Medical Record Service Research Articles

KELENGKAPAN FORMULIR ASSESMEN MEDIS RAWAT JALAN DI RSUD TONGAS

One effort to improve the quality of health services is by improving the quality of medical record services, including completeness and accuracy in providing information for health service needs. The completeness of filling out the outpatient medical assessment form at Tongas Regional Hospital, Probolinggo, still contains incomplete medical record forms, which affects patient information and routine reports made by medical records officers. The aim of this research is to identify the percentage of completeness of outpatient medical assessments at Tongas Probolinggo Regional Hospital. This type of research uses quantitative methods based on a descriptive approach, data collection techniques use random sampling techniques, this technique is used to take samples randomly and come from members of the population and data was collected using observation and literature review techniques using the Slovin formula with the results of 92 medical record forms. The results of the completeness of filling out outpatient medical assessments at Tongas Probolinggo Regional Hospital from 92 medical records taken in January 2024 showed a percentage of completeness of 95% and incompleteness of 5%.

Hubungan Kualitas Informasi Terhadap Kepuasan Pengguna Layanan Rekam Medis Elektronik (RME) di Rawat Jalan RSU Queen Latifa Yogyakarta

Introduction: The application of electronic medical records is increasing in developing countries, including Indonesia. Electronic medical records are increasingly being implemented in hospitals to achieve improved service quality. The increasing number of hospital investments in information systems indicates that hospitals understand the importance of end-user and system-user satisfaction. User satisfaction is one way to determine the effectiveness and success of an information system. Research explains that information quality influences user satisfaction. Research objective: to determine the relationship between information quality and user satisfaction with electronic medical record services at outpatient hospital Queen Latifa Yogyakarta. Research Method: this research is quantitative. The population is officers who input medical record data into Sitiql (electronic medical records). The sampling technique uses accidental sampling. The sample was 81 people. The data collection technique uses a questionnaire. Data analysis uses Spearman rank. Research results: explain that the p-value is 0,596, namely that there is no relationship between the quality of information and the satisfaction of users of electronic medical record services at RSU Queen Latifa Yogyakarta. Conclusion: Information quality cannot increase user satisfaction with electronic medical record services at RSU Queen Latifa Yogyakarta.

Analysis of Storage Spaces to Support the Health Service System at Santosa Hospital Bandung Central in 2021

One of the health services provided by the hospital is the medical record service. The implementation of good medical file storage through systematic procedures is one of the keys to the success of health service, it is also one of this study was to determine the medical record storage space, the obstacles that occurred, and the effort made in the storage room at the Santosa Hospital Bandung Central. The research method used is descriptive qualitative research, by describing the relevant data. Data collection techniques in the form of interviews and document studies. From the results of the study it can be said that the layout and environment for storing medical records at Santosa Hospital Bandung Central is appropriate, the number of visits that continues to increase is not comparable to the medical record storage space contained in the storage room, the use of medical records is an effort made by Santosa Hospital Bandung Central. The use of electronic medical records overcomes problems in the storage space so as to minimize disruption of health services provided by the Santosa Hospital Bandung Central to patients.

Tinjauan Faktor Yang Mempengaruhi Waktu Tunggu Pelayanan Pendaftaran Pasien Rawat Jalan Di RS DKT Sidoarjo

One form of administrative service at the hospital is the medical record service. The problem in the medical record installation at DKT Sidoarjo Hospital is the waiting time for outpatient medical record services. Based on Permenkes RI No.129/Menkes/SK/II/2008 for patient medical record services at outpatient registration, namely > 10 minutes. This study aims to determine the factors that influence the waiting time for medical record services at outpatient registration at DKT Sidoarjo Hospital. The research method is descriptive with instruments in the form of observations and interviews conducted with the head of medical records and medical records officers in the registration section. The results of this study indicate that the factor that greatly influences the waiting time for medical record services at TPPRJ DKT Sidoarjo Hospital is medical record activities, namely the provision of medical records in the storage section. On the Man Factor, namely the number of officers and educational qualifications of officers who are not from medical records. On the Money Factor there are no funds for the education and training of registration officers and no rewards for officers who are disciplined and friendly in service. In the Methode Factor the use of Registration SOP is not optimal. In Material Factors there is no use of tracers on storage racks. On the Machine Factor, namely frequent errors on SIMRS when performing services.

