Medical Record Officers Research Articles

Analysis of the Completeness of Medical Records in RSJ. Prof. Dr. Saanin Padang

Complete medical records are very useful for knowing in detail the patient's history, examinations that have been carried out, and planning further actions. To achieve this, the medical records department is obliged to carry out quality monitoring by carrying out quantitative, qualitative, and statistical analysis. To know whether a medical record file is complete or incomplete, it is necessary to carry out a quantitative analysis, namely four reviews consisting of an identity review, recording review, reporting review, and authentication review. Based on the results of a preliminary study with existing medical record officers, it was stated that every patient's medical record file received from inpatient care was always assessed for completeness but was still not optimal, and incomplete values ​​were always obtained. One of the problems, among others, is in terms of input, namely the high workload of medical record officers, facilities, and infrastructure, especially storage space and technology, which are not yet optimal. It is important to discuss this problem so that researchers research to find out the completeness of medical record files in RSJ. Prof. HB. Saanin Padang City. This research was carried out in March 2024 at RSJ. Prof. HB. Sa'anin Padang. From the study, it was found that the highest percentage of completeness in filling out identification components was the name item at 97.98%, the highest percentage of completeness in important report components was found in the discharge summary form, CPPT and General consent each at 100%, the percentage of completeness in the recording method component was highest in You can use item type x at 100%. In the medical record file, no type-x was used. There is a need for policies regarding filling rules and periodic audits regarding the completeness of medical record files. Keywords: Completeness, Medical record, files, hospital, analysis.

Perancangan Sistem Informasi Pengolahan Data Morbiditas Rawat Inap Guna Menunjang Tata Kelola Pelaporan Rawat Inap

Morbidity is a crucial aspect that must be reported regularly, specifically quarterly (RL4a). This study aims to support the governance of inpatient unit reporting, especially in the aspect of morbidity, and make it easier for medical record officers as system users to process morbidity data of inpatient unit patients into a report that is needed quickly, accurately, and efficiently. This research is qualitative, and data is collected using observation techniques. This research's system development method is the waterfall model, which is a consecutive development method analogous to a waterfall that flows across all project stages. Designing an inpatient morbidity data processing system to support inpatient reporting governance is described using a flow map, Context diagram, Data flow diagram, and Entity relationship diagram. Then, it was implemented into the website using Microsoft Visual Studio Code using the Hypertext Preprocessor, Javascript programming language, and supported by MySQL as a data store. This study results in a system that can quickly process the morbidity of inpatient units, make the extensive ten disease reports, and reduce user error. Therefore, the governance of inpatient reporting can run accurately and efficiently.

Perancangan Sistem Informasi Pengolahan Data Rekam Medis Elektronik Guna Menunjang Tata Kelola Pelaporan Rawat Jalan

Recording and reporting medical records is the main activity in health service institutions, and hospital information systems play an essential role in this process. Outpatient data processing at XYZ Hospital uses spreadsheets and Google Sheets even though it has yet to implement SIMRS fully. Because the data in the SIMRS must be changed for each spreadsheet report, there are several reporting problems. Therefore, the authors begin to develop a web-based outpatient reporting system after researching the need for more efficient applications. This study uses a qualitative approach to data collection through interviews and observations, focusing on developing a waterfall software. The results showed that searching and managing patient data and making outpatient recapitulation reports became easier for medical record officers. Implementing this system brings several concrete impacts, including reducing human errors in data recording, increasing the speed of access to medical information, and increasing time efficiency in making reports. This system also allows better data integration between hospital departments, improving patient care coordination and the overall quality of health services.

Tinjauan Pengetahuan Petugas Rekam Medis Dalam Peralihan Rekam Medis Manual Ke Rekam Medis Elektronik Di Puskesmas Kabupaten Tapin

Information and Communication Technology (ICT) systems have become an inseparable part in various aspects of life, including health services. Electronic Medical Records (RME) is a form of application of ICT in the health service system through computerization of patient data. RME development requires an assessment of the readiness to implement RME from the aspects of human resources, governance leadership, organizational culture and infrastructure. This study aimed to research is to determine the knowledge of medical records officers in transitioning manual medical records to electronic medical records at the Tapin Regency Health Center. The results of this study indicate that most of the medical record officers' knowledge is in transition manual medical records to electronic medical records mostly 17 people (60.7%) have sufficient knowledge. It would be better if the education of medical records officers at community health centers is well-educated behind the medical recorder so that they can carry out services in the medical records unit well and competently in their field because with appropriate education it will influence the officers' knowledge to be better and training is held to increase knowledge for medical record officers regarding the use of Electronic Medical Records (RME).

