOMORAN DI PUSKESMAS SUGIHMUKTI GUNA MENCEGAH TERTUKARNYA BERKAS REKAM MEDIS

The implementation of medical record numbering at the Sugihmukti Health Center applies a Family Numbering System, where documents in one family will be stored in one folder and given an identity with a family number. This Family Numbering System provides convenience in retrieval of Medical Records, saves storage space, and prevents medical record files from being exchanged. The medical record storage shelves at the Sugihmukti Health Center are grouped based on the area where the patient lives, making it easier for officers to find the file. The purpose of this study was to determine the cause of medical record files being confused, to identify the medical record numbering system at the Sugihmukti Health Center. This research method uses qualitative methods and descriptive cases. The population is 40,020 medical record files and the sample is 4,002 medical record files as respondents. The numbering classification used is the first 2 digits, namely the area code, the middle 4-6 digits as the number of the head of the family, and the last 2 digits as the family sequence code. The data collection technique we used in this study was observation. The results of the study were one medical record number was used for all family members classified by area code and family order code. From the results of the study, it was found that the number of medical records that were duplicated was (2.99%) and the number of medical records that were not duplicated was (97.11%). Based on the results of our research, it can be concluded that the limitations of Human Resources cause performance to be less than optimal.

KETIDAKLENGKAPAN DOSCHARGE SUMMARY DAN LAMA PENGEMBALIAN BERKAS REKAM MEDIS DALAM PENINGKATAN MUTU PELAYANAN REKAM MEDIS DI RS X BANDUNG

Hospitals are a complex institution of health care, because hospital service involves various functions of service, education, and research, and covers a wide range of degrees and kinds of discipline. To enable hospitals to perform professional functions both in the field of medical engineering and in health administration. Hospital maintenance and improvement requires that it have a measure of quality at all levels. The purpose of this study is to know the incompletion review of discharge summary and the long retrieval of medical record files. The method the writer is a quantitative descriptive,50 files of medical records were taken, Analysts used were observation and interview, The subjects in this study are doctors and medical recorders. The results of this study amounted to 79% complete medical records and 21% incomplete files. 75% of files returned on time, and 25% of files returned intime. It seems that hospital x has filled the SOP and the technical instructions are in place. The incompleteness of medical record files greatly affects the quality of hospital health care. It is therefore expected that all officers will be able to perform their duties according to the SOP in the hospital and increase the number for the medical record file. Hospitals can maintain the quality of service for inpatients and outpatients. Word key : discharge summary, hospital, medical record.

Perancangan dan Pembuatan Aplikasi Retensi dan Pemusnahan Berkas Rekam Medis Di Rsud Dr. H. Moch. Ansari Saleh Banjarmasin

One of the hospitals that have carried out retention and destruction activities is Dr. H. Moch. Ansari Saleh Banjarmasin. The retention and destruction of medical records are still done manually. This research’s purpose by design and create a retention and extermination application of medical records file. This type of research uses qualitative research with the development of the waterfall model system. Data collection includes interviews, observation, FGD, and documentation. The results of the study are functional and non-functional system requirements for making retention and destruction applications, based on the results of the FGD to the medical record filling staff and the head of the medical record unit. The results of the requirements that have been obtained are interpreted in the design of systems and software made through flowchart systems, context diagrams, data flow diagrams (DFD), and entity-relationship diagrams (ERD). The implementation process and unit test use the MySQL database and the PHP programming language and the interface design uses the Codeigniter Framework. The application system integration test uses the functional test of the Black Box Test method with a 100% system trial success rate. . The results of this functional test indicate that the retention and destruction applications can be integrated and function properly with innovations in the form of an annual import database feature, a feature for retention and destruction reports, and storage of scanned files in pdf format. The existence of this application can help the implementation of retention and destruction of medical record files at Dr. H. Moch. Ansari Saleh Banjarmasin has become more effective and efficient in terms of time, use value, and data security.

Review Procedures Borrowing And Return Record Files Medical Outpatient Medical Record in Health Unit River Candle

The borrowing of medical record documents at the puskesmas is used for internal or external purposes which include needs in aspects of the usefulness of medical record documents such as administrative, medical, legal, financial, research, and educational aspects. Based on a survey at the puskesmas, the procedure for borrowing and returning medical record files has not been carried out effectively, for example, the return of outpatient medical record files is often not in accordance with the provisions, namely a maximum of 1 (one) hour before the end of working hours, thus hampering the implementation of medical record retrieval at any time. The time is needed by patients, doctors, and parties who need medical record files. The purpose of this study was to determine the procedure for borrowing and returning outpatient medical record files. This research is a type of descriptive research. The object of the research is the procedure for borrowing and returning medical record files of outpatients in the medical record unit. The instruments used are observation guidelines and interview guidelines.