Tinjauan Pemberian Kompensasi Terhadap Produktifitas Kerja Petugas Rekam Medis Di Rumah Sakit Tere Margareth Tahun 2022

An employee can be said to be productive if he is able to produce goods or services as expected in a short or precise time. The population of this study is medical records officers in the medical records room at RSU Tere Margareth. The sample size is 5 RM employees. The instrument in this research used interviews with respondents who were RM officers at RSU Tere Margareth. The research results showed that the distribution of respondents' answers based on interviews showed that the identification of the Main Duties of Officers in the Hospital Medical Records Unit. Tere Margareth already has a medical record service manual No. Kep/095/I/2019 as follows regarding working time arrangements at Tere Margareth Medan Hospital, divided into 2 work shifts. The performance of medical records officers at Tere Margareth Hospital has two meanings, where first, compensation and performance are directly proportional to the implementation of the quality of work of medical records officers, where from the results of interviews it was found that officers felt very happy, enthusiastic and eager to carry out their responsibilities if their work compensation was increased. However, in the second aspect, whether or not there is compensation for medical records officers, they are still enthusiastic about doing their work because it is their responsibility to do daily work without having to be lured by high compensation. This indicates that awareness of the work responsibilities of medical records officers in Tere Margareth Hospital is good. Based on the results of the research conducted, it can be concluded that RSU.Tere Margareth should pay attention to officer compensation, so that it can help in increasing the productivity of medical records officers at Tere Margareth Hospital, Medan City and officers must also be aware that without compensation, officers continue to work and are responsible for his job.

Hubungan Kualitas Pelayanan Rumah Sakit dengan Kepuasan Pasien Rawat Inap di Rumah Sakit

One aspect that needs to be considered in medical record services in the registration section in order to have good quality is the quality of service of officers in providing medical record documents. Medical record services provided in the registration section are registration services, searching and distributing medical records, the Methods used, namely literature review, can be used to understand and describe the current state of research in fields related to the topic under study. The results showed that there was a positive and significant relationship between service quality and patient satisfaction in the hospital, the Relationship between Hospital Service Quality and Patient Satisfaction in Hospitals is a concept that shows that the quality of service provided by the hospital affects the level of patient satisfaction. The results showed that there is a positive and significant relationship between service quality and patient satisfaction in the hospital. Conclusion In the research conducted, there are patients who are dissatisfied with hospital services and patients who are satisfied with hospital services. This shows that the quality of service provided by the hospital affects the level of patient satisfaction. Therefore, it is important for hospitals to improve the quality of services provided in order to increase patient satisfaction and provide better health services.

Implementation of Sanctions for Health Facilities that Have Not Implemented Electronic Medical Records (EMR)

Hospitals are health care institutions that provide inpatient, outpatient, and emergency services. One of the services in the hospital is medical record services. This medical record stores various records regarding the identity, examination, treatment, actions, and other services performed on the patient. Along with the development of technology, medical records are present in digital form or called Electronic Medical Records (RME). The purpose of this study is to analyze sanctions for health facilities that have not implemented Electronic Medical Records (RME). The research method used is a literature review with a qualitative approach. The results show that with the regulatory provisions and sanctions, the implementation of RME is expected to improve the overall standard of health services. In accordance with circular number HK.02.01/MENKES/1030/2023, health facilities that do not comply with the RME implementation deadline may face administrative sanctions, including recommendations for revocation of accreditation status. These sanctions also apply to health facilities that have not integrated with the SATUSEHAT Platform by March 2024 or have not submitted patient visit data as required. This regulation is not only a guide, but also an encouragement for health service delivery to become more sophisticated, efficient, and safe through the implementation of RME.

An Evaluation of Application Use in Outpatient Reservation at Bunda Thamrin RSU Medan

Hospitals need to implement a management system that is oriented towards patient satisfaction. The hospital has an outpatient registration system which aims to register patients and manage patient data for treatment until they are discharged from the hospital. This research is a qualitative descriptive study with research subjects or informants consisting of 7 informants including the head of the medical service installation, the person in charge of the medical record service and the online reservation officer. In this study data analysis was carried out by triangulating sources, techniques and time and continued with reduction. data, presenting data and drawing conclusions. The research results show that the planning process for using the application in outpatient reservations at Hospital Bunda Thamrin Medan has gone well, but the results are still not optimal, which can be seen from the number of registered patients and the number of patients taking the queue. In conclusion, the use of the application in outpatient reservations at Hospital Bunda Thamrin Medan has gone well. Keywords: Application use, Patient reservations, Outpatient care

Strategy For Developing Medical Record Service Capabilities For Health Human Resources At Pertamina Pangkalan Brandan Hospital In 2023