ANALISIS BEBAN KERJA REKAM MEDIS BERDASARKAN METODE WORKLOAD INDICATOR STAFF NEED (WISN) DI RSUD SUNGAI LILIN

The WISN (Workload Indicator Staff Need) method is an indicator that shows the amount of staff needed in health facilities based on workload, so that the allocation/relocation is easier and more rational. Services in hospitals are administrative in nature, namely service that is orderly, neat and thorough. In addition, because other people are facing it, efforts must be made to be fast and not create queues, so a sufficient number of officers or health workers is needed. to calculate the medical record workforce at Sungai Lilin Hospital. This research uses quantitative research with a descriptive approach. The data collection method in this study was observation, direct interviews with officers at Sungai Lilin Hospital. it is known that the available working time is 2,088 hours/year or 125,280 minutes/year, the workload requirement for medical record officers in the medical record room is 642,959 minutes, the calculation of the standard time allowance is 0.15 minutes. The calculation of the medical record workforce in the medical record room is 4 workers. 3 people are already in the medical record room. So we need 1 more worker.

Perencanaan Kegiatan Retensi Rekam Medis di Rumah Sakit Islam Jakarta Pondok Kopi

Medical record retention (shrinkage) is the reduction of archives through the process of sorting documents 5 years after the patient dies or the last date of treatment. This study aims to plan medical record retention activities at RSIJ Pondok Kopi to overcome the problem of file accumulation, improve the efficiency of medical record management, and support better health services. This study uses a qualitative descriptive method and is sourced from 4 informants consisting of the head of medical records and medical record officers, in attracting informants using purposive sampling techniques. In the initial observation, the Jakarta Islamic Hospital Pondok Kopi has not resumed retention of medical records for the last 4 years due to hospital policies regarding service priorities. The results of this study indicate that RSIJ Pondok Kopi already has adequate retention SOPs, but has not retained medical records since 2020. This has resulted in the accumulation of medical record files in the storage room. Based on the results of the study, it can be concluded that RSIJ Pondok Kopi needs to immediately implement medical record retention to overcome the problem of file accumulation. The retention activity plan was made as input for retention so that it can overcome the problems in the medical record unit due to not having medical record retention.

Factors influencing the intention to use the ICD-11 among medical record officers (MROs) and assistant medical record officers (AMROs) in Ministry of Health, Malaysia.

The transition of ICD has never been a straightforward initiative. As nations transition to ICD-11, ensuring its acceptance among the users is essential. To our knowledge, there are limited studies about the instrument and ICD-11 adoption. Therefore, the purpose of this study was to design an instrument and investigate the factors influencing the intention to use the ICD-11 among medical record officers (MROs) and assistant medical record officers (AMROs) at Ministry of Health (MOH) Malaysia facilities. Based on the current literature, a model based on the decomposed theory of planned behaviour (DTPB) was proposed. The model consisted of 13 dimensions and 12 hypotheses identified from previous studies. Using PLS-SEM, 185 survey data points were analysed. The study findings showed that ten factors have a significant impact on the suggested model. Users' subjective norm was the most influential factor in their intention to use ICD-11. Unexpectedly, perceived usefulness and was found to have no significant influence. This study is important for policymakers in strategising ICD-11 implementation efforts. This study's novelty lies in applying a DTPB theory model in the context of the intention to use ICD-11.