Review Procedures Borrowing And Return Record Files Medical Outpatient Medical Record in Health Unit River Candle

The borrowing of medical record documents at the puskesmas is used for internal or external purposes which include needs in aspects of the usefulness of medical record documents such as administrative, medical, legal, financial, research, and educational aspects. Based on a survey at the puskesmas, the procedure for borrowing and returning medical record files has not been carried out effectively, for example, the return of outpatient medical record files is often not in accordance with the provisions, namely a maximum of 1 (one) hour before the end of working hours, thus hampering the implementation of medical record retrieval at any time. The time is needed by patients, doctors, and parties who need medical record files. The purpose of this study was to determine the procedure for borrowing and returning outpatient medical record files. This research is a type of descriptive research. The object of the research is the procedure for borrowing and returning medical record files of outpatients in the medical record unit. The instruments used are observation guidelines and interview guidelines.

Review Of Inactive Medical Record Destruction Activities At Hermina Hospital Palembang Year 2021

Various methods and systems used to improve the quality of the management and storage of medical record files, one of which is to reduce the volume of archives that have no use value, to reduce archive buildup and create better and more efficient storage space, making it easier for officers to carry out their duties search and expedite the patient's treatment process. This study uses a qualitative type of research, with a descriptive method. The data collection in this study used the interview and observation (checklist) method. The population in this study were officers of the medical record work unit at Hermina Hospital Palembang in 2021. Based on the research, it can be concluded that the retention of inactive medical record files in 2021 is being carried out by medical record officers and the destruction of inactive medical record files has not been carried out because constrained by the COVID-19 pandemic, there are officers who carry out WFH (Work from Home) along with service hours. At the Hermina Hospital in Palembang, the standard operating procedure (SOP) regarding the destruction of inactive medical record files at the Hermina Palembang hospital already exists, but has not been implemented is 0.000 <0.05, it can be concluded that it is accepted, meaning that there is a difference in scores between before and after being treated with water tube media

Review Of Inactive Medical Record Destruction Activities At Hermina Hospital Palembang Year 2021

Various methods and systems used to improve the quality of the management and storage of medical record files, one of which is to reduce the volume of archives that have no use value, to reduce archive buildup and create better and more efficient storage space, making it easier for officers to carry out their duties search and expedite the patient's treatment process. This study uses a qualitative type of research, with a descriptive method. The data collection in this study used the interview and observation (checklist) method. The population in this study were officers of the medical record work unit at Hermina Hospital Palembang in 2021. Based on the research, it can be concluded that the retention of inactive medical record files in 2021 is being carried out by medical record officers and the destruction of inactive medical record files has not been carried out because constrained by the COVID-19 pandemic, there are officers who carry out WFH (Work from Home) along with service hours. At the Hermina Hospital in Palembang, the standard operating procedure (SOP) regarding the destruction of inactive medical record files at the Hermina Palembang hospital already exists, but has not been implemented is 0.000 <0.05, it can be concluded that it is accepted, meaning that there is a difference in scores between before and after being treated with water tube media

Faktor-faktor yang Berhubungan dengan Ketepatan Pengembalian Berkas Rekam Medis di Ruang Rawat Inap Terpadu (RINDU) A di RSUP H. Adam Malik

THE RELATED FACTORS TO THE ACCURACY OF RETURNING MEDICAL RECORD FILES IN AN INTEGRATED INPATIENT (RINDU) A AT H. ADAM MALIK CENTRAL GENERAL HOSPITAL AGUSTINA GINTING 1602042001 The acuracy of returning medical record files that are in accordance with the established rules, ie 1x24 hours, is one of the factors of several factors of quality improvement in information quality in hospitals. Returning the right medical record file is very necessary to avoid disruption of the service system and reduced quality of the hospital. The method in this study is a cross-sectional quantitative method, which is one of the research designs or it can also be seen as one of the social research methodologies by involving more than one case in one process and also involving several variabels to see the relationship pattern. Chi-square test between education variables with variable accuracy of returning medical record files results there was a relationship. It is known that Ha is accepted because the value of p=. 023 (p value 0,05). Chi-square between working time variables with a variable accuracy of returning medical record files results n no relationship. It is known that the value of Ho is accepted because of the value of p=. 1889 (p value >0,05). Chi-square test between work environment varibles and the variable accuracy of returning medical record files results in no relationship. It is known that Ho is accepted because tje value of p =.798 (p value >0,05). The conclusion in thi study is that the medical record file returned from the medical record file returned from the integrated inpatient (Rindu) A has returned on time. Where if seen from the criteria for the return of medical records or commonly abbreviated as PRM, the return medical record has reached 80% of the 100% target. The advice that can be given is that the management and the medical record installation unit need to provide socialization related to the importance of returning the medical record file in a timely manner. In order to incrase the percentage of return on medical record files, and further examine the factors that affect the accuracy of the return of medical record files. Keywords; Accuracy of Returns, Medical Record, Inpatient

