Medical Record Management Research Articles

Information Technology-Based Medical Record Governance For Cancer Classification With The Waterfall Method

Information technology can help improve the quality of medical record management. Information technology-based medical record management can help improve the efficiency, accuracy and accessibility of medical records. The aim of this research is to build an information technology-based medical record management system for cancer classification using the waterfall method. This research uses a system development research method using the waterfall method. The data collection techniques used were observation, interviews and literature study. The data that has been collected is then analyzed qualitatively. The research results show that an information system designed specifically for patients who register directly makes it easier for officers to separate patients who register online from those who register in person. This system allows officers to report information quickly and accurately, and to be better integrated in quality improvement and hospital accreditation.

THE CORRELATION BETWEEN TYPE 2 DIABETES MELLITUS WITH BACTERIAL INFECTION IN COVID-19 PATIENTS ADMITTED TO INTENSIVE CARE UNIT AT CENTRAL GENERAL HOSPITAL PROF. DR. I.G.N.G. NGOERAH DENPASAR IN 2021-2022

Type 2 Diabetes Mellitus (T2DM) has a detrimental impact on the immune system, resulting in a decrease in the body's immune response, making patients highly susceptible to bacterial infections. Patients with T2DM, especially those treated in the Intensive Care Unit (ICU) of a hospital, face an increased risk of infection. The emergence of COVID-19, which also infects T2DM patients, further diminishes the immune system's function in these patients. Consequently, individuals with both T2DM and COVID-19 are at a heightened risk of developing secondary infections, commonly referred to as Hospital-Acquired Infections.This research aims to explore the relationship between T2DM, assessed through blood sugar levels, and the occurrence of bacterial infections in COVID-19 patients treated in the ICU of Prof. Dr. I.G.N.G. Ngoerah Central Hospital from 2021 to 2022. The research design employed is quantitative analytical correlational study using a cross-sectional approach, with a sample size of 98 patients collected from the Medical Records and Hospital Management System of Prof. Dr. I.G.N.G. Ngoerah Central Hospital in Denpasar. This study found that there is a significant correlation between patient’s infection profile with random blood glucose levels with an Odds Ratio (OR) of 1.15 (95% CI: 1.04 – 1.27; p = 0.013). Additionally, a significant relationship was observed between the severity of COVID-19 and bacterial infections in patients, with an Odds Ratio of 1.12 (95% CI: 1.01 – 1.26; p = 0.04).
 Keywords : T2DM, ICU, Hospital-Acquired Infection

Decentralized Medical Record Management with Blockchain Technology and Artificial Intelligence

The objective of this undertaking is to make a decentralized and straightforward clinical records the executives framework utilizing blockchain innovation. The undertaking intends to work on the respectability, security and openness of clinical records by decentralizing them. The objective is to engage individuals with more command over their medical services data, work with consistent and secure information dividing among approved elements and drive development in the field of medical services examination and investigation. The objective of the venture is to assist with making a cutting edge patient-centered medical services environment that puts protection, effectiveness and the smooth trade of wellbeing data at the focal point of all that we do. This theoretical exemplifies the quintessence of the undertaking, framing its goals, philosophy, and expected influence on medical services frameworks. We will likewise give an outline of what is right now had some significant awareness of decentralized clinical records the board utilizing blockchain innovation, as well as certain thoughts for additional exploration and execution.

Analisis Kelengkapan Kuantitatif Berkas Resume Medis di Rumah Sakit Angkatan Laut Dr. Ramelan Surabaya

A complete medical record form is an indicator of good medical record management and directly affects service quality. Analysis of the completeness of medical record files at Dr. Ramelan Surabaya found that the completeness of the medical resume had not reached 100%, only 90% completeness. The purpose of this study was to analyze the completeness of medical resume files at Dr. Ramelan Surabaya with descriptive method. Data collection used the cross sectional method in September 2022 as many as 21 medical resume forms. The results showed that the identification review obtained 100% complete in filling out medical resumes. Completion of medical resumes on critical report reviews is at least 19% on treatment while being treated. Authentication review is only 76% for filling in the patient's full name. Review the documentation that is correct, the blank part is 19%. The conclusion of this study is the highest incompleteness in the treatment while being treated by 81% in the review of important reports, so filling out the medical record file at RSPAL Dr. Ramelan is said to be still incomplete.