Pengaruh Kompetensi PMIK Terhadap Kinerja Petugas Rekam Medis Di Rumah Sakit Angkatan Udara Dr. Esnawan Antariksa

This research was conducted with the aim of determining the influence of PMIK (Medical Recorder and Health Information) professional competence on the performance of medical record officers at the Dr. Air Force Hospital. Esnawan Antariksa. The research method used is quantitative with inferential analysis. The data collection techniques used were observation, interviews and questionnaires. The sampling technique used a total saturated sampling technique of 14 people. Obtained from 7 PMIK competency standard indicators (Noble Professionalism, Ethics and Legal, Introspection and Personal Development, Effective Communication, Health Data and Information Management, Clinical classification skills, Disease coding and other Health Problems as well as Clinical Procedures, Health Statistics Applications, Basic Epidemiology, and Biomedicine, Management of Medical Records Services and Health Information, there are still 2 indicators in the percentage that are not good, and in the 5 performance indicators of medical record officers (Quality of Work, Quantity of Work, Supervision, Attendance, Conservation) there are still 2 indicators in the percentage not good. It was found that 3 officers had a D-III RMIK education and 11 officers still had a high school education. Based on the results of the T test, it was found that the Sig. value was 275. It could be concluded that there was no influence of PMIK competency on the performance of medical records officers.

PELATIHAN MANAJEMEN REKAM MEDIS DAN INFORMASI KESEHATAN PETUGAS REKAM MEDIS SEBAGAI CLINICAL INSTRUCTUR (CI) DI PUSKESMAS KAB.CIREBON

Education and training is one of the efforts to increase human resources and a series of activities or efforts that are carried out continuously, gradually and integratedly. The training was carried out to develop Clinical Instructor competency in organizing student clinical practice activities at community health centers. The limited knowledge of Clinical Instructors in terms of competencies that must be achieved by practical students influences the implementation of clinical practical learning and when giving assessments. One of the competencies that must be achieved during clinical practice is the basic management of medical records. This research aims to increase CI's knowledge and competence in implementing clinical practice guidance for students. The method used is training with several stages of activities, namely competency identification analysis in the form of training system design, then implementation of activities, and evaluation. The increase in competency is proven by an increase in post test results from an average pre test score of 71.59 and an average post test result of 87.73. The evaluation results of training implementation can be assessed on 4 scales, namely training implementation, speakers, materials, etc. Each scale has an average value of 3.5, these results prove that the training implementation process is in the good category. Implementation of training can improve the competency of medical record officers as Clinical Instructors in administering clinical practice students at community health centers.

ANALYSIS OF INSTALLING HISTORY SUMMARY FORM IN AND OUT OF ADULT PATIENTS IN KINDERGARTEN HOSPITAL. IV KENCANA SERANG

Background: A summary form of admission and discharge history is a medical record form that is used to record a summary of the course of the disease from the time the patient enters until the patient leaves the hospital. Therefore, it is one of the forms that are immortalized, so it is necessary to design a design that is in accordance with the standards.Research Objectives: To identify the physical aspects, anatomical aspects, and aspects of the contents of the summary form of admission and discharge history of adult patients at the Kindergarten Hospital. IV Kencana Serang in 2022. Research Methodology: This study used descriptive research with observation and interview methods. The subjects in this study were medical record officers and the object in this study was a summary form of admission and discharge history of adult patients. The research instrument used observation sheets and interview guidelines. Research results: From the physical aspect, the material is HVS 75 gram paper, rectangular shape, HVS F4 paper size, the color of the paper is white with black ink writing. From the anatomical aspect, the heading in the form of the title of the form has been included, the subtitles are missing, the name of the hospital has been included, the hospital logo is not included, the revision number is not included. page numbers are included. Introduction in the form of the title of the form. Instruction in the form of * Adult and child patients. Body in the form of top margin (5 cm), bottom margin (2 cm), side margin (1.5 cm), back margin (1.5 cm). Spacing 1.15 spaces. Vertical and horizontal rules. Type Style Times New Roman with font size 11. The way of recording is done by handwriting. Close in the form of a clear name and signature has been included. From the aspect of content, the completeness of the data items is appropriate. Terminology / Terms in the form of diagnosis, complications, anesthesia, transfusion. Abbreviations in the form of Date, Goal, NRP, NIP, Kls, dr, Sp, Lk / Pr, Is / Kk / Kp / H / B, S / N / J / D. The symbol is the symbol * Adult and child patients. Suggestion: It is necessary to redesign the entry and exit history summary form for adult patients from the physical, anatomical and content aspects.