Primary Malignant Tumors of Oral and Maxillofacial Region in Libyan Population: A single institution experience of 171 cases

background: Globally, a significantly high rate of mortality was caused by oral cancer; however, epidemiological data of oral cancer is still scanty, particularly in Arab countries. This retrospective study was designed to provide a systematic analysis of the histological subtypes of oral and maxillofacial malignant neoplasms in Libyan population during two decades, and to compare the results with previous reports from Libya and other countries.
 Method: data were gathered using patients medical record and biopsy files, and the histological slides were revaluated. The tumors were classified according WHO criteria (2017). 
 Results: Carcinoma was found in 145 patients, forming (84.7%) of all the malignant oral and maxillofacial neoplasms, followed by lymphoma and sarcoma (6.4%), and neural crest cell tumours (2.3%). Males were more affected than females at a ratio of 1.3:1. Most of the patients (70.8%) were above the age of 40 with a mean age of 51.7years old at the time of the diagnosis. Only 1% of the malignant neoplasms were odontogenic in origin. Squamous cell carcinoma (67.5%) was the most common epithelial neoplasm, followed by mucoepidermoid carcinoma (9.7%) and adenoid cystic carcinoma (4.1%). The tongue was the most common site for squamous cell carcinoma (41.1%), followed by buccal mucosa (16.8%).
 Conclusion: compared to previous reports from eastern and some western countries; the prevalence of malignant neoplasms of oral and maxillofacial region in Libyan populations is considerably low.

Provision of dental care by public health dental clinics during the COVID-19 pandemic in Alberta, Canada.

This study aims to describe dental services provided to a low income population in dental public health settings during the first wave of COVID-19 pandemic in Alberta, Canada. Routinely collected clinical data were recorded by dentists in electronic medical record files at Alberta's two Public Health Dental Clinics (PHDCs). Patient contact was via teledentistry or in person, respecting phased provincial pandemic restrictions. A descriptive analysis of data relating to all patients contacting PHDC with dental problems between 17 March - 31 October 2020 was undertaken and compared to equivalent pre-COVID 2019 data. In the period examined, 851 teledentistry consultations and 1031 in person visits were performed. Compared to the same period in 2019, 46% fewer patients were treated, representing a decrease in dental procedures: tooth extractions (17%), silver diamine fluoride applications (17%), endodontic treatments (82%) and fillings (84%). By contrast, prescriptions increased by 66% overall; representing 76%, 121% and 44% in antibiotics, non-opioid analgesics, and opioid analgesics respectively. In both years, antibiotics were the most prescribed drugs (66% in 2019 versus 62% in 2020) followed by non-opioid analgesics (28% in 2019 versus 33% in 2020); opioids accounted for the remainder (6.5% in 2019 and 5% in 2020). The largest drug prescription increases occurred during April-May 2020, when access to care was most restricted: antibiotics and non-opioid analgesics were 300% and 738% higher than the same time in 2019. Teledentistry and pharmacotherapy were used to triage and organise dental patients accessing care during the early stages of the pandemic. However, teledentistry did not replace definitive in person dental treatment, particularly for low income populations with high incidence of toothache and odontogenic infection. Reduced provision of dental procedures was accompanied by an increase in drug prescribing. Expedient access to care must be provided to address the dental needs of this population avoiding risks of further complications associated with infection and overprescribing antibiotics and opiates.