The applications and prospects of intelligent services robots in medicine

With the rapid growth of the ageing population and the increasing demand for medical services, the medical market is facing great challenges and opportunities. Intelligent service robots can provide various medical services, such as patient monitoring, drug distribution, medical record management, etc., which can improve medical efficiency, reduce the burden of medical staff, and have the advantage of 24-hour uninterrupted service. However, the application of intelligent service robots in the medical field still faces some challenges, such as technical limitations, legal and ethical issues. In addition, there are also differences in patient acceptance and demand for intelligent service robots. Based on the summary of intelligent medical treatment, this paper will introduce the application of intelligent service robots, study the application and prospect of intelligent service robots in medical treatment and the innovation of intelligent service robots in business models. Through literature review, SWOT analysis and data, the paper explains the wide application of intelligent service robots and their future opportunities and challenges.

Analisis Efektivitas Program Pendidikan dan Pelatihan dalam Meningkatkan Kinerja Pegawai Rekam Medis

There is an era 4.0 where information and communication technology is maximally utilized. Medical records and registration are written evidence of the service process that contains the patient’s clinical data during the diagnosis and treatment process. Medical record management in hospitals is to support the achievement of orderly administration in order to achieve hospital goals, namely improving the quality of health services in hospitals by conducting education and training programs for employees. The purpose of this study is to measure the extent to which the success of the program, the success of the program objectives, satisfaction with the program, the level of input and output produced and the achievement of overall goals need attention from the organizers of education and training (diklat). This research is a qualitative research using primary data and secondary data. Data collection techniques in this study were through observation and interviews. The selection of informants in this study was carried out using purposive sampling method. The results of this study as what has been conveyed by the three informants can be said that the implementation of the education and training program (diklat) in xyz hospital has not been able to meet its objectives, namely to increase employee motivation, employee productivity, and organizational performance.

Electronic Health Record System using Blockchain Technology

The healthcare sector is frequently known for being delicate and intricate.Individuals' sensitive information must be kept safe, secure, and protected.Blocks of the blockchain are secured and bound to each other using cryptographic principles.
 By maintaining the patient at the centre of the medical ecosystem system and establishing greater security, interoperability, and privacy of stored patient records, blockchain has the potential to eradicate the problems ailing the industry and transform healthcare.
 By decentralizing and encrypting health records, blockchain ensures that patient data is securely stored and tamper-proof. Additionally, blockchain can facilitate the seamless exchange of medical information between different healthcare providers, leading to better coordination of care and reduced medical errors. By leveraging Ethereum's smart contract functionality, healthcare organizations can securely store and
 share patient data, ensuring its integrity and confidentiality. Moreover, Ethereum's programmable nature allows for the development of decentralized applications (DApps) that can streamline various healthcare processes, such as medical record management, supply chain tracking, and clinical trials. Overall, the integration of blockchain in the healthcare industry has the potential to revolutionize the way healthcare data is managed, ensuring privacy, security, and efficiency in patient care.

Secure Medical Records Through Big Data Analytics and Blockchain

As healthcare shifts to digital platforms, the healthcare sector is suffering from multiple security vulnerabilities that make it vulnerable to various types of cyberattacks. Therefore, robust security solutions need to be implemented to resolve these vulnerabilities. In this context, blockchain technology has emerged as a promising solution in several sectors, including the healthcare sector. This study harnesses blockchain technology to improve medical record management. By integrating blockchain, we address issues like data breaches and inefficient data sharing. The proposed study ensures a seamless health record exchange that is secure, transparent, and beneficial to both patients and healthcare providers. The goal of this study is to empower patients to be more in control of their data while streamlining processes and enhancing security for healthcare institutions. Medical records are increasingly secure, interoperable, and accessible when blockchain technology and big data are used. According to the study, healthcare workers recognize the importance of protecting medical records through blockchain technology and big data, which can improve security, interoperability, and accessibility. This minimizes concerns related to data manipulation while providing a more cost-effective and efficient method of managing medical records. Medical records management is made more cost-effective and efficient by reducing concerns related to data manipulation.