Human resource development is basically a strategy to improve the performance of health workers which reflects the ability of organizational members to work, meaning that the performance of each health worker is assessed and measured according to criteria determined by the hospital organization. This research aims to analyze development of medical record service capabilities for Health Human Resources. This type of research is quantitative using a cross-sectional study.This research conducted inPertamina Pangkalan Brandan Hospitalon the monthSeptember 2022 to Mayin 2023.The sample in this study was all health workers who worked at Pertamina Pangkalan Brandan Hospital,namely as many as 140 people. Data analysis was carried out using univariate and bivariate analysis. Based on the research results, it is known that there is an impact on the development of human resources using the on-the-job training method in the field of Medical Records services, there is an impact on the development of human resources using the demonstrator and example training method in the field of Medical Records services, there is an impact on the development of human resources using the Apprenticeship training method in the field of Medical Records services in Pertamina Pangkalan Brandan Hospital in 2023. Based on the conclusions, it is hoped that the Training Team, which is likened to activating and managing human resources in Pertamina Pangkalan Brandan Hospital, should always be able to evaluate the training needs of its employees. The training required by each nurse, such as new nurses, staff who have worked for a long time, will of course be different.

Evaluasi dan Pengembangan Sistem Informasi Rekam Medis Berbasis Cloud: Transformasi Pelayanan Kesehatan

The problem that is often encountered in medical record services at the hospital, is that processing registration data is less efficient and effective because it still uses manual bookkeeping as an archive so there are several obstacles such as difficulties in searching patient data and the risk of data redundancy. When the patient does not bring a medical card, there is a risk of damage or loss of patient data, as well as the risk of accumulation of patient data books which require special storage space. Therefore, in this research a medical record information system was built using the waterfall method, which consists of requirements, design, implementation, verification and maintenance. Based on the results of white box testing, the cyclomatic complexity is 27, region = 27 and independent path = 27, which shows the system is running well without errors. Furthermore, UAT (User Acceptance Testing) testing resulted in a percentage of 81.5% from 10 respondents indicating the system received good responses from users.

Supporting and Inhibiting Factors in Implementing Electronic Medical Records (EMR) Policy in Indonesia

Health service facilities are obliged to provide quality services to patients. The increasingly rapid pace of information technology has influenced digital health services, one of which is through Electronic Medical Record (EMR) services. EMR, can improve the quality of health services for patients. The government issued a policy regarding medical records through the Indonesian Ministry of Health’s Regulation Number 24 of 2022 on Medical Records mandating that all health facilities implement EMR by December 2023. However, health facilities have not fully complied this policy. Based on the monitoring of the SATU SEHAT implementation, only 61.42% of health service facilities in Indonesia have adopted EMR due to several obstacles related to human resources, infrastructure, and management elements. This research aims to analyze the supporting and inhibiting factors in the implementation of the EMR policy in health service facilities in Indonesia. The research used a narrative review method by searching for articles using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline, resulting in16 journals that were the required criteria. The analysis of these 16 articles show that, in general, health service facilities in Indonesia are ready to implement EMR. However, the implementation of the EMR policy faces inhibiting factors, such as unprepared IT infrastructure, lack of EMR implementation guidelines, and insufficient human resource training. Supporting factors include policies regulated by the Ministry of Health and government facilitation in implementing EMR. To achieve success in implementing the EMR policy, efforts are needed to improve IT infrastructure, improve the quality of EMR, develop strategies for EMR implementation, and provide continuous government assistance from the to health service facilities.

Determining Factors For The Accuracy Of Diagnosis Codes Using ICD-10 In Obstetric Cases: Riview Systematics

Medical record coder has complete duties, responsibilities, authority and rights to carry out medical record service activities in health service units. The accuracy of the disease diagnosis code is crucial, the accuracy of the diagnosis code will affect the claim for treatment costs, the allocation of health resources and the accuracy of hospital statistical data. This research systematically reviews articles uses the PRISMA diagram to help sort articles to use, also have criteria: research data is data from Indonesia, uses Indonesian or English, the article was published 2018-2023, the article can be downloaded in full and is not a thesis. This research searched articles through the Google Scholar database, Garuda Portal and Research Gate. As a result of the review of the 7 articles, it is known that inaccurate diagnosis codes in obstetric cases are caused by 7 different factors. The most influential factors are information in MRD (Medical Record Document) is written as unclear or incomplete. The second reason is MRD is not double-checked or inspected and the last is code errors in categories and sub-categories.

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.