HUBUNGAN PEMBERIAN ASI DENGAN KEJADIAN IKTERUS BAYI HIPERBILIRUBINEMIA DI RSIA PURI BUNDA DENPASAR

Early exclusive breastfeeding has an important role in reducing the incidence of jaundice, where jaundice is a change in the skin or other organs due to a buildup of bilirubin levels in the blood and an increase in the level of bilirubin in the blood, which is called hyperbilirubinemia. This study aimed to determine the correlation between breastfeeding and the incidence of hyperbilirubinemia infant jaundice at RSIA Puri Bunda Denpasar. This study used a case-control method, comparing the case group with the control group and a retrospective approach. The number of samples was 86 patients' medical record files. The sampling was using purposive sampling through the observation sheet and data analysis using the Chi-Square test. This study showed that exclusive breastfeeding had less incidence of jaundice (16.7% in the case and control groups) while the incidence of jaundice was higher in breastfeeding and formula milk in both the case and control groups. The results of the chi-square statistical test obtained p-value = 0.023, meaning that there was a significant correlation between breastfeeding and the incidence of jaundice in hyperbilirubinemia infants. It is recommended that the hospital be able to educate and socialize early exclusive breastfeeding to patients.

ANALISIS PENYIMPANAN REKAM MEDIS AKTIF RAWAT JALAN GUNA MENINGKATKAN EFEKTIVITAS PELAYANAN DI PUSKESMAS CILENGKRANG KABUPATEN BANDUNG

Based on the results of research studies at the Cilengkrang Health Center, Bandung Regency, it is known that in the implementation of the alignment of medical record documents there are still misplaced and missing (misfiles) so that it hinders the process of taking and returning medical record documents both stored and to be borrowed. This misplaced and missing file can affect patient care because it can hamper the examination process, besides that the lost medical record will be regenerated with a new medical record so that the contents of the medical record become ineffective. The purpose of this study was to analyze, to know the description of the lending system on the occurrence of missfiles of outpatient medical record files in the filling room by means of qualitative methods and data collection by interviews, as well as observations at the Cilengkrang Health Center, Bandung Regency. The results showed that from 1,044 outpatient medical record files, 5%, namely 52.2 medical record files, had missfiles, which were not appropriate in placing/compiling medical record files on the proper shelves. Efforts to fix this problem are redesigning the filling room so that the distance between the filling racks is more ergonomic, using tracers and installing procedures / SOPs in the storage room (filling), and using color coding on the folder folder.

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.

Pengaruh Pemberian Kode Warna Wilayah Pada Folder Terhadap Ketepatan Penyimpanan Berkas Rekam Medis Di Puskesmas Wadaslintang 1

A Medical records are files containing notes and documents regarding the patient's identity, examination, treatment, actions and other services that have been provided to patients. So that a medical file is strictly protected so that it is not damaged or lost.Based on observations, it was found that there were several files of medical records that were interchanged or not in the normal filling rack. Medical record files can be exchanged due to the large number of regional shelf columns so that alternatives and innovations are needed to increase the accuracy of returning and retrieving medical record files correctly.Troubleshooting efforts are being made, namely by providing a regional color code in the medical record file folder so that errors in taking and returning medical record files can be minimized.Based on the results of observations made by the author, it was found that there was an effect before and after color coding the region in the medical record file folder.

Analisis Retensi Rekam Medis Rawat Jalan Aktif ke Inaktif di UPT Puskesmas Sukarasa

Medical record retention is an activity of transferring medical record documents from an active storage room to an inactive storage room. Based on a preliminary survey at UPT Puskesmas Sukarasa, it is known that the puskesmas has retained outpatient medical record files 2 times in 2018 and 2019. But the retention is not done according to the SOP. The purpose of the study was to determine the implementation of outpatient medical record file retention at UPT Puskesmas Sukarasa. This type of research is descriptive with a retrospective approach. The research instrument was carried out by observation, interviews and checklist forms. The object of the research is the implementation of active to inactive outpatient medical record retention at UPT Puskesmas Sukarasa. The research subjects are the officer in charge of medical records and the person in charge of registration who performs retention of outpatient medical records.It is also known that the UPT Puskesmas Sukarasa already has an SOP on retention of medical records, but the SOP has not been implemented due to the lack of special staff for retention and the accumulation of medical record files on active storage shelves. Files that are retained are files for 2016-2018 without looking at the last date of treatment but based on the year number in the medical record file. Then the file is immediately moved to the inactive storage rack. It can be concluded that the implementation of retention at UPT Puskesmas Sukarasa is not in accordance with the SOP. It would be better if the retention is carried out according to the SOP with special and scheduled officers so that there is no accumulation of medical record files.