Current Situation, Challenges, and Improvement Strategies of Hospital Medical Record Management

Current Situation, Challenges, and Improvement Strategies of Hospital Medical Record Management

Application of the Caprini risk model in preventing deep venous thrombosis formation in patients with nephrotic syndrome.

To explore the effectiveness of the Caprini model in preventing Deep venous thrombosis (DVT) in patients with nephrotic syndrome (NS), in order to provide a reference for reducing poor prognosis in patients with NS. A retrospective study was conducted on 150 cases of NS patients treated at Zibo Central Hospital from January 2021 to January 2023. Their clinical data were collected from the medical record management system of the hospital. The patients were divided into two groups: an observation group (75 patients) who received Caprini risk evaluation at admission and designed interventions based on their risk level, and a routine group (75 patients) who received conventional interventions. Clinical data, including the occurrence of DVT, renal function, inflammation, complications and satisfaction with the work of medical staff, were compared between the evaluation and routine groups. The incidence of DVT in the observation group (6.67%) was significantly lower than that in the Routine group (17.33%) (P < 0.05). Three days after surgery, the difference in thigh circumference increased in both groups. However over time, the difference decreased, with the observation group consistently showing lower values (P < 0.05). On the fifth day after surgery, the D-D level was lower, and PT level higher in the observation group compared to the Routine group (both P < 0.05). Before intervention, 24 h urinary protein, BUN, SCr, WBC, Hs-CRP and IL-6 levels were similar between the two groups (all P > 0.05). After intervention, renal function and inflammation improved in both groups, with greater improvement observed in the observation group (P < 0.05). Additionally, the incidence of complications (except DVT) in the observation group (8.00%) was lower than in the Routine group (21.33%) (P < 0.05). Patients in the observation group also reported higher satisfaction with nursing and treatment. The Caprini score is an effective tool for guiding predictive care in NS patients, significantly reducing the risk of DVT. Additionally, implementing risk-based interventions according to the Caprini score enhances renal function, decreases the incidence of complications, and improves patient satisfaction with nursing and treatment.

Professional Ethics, Challenges and Opportunities for Blockchain Technology in Healthcare Sector: A Systematic Review

Background:: The healthcare sector faces numerous issues, such as insurance fraud, electronic medical record management, interoperability, insecure dissemination of information, etc. The novel Blockchain technology holds tremendous potential to transform the healthcare sector by addressing these rising challenges in the industry. It provides a secure platform for storing, disseminating, and retrieving sensitive patient data and health records while preserving the ethical principles of the healthcare sector. Method:: In this study, we systematically reviewed the literature on blockchain technology in healthcare using PRISMA and highlighted how blockchain technology might promote innovation and deliver major improvements in the healthcare sector. Result:: Our goal is to examine the present status of this discipline, focusing on limits and potential advances. Queries were used to gather Scopus, PubMed, SpringerLink, IEEE Xplore, and Web of Science publications that met the criteria for the selection of papers. Conclusion:: This article, thus, analyses the potential for blockchain in the healthcare industry and outlines blockchain-based products in healthcare. Our study enhances and complements prior healthcare blockchain research.

간호대학생의 디지털 헬스교육에 대한 인식과 기대

Purpose : This study aimed to explore the perceptions and expectations of nursing students regarding digital health education. Methods : We conducted focus group interviews among 10 nursing students in Seoul and Gyeonggi-do. Data were collected from July 31 to August 4, 2023. Results : The participants perceived various benefits and possibilities of digital health and expected it to help improve personalized nursing care and medical record management. Digital health may aid medical aspects, such as diagnosis, treatment selection, and predicting clinical outcomes. Participants also understood that digital health can aid patient location, emergency response, and health status monitoring. However, they recognized that patient safety and privacy are important when adopting digital health and that they need to be prepared and educated on digital security issues. Participants also recognized a need to understand the latest technologies and to develop digital competencies through digital health education, as well as the need for education in a practical environment and in using advanced technologies. Conclusion : Digital nursing competencies are considered part of the core competencies among nursing students to grow as future nursing professionals. Continual updating of their curriculum and improvement in field experience are considered the most important.