Gambaran Beban Kerja Unit Rekam Medis Rumah Sakit Tingkat IV Kesdam Jaya Cijantung

Introduction: The medical record service unit is a supporting service in a hospital. The competence of medical staff greatly influences the quality of the workload in the implementation of the medical record unit. Objectives: This study aimed to find an overview of the Medical Record Unit Workload System at Level IV Kesdam Jaya Cijantung Hospital. Method: This research is a type of descriptive research with a qualitative approach. Descriptive research with a qualitative approach is based on observation or in-depth interviews which are used to collect accurate data to provide an overview of the workload in the medical records unit at Tk.IV Kesdam Jaya Cijantung Hospital. In this research, in-depth interviews were conducted with 5 informants. Data collection methods use interview techniques, observation, and document review. Result: Based on the results of research at the medical record unit at Kesdam Jaya Cijantung Hospital, the existing human resources do not meet the educational qualification standards. There is no SOP from the hospital regarding the distribution of working groups for each employee. The division of tasks has been well structured and structured, but there are still some obstacles in implementation. Employees still often do double jobs due to several high demands. Conclusion: The effectiveness and efficiency of the medical records department at Level IV Kesdam Jaya Cijantung Hospital are classified as very good in several divisions. This kindness is assessed from the time worked, the amount of energy, and the tasks that exist. However, judging from the educational qualifications of human resources, workspace, and inadequate facilities

Inovasi Pelayanan Publik dalam Meningkatkan Kinerja Puskesmas Patimpeng di Kabupaten Bone

This research aims to find out the innovation of state civil apparatus in improving public service performance. Innovation in public services will be largely determined by a tradition that applies in an agency, building creativity, besides that the available space is often an obstacle to the creation of innovation ideas that are launched. This then becomes the focus of this research, namely innovation in improving the performance of public services. The idea of innovation is based on the slow service and the number of patients who lose their health cards, the limited number of patients who get services, namely 20 to 30 people a day. With the duration of medical record services previously 15 minutes after the innovation is not enough 5 minutes because the patient only mentions the house number. With administrative services until 15.00. This research was conducted at Patimpeng Health Centre, Bone Regency, which focuses on resource support, reward and punishment systems, organisational environment, budget support and personal based organisation as well as institutional strengthening in supporting the blessing innovations launched at Patimpeng Health Centre, Bone Regency. The research method used in this research is qualitative descriptive. The data collection process is interviews and documentation, and observation then the data obtained is reduced, coding the data to sort out the data in accordance with the indicators in the study and then drawing conclusions based on interview data, observation and documentation. The number of respondents in this study were 5 people consisting of puskesmas officers, the community and also the leadership of the Bone Regency health office. The results of this study found that the innovations carried out are still constrained by human resource support, budget limitations and also the understanding of the community regarding the new service system so that institutional strengthening still needs to be improved for the sustainability of these blessed innovations.

ANALISIS KESIAPAN IMPLEMENTASI REKAM MEDIS ELEKTRNIK DITINJAU DARI SUMBER DAYA MANUSIA DAN SARANA DAN PRASARANA DI RUMAH SAKIT UMUM DAERAH Dr. DARSONO KABUPATEN PACITAN PROVINSI JAWA TIMUR

Technological developments have made the medical record paradigm develop from traditional paper to digital/electronic, and the implementation of PMK Number 24 of 2022 concerning medical record in 2023. Implementation of medical record services at RS Dr. Darsono, Pacitan Regency, the obstacles that are often encountered are delays in sending outpatient medical records, errors in collection and storage, increasingly limited storage space for medical records as the number of patients increases, ambiguity in filling out medical records so that it is possible for misinterpretation to occur among users of the record data. medical. This research aims to determine the readiness to implement electronic medical records from the human resources and infrastructure aspects. This research design uses descriptive research methods with a qualitative approach. The research sample is RME users consisting of doctors, nurses, medical records officers, and IT personnel. The sampling technique is purposive sampling. The research instrument uses an interview guide. Data analysis methods include data reduction, data presentation, and conclusion. The research results from human resources and infrastructure aspects are quite ready to implement RME. In the HR aspect of the service, officers are available, in IT, programmers are still needed to develop the RME system and HR needs to receive training. In terms of infrastructure, both infrastructure and financial aspects are available to support the implementation of RME, but there needs to be additional facilities to support the smooth running of RME. Dr Darsono Hospital needs to carry out a needs analysis to prepare for the implementation of RME and compatible infrastructure and competent human resources to support the implementation of RME. Keywords: Electronic medical records, human resources, infrastructure

Improving cloud storage and privacy security for digital twin based medical records