DISCLOSURE OF MEDICAL RECORD INFORMATION TO GUARANTEE LEGAL ASPECTS OF CONFIDENTIALITY OF MEDICAL RECORDS IN TIRTAYASA PUSKESMAS

Background Medical Record according to Permenkes No.269/Menkes/Per/III/2008, Medical Record is a file that contains notes and documents about the patient's identity, examination results, treatment that has been given to the patient. Health facilities are responsible for protecting health information contained in medical records against possible loss, damage, falsification and unauthorized access. Maintaining information security, accuracy of information and ease of access to information are demands of health service organizations and health practitioners as well as authorized third parties. Meanwhile, parties who need information must always respect patient privacy. Overall, security, privacy, confidentiality and safety are devices that fortify information in medical records [1]. The purpose of this study was to determine the review of the release of medical record information in ensuring the legal aspects of the confidentiality of medical records at Kencana Hospital. Research method The research design used is descriptive research, which is a research method whose purpose is to present a complete picture of the social setting by describing a number of variables that are relevant to the problem and the unit under study among the phenomena being tested. This type of research is used to determine the process of providing medical record information and guaranteeing the legal aspects of medical record confidentiality at Kencana Hospital. The population in this study were all officers involved in the process of providing medical record information at Kencana Hospital which had 8 employees, which were divided into 3 medical record officers (1 head of medical records and 2 people served as distribution and retrieval officers), 2 people who handles related to insurance and 2 officers handles related to BPJS. In this study, the sample used was the party from the medical record unit, namely the medical record officer who has the authority in the process of providing patient medical information to a third party. The instruments used are Checklist Sheets and interview guidelines. In this study, the sampling used was purposive sampling technique because in sampling the authors considered certain things related to the research, The results of the research on StandardOperating Procedures related to providing patient medical information at the Kencana Hospital have an SOP. This SOP contains points for the process of releasing patient medical information, each point with a slightly different procedure depending on who the 3rd party is requesting. What is meant by 3rd parties here are patients, insurance companies, and legal institutions (courts). Each of these 3rd parties has made their respective procedures. The parties involved in the process of releasing patient medical information at Kencana Hospital are all medical record officers totaling15 people (8 officers in the filing section), (2 people in the distribution of medical record files), and (5 people in the registration section). The information released is in the form of a photocopy of a medical resume sheet. At Kencana Hospital, the only party who can decide on the release of patient medical information is the medical record officer. Kencana Hospital does not yet have special security related to the process of releasing patient medical information, but if a patient is represented in the process of requesting release of information, the representative must have a power of attorney from the patient concerned. If the request for release of information is not represented, the patient will be given a release approval form from the medical record unit. Suggestion It is better to make Standard Operating Procedures related to the Release of Patient Medical Information referring to the Regulation of the Minister of Health of the Republic of Indonesia Number 36 of 2012 concerning Medical Secrets and Guidelines for the Implementation and Procedures of Indonesian Hospital Medical Records issued by the Director General of Yanmed.

PENGARUH TATA RUANG REKAM MEDIS AKTIF TERHADAP PRODUKTIVITAS PETUGAS REKAM MEDIS DI RSUD SUMEDANG

The aim of this study is to find out how the spatial layout of active medical records affects the productivity of medical records officers at RSUD Sumedang. In this study, quantitative methods are used, with data collected through questionnaires. The data analysis used is simple linear regression analysis. The results of the study showed that the layout of the active medical record has a significant impact on the productivity of medical record officers in RSUD Sumedang. Therefore, it can be concluded that the structure of active medical records has a significant effect on the production of medical records officers at RSUD. To improve the efficiency and productivity of medical records officers, it is necessary to improve the spatial structure of active medical records and the quality of training.

ANALISIS PENYEBAB DAN JENIS KERUSAKAN REKAM MEDIS PASIEN RAWAT INAP DI RUMAH SAKIT ANGKATAN DARAT TINGKAT IV DR. R. ISMOYO KENDARI