Revolutionizing the Medical Record Department with a Blockchain-Enhanced Nonlinear Approach to Medical Record Management (MRM) Systems

This work presents a thorough design and construction overview in order to meet the impending issues associated with conducting a groundbreaking project. The centerpiece is a cutting-edge, specially designed for government dentistry institutions, Blockchain-Enhanced Nonlinear Approach to Medical Record Management Systems. The system's goal is to keep patient data safely while offering a user-friendly interface, reliable backup systems, and security. In the first stage, a blockchain-based medical record system will be put into place, and medical staff members will be asked for vital information to be authenticated. The ability to save and manage patient data, including crucial information like patient classifications, is subsequently provided to these verified individuals. The system determines a patient's eligibility to pay medical care costs by intelligently classifying them into groups. For example, BPL holders, elderly residents, and convicts are not required to pay for medical care. This paradigm places a high priority on security, and the article presents the idea of cryptography inside the blockchain. A secret common key is used to assist the encryption and decryption operations that are applied to data. Sensitive medical information is protected by this cryptographic technique, which guarantees the secrecy of discussions between two entities. The data may be retrieved by using this private key, which guarantees the privacy and availability of patient records that are saved.

Factors Affecting Medical Records Management in Karakah Health Center Padang

Medical records are an administration system that starts from recording while the patient is receiving medical services, followed by handling medical record files which includes organizing storage and removing files from storage to serve requests/borrowing from patients or for other purposes. All health service facilities are required to maintain medical records, including community health centers (Puskesmas). Based on initial data collection observations, it was found that medical record management was still carried out manually, for the information system the government still used the BPJS system. The health center is still relatively new, so several problems are still found regarding the administration of medical records, one of which is numbering medical records, storage that is not yet ideal, unclear policies regarding standard operational procedures and a shortage of medical record officers. Currently the puskesmas only has one medical records officer who holds a D3 RM degree, the rest are assisted by officers who have high school/equivalent qualifications. This research was carried out from March to May 2023. The results of the research state that the storage of medical record files at the Parak Karakah Health Center is still not optimal and needs to be improved. Judging from the human resource elements which are still insufficient, the management of medical records has not been carried out well. The large number of files found that do not have folders is also a concern for the future. Storage carried out using a decentralized method is considered not optimal in community health centers because it creates separate medical record files. Ideally, storage in community health centers is carried out using a centralized system because it only accepts outpatients. Keywords: Medical record, Management, Health Center, Factors

Types of Patient Safety Incidents in Public Health Centers

Background: Developing a patient safety culture in the public health center is less significant than in hospitals. According to WHO, primary care services can prevent up to 80% of injuries, which accounts for half the global burden of patient injury. Objectives: This study aims to determine the type of patient safety incidents in public health centers in Surabaya. Methods: This research is classified as descriptive-analytic research with a cross-sectional research design, used secondary data collected through the monthly reports of "Public Health Center X" located in Surabaya in the period from January to July 2022. Results: The frequency of patient safety incidents was 65 cases consisting of order entry error (10.76%), administration error (24.61%), human error (10.76%), medical error (3.07%), healthcare-acquired infection (6.15%), patient falls (18.46%), medication error (13.84%) and technical error (12.3%). Most patient safety errors were considered preventable, and 29% of the errors from human error and patient falls were viewed as having the potential to cause serious harm to the patients. Conclusions: The types of patient safety errors are mostly administration errors, that occur in the management of medical record documents.

The Relationship Of The Completeness Of Filling In Medical Records With The Quality Of Medical Record Documents In Inpamentation Patients At Grandmed Lubuk Pakam Hospital In 2023

Medical records are one of the important parts in shaping the implementation of service delivery to patients in hospitals. Completeness of filling out medical records that are accurate, complete, and timely is needed in health services to fulfill the requirements in medical record management. Completeness of filling out medical records with the quality of medical record documents has a very significant role where the higher the completeness of filling out medical records, he higher the quality of medical record documents. This study aims to determine the relationship between the completeness of filling out medical records and the quality of medical records document for inpatients at Grandmed Lubuk Pakam in 2023. The method used in this research is analytic observational with cross sectional research design. The population of thes study were all medical record files of inpatients and sampling using simple random sampling technique as many as 77 files. The study was conducted by checking the observation sheet on the medical record files of hospitalized patients. Data analysis of this study used chi square test with 95% confidence level, (? = 0,05). The results showed that there was a retionship between the completenees of medical record filling and the quality of medical record documents for inpatiens ( p = 0,001 &gt; 0,05 ). It is hoped that hospital will pay more attention to the completeness of filling out medical records on each sheet (form) in order to improve and maintain the quality of hospital services.