As digital transformation progresses across industries, digital twins have emerged as an important technology. In healthcare, digital twins are created by digitizing patient parameters, medical records, and treatment plans to enable personalized care, assist diagnosis, and improve planning. Data is core to digital twins, originating from physical and virtual entities as well as services. Once processed and integrated, data drives various components. Medical records are critical healthcare data but present unique challenges for digital twins. However, directly storing or encrypting medical records has issues. Plaintext risks privacy leaks while encryption hinders retrieval. To address this, we present a cloud-based solution combining post-quantum searchable encryption. Our system includes key generation using Physical Unable Functions (PUF). It encrypts medical records in cloud storage, verifies records using blockchain, and retrieves records via cloud. By integrating cloud encryption, blockchain verification and cloud retrieval, we propose a secure and efficient cloud-based medical records system for digital twins. Our implementation demonstrates the system provides users efficient and secure medical record services, compared to related designs. This highlights digital twins’ potential to transform healthcare through secure data-driven personalized care, diagnosis and planning.

Hepatitis C Treatment for Patients Without Insurance in a Student-Run Free Clinic: Analysis of Demographics, Cost, and Outcomes

Background: Hepatitis C virus (HCV) predominantly affects marginalized patients, who have been reported to lack access to effective treatment. A high overlap exists between those at risk for HCV and those cared for by student-run free clinics. The purpose of this study is to present how one student-run free clinic provides accessible HCV care to patients as a model for other free clinics to offer similar services.
 Methods: Data was reviewed from the electronic medical record and MedData Services, a software for management of patient assistance program (PAP) applications. Data collected included information regarding HCV diagnosis, treatment, and medication access process.
 Results: At our clinic, there were 23 patients with a documented diagnosis or prior history of HCV infection. Treatment was initiated in 83% (n = 19) of patients, and 89% (n = 17) of these patients completed treatment. Most patients (84%, n = 16) received HCV medications directly through Shade Tree Clinic. All but three patients were treated with Harvoni®. All patients with available laboratory data (n = 13) at >12 weeks status-post treatment had achieved sustained viral response. PAP applications were successfully approved for 89% (n = 17) of submitted applications (n = 19), representing the primary avenue for our clinic to access HCV treatments.
 Conclusions: Our experience with HCV demonstrates that effective HCV treatment is feasible in a student-run free clinic setting.

Overview of Waiting Time for Provision of Outpatient Medical Records Based on Minimum Service Standards (SPM) at dr. Mintohardjo Hospital, Jakarta, Indonesia

Timely provision of outpatient medical records results in quality medical record services. The time for providing outpatient records according to minimum service standards is ≤ 10 minutes. This study aimed to determine the length of waiting time for outpatient medical records at dr. Mintohardjo Hospital. The method in this research uses a descriptive method with a quantitative approach. The sampling technique used accidental sampling with a sample size based on an estimated proportion of 106 medical records. The research results showed that 14 medical records (13.2%) were on time and 92 medical records (86.8%) were not on time, most of which were not on time, namely > 31-40 minutes, 31 medical records (29.2%). In identifying the causes of delays in providing outpatient medical records, researchers used the 5M factors. Man factor of occurrence of misfile, there are medical records that have not been returned from the polyclinic or inpatient room, and there is a lack of knowledge and education. The money factor has not yet been budgeted for repairing the Roll O Pack. The material factor for printing loan receipts and medical records is not automatic in the SIMRS application, and only 1 printer machine is available out of 7 computers, so the number of printers needs to be increased. Machine factor occurs Roll O Pack damage and interference with software from downtime (the time when a system, application, and service cannot be accessed/does not function) in the SIMRS application. The method factor is that there is no SOP for providing outpatient medical records.

Aplikasi Rekam Medis Pada Puskesmas Bulukandang Berbasis Android Dengan Metode Waterfall

Medical records are patient record files containing patient examinations and examination histories from the initial patient treatment until they are needed again. At the Bulukandang Health Center, there are obstacles in the patient's medical record service, because recording is still carried out using a hybrid system. The hybrid filing system used by the Bulukandang Health Center is in the form of physical documents and archiving of paper documents. The purpose of this research is to create a Medical Record application at the Bulukandang Health Center based on Android. Before this application is built, this application is first designed using Figma. Then this medical record application was built using Android Studio software, accessing the data with get and post methods through the RESTFUL API. The Waterfall method is used in system development. Based on the results of Black Box testing the application built can be used without errors and bugs. Based on testing using the usability scale obtained a score of 81 from 10 respondents' responses, indicating that a score of 81 for the Acceptability Ranges version was obtained Acceptable. So that this application can help staff and employees of the health center, so that work is more effective and efficient.