Background: Based on the results of observations made in September 2022-December 2022 in the medical record storage room of the Tk. IV Dr. R. Ismoyo Kendari, there were 427 inpatient medical records and 254 (59%) inpatient medical records that suffered damage caused by physical, chemical and biological factors. The purpose of this study was to determine the causes and types of damage to the medical records of inpatients due to physical, chemical and biological factors in the medical record storage room of the Tk Army Hospital. IVDr. R. Ismoyo Kendari.Methods: This study used a qualitative analytic descriptive design, especially the cross sectional type. The sample in this study consisted of 4 medical record officers, namely 1 Head of Medical Records, 1 Secretary of Medical Records, 1 registration officer and 1 filling officer in the medical record storage room of the Tk Army Hospital. IV Dr.R.Ismoyo Kendari and 254 medical records of inpatients in September 2022 - December 2022 who were damaged. The research instrument used observation, checklists, and interview guidelines. Results: The results of this study indicate that physical factors, chemical factors, and biological factors cause damage caused by negligence of officers, exposure to sunlight, dust, ink, rust, mold, and insects. Conclusion:The conclusion of this study found forms of damage such as torn, detached/missing medical record forms, and yellow to brown in color as a result of physical factors, chemical factors, and biological factors.

Optimalkan Pelayanan Kesehatan Masyarakat: Pemahaman Mendalam Tentang Rekam Medis Elektronik Bagi Petugas Rekam Medis Di Puskesmas Tabunganen

This community service aims to optimize healthcare services by enhancing the knowledge of medical record officers at Puskesmas Tabunganen regarding electronic medical records. In order to achieve this goal, a profound understanding of EMR becomes a crucial key, particularly for medical record officers. By comprehensively understanding the concepts and implementation of EMR, medical record officers at Puskesmas Tabunganen are expected to improve the efficiency of health data management. This community service makes a positive contribution to preparing the health center for the implementation of electronic medical records. This community service has a positive impact on preparing Puskesmas Tabunganen for the implementation of electronic medical records.

Peran Penting Rekam Medis Elektronik Dalam Transformasi Digital Di Puskesmas Tabunganen

This community service aims to enhance the knowledge of medical record officers regarding electronic medical records. Electronic medical records have been adopted in community health centers as a technological innovation to optimize public health services. A profound understanding of EHR by medical record officers is crucial in improving the efficiency and effectiveness of health services. Community health centers face the risk of lagging behind in EHR implementation due to their large scale and small number. This community service provides a positive contribution in preparing Tabunganen Community Health Center to implement electronic medical records.

KORELASI KETEPATAN PENCATATAN TERMINOLOGI MEDIS DAN KEAKURATAN KODE DIAGNOSIS MORBIDITAS RESPIRASI DI RUMAH SAKIT MUSLIMAT MALANG

Based on Permenkes No. 55 of 2013 concerning the Implementation of Medical Recorder Work states that coding patient diagnoses must be carried out by medical record officers who have competence related to disease classification and codification. This research method is quantitative with a cross-sectional approach. The research variables are medical terminology accuracy and diagnosis coding accuracy. The sample for this study consists of outpatient medical records for respiratory diseases in December 2022 at Muslimat Singosari Hospital in Malang. The results of this research showed that the accuracy of medical terminology based on the use of terms is 81%, the accuracy of medical terminology based on the use of abbreviations is 83%, and the accuracy of respiratory disease diagnosis code is 80.3%. Based on the Chi-Squared test results, the p-value is 0.042. Therefore, with a p-value of 0.042 < alpha value of 0.05, it is interpreted that H0 (null hypothesis) is rejected and H1 (alternative hypothesis) is accepted, indicating a relationship between the accuracy of medical terminology and the accuracy of respiratory disease diagnosis codes at Muslimat Singosari Hospital in Malang. The suggestions to consider include standardizing or establishing medical terminology in accordance with ICD-10 and the Dorland's dictionary, implementing clearer regulations regarding reference guidelines for diagnosis coding to minimize inaccuracies in diagnosis codes, and appointing employees with relevant medical record qualifications to their respective roles.

Human Resources Needs for Medical Records Officers at the Mataram City Health Center

Human resources are the most important and integral part of any organization, including the health sector. Therefore, this study aimed to examine human resources needs in the medical records field, with a particular focus on the roles and responsibilities of medical records officers. The analysis was carried out to identify critical challenges faced by medical record officers in meeting health service standards and managing patient data. Secondary data were collected from a survey of workload and human resources needs for medical records in 2023. The samples were selected using the Stratified Sampling method, by dividing the population into two groups (strata) based on the accreditation levels of health centers in Mataram city. Specifically, Tanjung Karang represented the main accredited center, while Babangan was categorized as a basic accredited center. Data analysis was performed with the Workload Indicators of Staffing Need Method (WISN) to calculate labor requirements and health crew members necessary for evaluating the distribution of health worker availability. The results showed the scarcity of medical record officers, difficulties in managing patient data, as well as the need for training and skills development in line with advances in information technology within the health sector.