Clinical Information System Using Extreme Programming Method

Clinic is a health service facility that organizes individual health services and provides basic and/or specialist medical services. If the clinic does not use a computerized system, it will hamper the patient handling process. Obstacles were found at the Rantauprapat Internal Clinic Clinic, including patient registration which was still done manually with patients having to fill out paper forms directly to the clinic, not having a queuing system for treatment, medical record management which was still manual by handwriting. This can take a lot of time in the data search process. The purpose of this application is to facilitate daily operational activities in clinics that run quickly and precisely, as well as medical data management to be more accurate (minimizing human error). The analysis method uses the Soft System Methodology (SSM), and the system development method uses Extreme Programming (XP). This website-based application uses the PHP programming language which is supported by the MySQL database. Based on blackbox testing, all features can run/100% valid. This information system helps the work process in the clinic to be faster, documenting structured medical records, reducing paper use, and facilitating activities in patient care.

TATA KELOLA REKAM MEDIS BERBASIS TEKNOLOGI INFORMASI UNTUK LAPORAN INDEKS PENYAKIT POLI JANTUNG DI RSUD AL - IHSAN

At this time, technology is generally used to help the completion of work to be easier, faster and more accurate. One of the uses of technology in medical record management is an important part of success in implementing good corporate governance which aims to ensure that health service organizations are responsible for continuously improving the quality of their services and guaranteeing the provision of services with high standards by creating an environment where excellent service. Utilization of visual basic information technology in medical management which is intended to facilitate officers in the process of collecting data related to heart disease up to the process of analyzing and reporting. The research method used is a quantitative method with a descriptive approach. With data collection techniques in the form of observation, interviews and literature and using the waterfall system development method. The purpose of this study is that with this disease index data system, it is hoped that it will make it easier to make reports and can speed up the process of making disease index reports every month for reporting to the hospital management department.

TATA KELOLA REKAM MEDIS BERBASIS TEKNOLOGI INFORMASI DALAM PENANGANAN KERAHASIAAN DAN KEAMANAN DATA PASIEN DENGAN METODE KRIPTOGRAFI

Confidentiality and security of patient data in hospitals is very important and data protection is mandatory. In this study, a problem was found, namely that there was no guarantee of protecting the security and confidentiality of patient data which allowed the data to leak. This study aims to design an information technology-based medical record governance system to maintain the confidentiality and security of patient data. The research technique uses a qualitative methodology with a descriptive approach and collects data through observation, interviews and literature studies. While the waterfall method is used to develop the system through the stages of needs analysis, design, implementation and testing. The system design was carried out using Microsoft Visual Studio 2010 which was implemented using the AES (Advanced Encryption Standard) Rijndael cryptography algorithm. The results of the research that has been done are obtained that the existence of information technology-based medical record governance in handling the confidentiality and security of patient data using AES cryptography can increase the confidentiality and security of patient data in medical record management.

TATA KELOLA REKAM MEDIS BERBASIS ELEKTRONIK DALAM MONITORING PASIEN HEMODIALISA DI RSUD AL-IHSAN

This study aims to analyze the implementation of electronic-based medical record management using the waterfall method in monitoring hemodialysis patients at AL-IHSAN Hospital. The results of our research show that there are still manual hemodialysis patient services, namely dialysis scheduling services for hemodialysis patients, that have previously been scheduled by specialist doctors. What is currently being done is that management is still manual, so it requires time and accuracy to schedule when patients will be scheduled for dialysis. The research method that we use in our current scientific work is qualitative with a descriptive approach using the waterfall software design process. Then distributing questionnaires and interviews. This approach allows stakeholders to clearly understand system requirements and execute each development phase sequentially. Electronic-based medical record management results in increased efficiency in the process of monitoring hemodialysis patients, especially routine scheduling of patients who are already integrated with the system. Information that is well documented and available centrally reduces the need to search physical records or fill out forms manually. This saves medical staff time and effort, allowing them to focus on patient care.