Discovery and Analysis of Documentation Systems and Medical Record Service Procedures at Hospital Nacional Guido Valadares

Prepare information to facilitate the service process to patients and facilitate managerial decision making by clinical and administrative service providers in hospitals. This study aims to identify problems, root causes, carry out identification of alternative solutions, develop programs as selected solutions, and intervention plans to improve the causes of documentation systems and procedures for medical record services at Hospital Nacional Guido Valadares. This research is qualitative research. The subjects of the study were representatives of section heads and unit heads, representatives of medical record officers. Data collection is observation, interviews, documentation, recorder, Focus Group Discussion (FGD), Urgency Serousness Growth (USG) and brainstorming. Results of root cause identification using fishbone diagram and 5 why's analysis, alternative solutions using FMEA, risk priority number (RPN). The result of this study is that the officer provides medical record documents belonging to patients taken home, new patients do not bring referral letters from doctors, do not bring Electoral cards or other identity cards. Old patients forget to bring their identity cards for treatment, come back not according to the doctor's appointment. Suggestions for socialization efforts continue to be carried out to educate, remind patients and officers about the documentation and procedures that have been established and periodic evaluations.

ANALISIS TERJADINYA MISFILE REKAM MEDIS TERHADAP PENYIMPANAN DI PUSKESMAS MUKAPAYUNG

The purpose of this study is to find out how misfiles that occur in medical records are related to storage at the Mukapayung Health Center. The research was conducted using a qualitative descriptive method, namely analyzing and describing the data and explaining in full the results obtained regarding the occurrence of misfiles. The results showed that there were errors in filling out medical records because of the educational level of the 5 officers, only 2 (40%) had medical records, 3 (60%) did not have medical records. Medical record training of the 5 officers who received training, only 2 (40%) and 3 (60%) did not receive training. Based on the research results in the first quarter of 2023, out of 50 samples of medical record files, 19(38%) files were lost, 36(56%) files were not lost, on February 17 (34%). missed files, 33(66%) missed files, on March 14(28%) missed files 36(56%) missed files. Medical record officers 2 PNS medical record staff and 3 honorary no medical record staff. Elements of the SOP method regarding the management of medical records already exist but are incomplete and there is no specific SOP regarding the storage and return of medical record data. Suggestion Conduct regular training for staff on proper filing procedures and the importance of maintaining accurate medical files. This will improve staff understanding and reduce the possibility of misfiles.
 Keywords: Misfile,Medical Record,Storage.

TATA KELOLA REKAM MEDIS BERBASIS ELEKTRONIK DALAM PENGELOLAAN LAPORAN PASIEN RAWAT INAP BPJS KESEHATAN MENGGUNAKAN MICROSOFT VISUAL STUDIO

In medical records, patient report management is very important for hospitals in collecting data if there are new or old patients who have been treated will make it easier to find patient data. The Medical Recorder section in charge will carry out the data processing process by inputting user data, doctor data, diagnosis data, visit type data and polyclinic type data. Furthermore, the medical recorder, namely the reporting section, will get the information to be used as material for making patient data reports, BPJS Health inpatient visit reports. In the process of making reports of BPJS health inpatients at hospitals, there are still shortcomings. The obstacle in the process of making BPJS health inpatient reports is that the medical record file has not been filled in completely so that work becomes hampered and there are often delays in submitting reports. The purpose of this study is to design an electronic-based medical record information system in making BPJS health inpatient reports at hospitals. In this discussion, the research used is using qualitative methods in a descriptive approach. In collecting problems, the authors used observation methods and interviews with medical record officers. Inpatient reporting officers are the subject of research while BPJS health inpatient data is the object of research. The result of this study is the design of an information system for reporting inpatients of BPJS health at hospital. 
 Keywords: Report, Medical Record, Hospitalization, BPJS Health