Record Section Research Articles

FAKTOR YANG MEMPENGARUHI KEAKURATAN DATA SENSUS HARIAN RAWAT INAP DI RSUD DR. R SOEDARSONO PASURUAN

The process of operational planning and hospital decision making is assisted by the SIMRS system. Based on a preliminary survey conducted in the Medical Records section of RSUD doctors, R. Soedarsono found 400 SIMRS patient data and 300 manual patient data. Because staff members enter the same patient data multiple times, some of this data is duplicated. Information collected daily from short-term and inpatients is used for ongoing screening considerations from day to day, week to week, and month to month. The aim of this research is to find out what influences the accuracy of SIMRS daily inpatient census data. A quantitative approach with descriptive methods was used for this research. The subject of the examination was a medical records officer, while the object of exploration was a PC gadget. The results of the examination showed a variety of officers' information regarding using SIMRS: 20% inadequate, 40% adequate, and 40% good. The SIMRS strategy was seen as half inappropriate and half inappropriate, while the hardware was 60% complete and 40% short. Medical record officers should receive training on how to calculate daily inpatient census data correctly.

Grid-search method for short-term over long-term average parameter tuning: an application to Stromboli explosion quakes

The collection of a significant catalogue of seismo-volcanic data involves the selection of relevant parts of raw signals, which can be automatised by using the short-term over long-term average (STA/LTA) method. The STA/LTA method employs the “Characteristic Function” to describe a section of a seismic record in terms of trace amplitude and first-time difference. This function is calculated in a short-term and long-term window; the ratio between the two windows defines a quantity that is controlled through threshold values, i.e., trigger on and trigger off. These threshold values indicate whether there is an increase in the energy in the seismic signal compared to the background noise. The common approach to the selection of the STA/LTA values is the adoption of literature-suggested ones. This could be a limitation as there may be cases in which a choice adapted to a specific raw signal may significantly help in the extraction of the relevant parts. To overcome the possible drawbacks of a non-adaptive choice imposed by such standard literature values, in this study, we propose a methodology for the automatic selection of STA/LTA values that can optimise the extraction of explosion quakes (EQs) from a seismo-volcanic raw signal. The values are obtained through a grid search over an index named quality–numerosity index (QNI) that measures the accordance in the automatic cuts and the consequent number of triggered seismo-volcanic events with the ones suggested by a human expert. The method was applied in the volcano domain for the specific application of the explosion quake signal extraction at Stromboli volcano. The experiments were conducted by selecting a subset of the dataset as training where to search for the best values, which were subsequently adopted in a test set. The results prove that the values suggested by our approach significantly improve the quality of the relevant part compared to the one extracted by adopting the values indicated in the literature. The methodology presented in this study can be applied to a wider typology of signals of volcanic, seismic, and other origin, potentially becoming a widely used approach in parameter optimisation processes.

Assessment of the quality of oral squamous cell carcinoma clinical records in oral surgery with Surgical Tool for Auditing Records (STAR) scoring

BackgroundThe Surgical Tool for Auditing Records scoring system [STAR] focuses on surgical record auditing with promising outcomes. It offers a structured approach to evaluating the quality of surgical notes.Aims and objectivesThis study aimed to assess the effectiveness of the STAR in evaluating oral surgical records and identifying areas for improvement in documentation practices.Materials and methodsThe data was obtained from the Dental Information Archival Software (DIAS) of our institution. The sample size was determined using G*Power 3.1.9.4 software. Fifty consecutive oral surgery clinical records of oral squamous cell carcinoma patients were evaluated using STAR. Each record was reviewed for adherence to documentation standards including Initial Assessment (10 points), Follow-up Entries (8 points), Consent Documentation (7 points), Anesthesia Report (7 points), Surgical Log (9 points), and Discharge Synopsis (9 points). compiling a total STAR score (50 points). The data was tabulated in Google Sheets. The descriptive statistics with inter-observer agreement and the mean score were recorded.ResultsWe observed that each of the 50 records received a score of 49/50 points on the STAR. Deductions were necessary in the Operative record section due to the lack of information regarding the sutures used.ConclusionTo summarize, this study emphasizes the effectiveness of the STAR scoring system in evaluating the quality of oral surgical records. Identifying deficiencies, particularly in documenting operative details, can improve the completeness and accuracy of patient records. It can ultimately enhance patient care and facilitate better communication among healthcare professionals.

Generation and evolution of the Choiyoi granitic magmatism based on U-Pb zircon studies, Cordón del Portillo, Frontal Cordillera (Argentina)

Based on a relevant geochronological U-Pb zircon dataset (n = 47) from a sample (PBL-109) of the Cerro Punta Blanca pluton (CPB), which is part of a calc-alkaline suite, we corroborate the development of protracted magmatic activity with three major crystallization events for this Permian magmatism: 278 ± 1, 283 ± 2, and 289 ± 2 Ma, which outcrop in the Cordón del Portillo, Cordillera Frontal (CF) of Argentina. These ages can be assigned to the lower section of the magmatic record of the Choiyoi magmatism (ca., 290-265 Ma), while the age of 289 Ma represents the oldest known age for the Choiyoi, indicating the start of this magmatism during the Artinskiense. Considering these geochronological data, we postulate the presence of a deep mush reservoir where protracted magmatic activity permitted the prolonged crystallization of antecrysts (ca. 283–289 Ma). Migration of the parental magma from the mush reservoir zone occurred near the time of emplacement and culminated in the formation of an ephemeral magma chamber at shallow levels, where zircon autocrysts crystallized (ca. 278 Ma). Age spectra reported within individual samples support the idea of massive magma migration when conditions were favorable (e.g., thermally matured crust). In this view, the studied “older” Choiyoi magmatism represents a continuous magmatic event lasting 11 Ma and corresponds to a single magmatic episode rather than different periods of magmatic activity and subsequent emplacements. A later alkali-calcic magmatic event is recorded at 265 ± 4 Ma from a sample of the Cerro Bayo pluton (MH-0113), which could represent the end of the lower section of the Choiyoi magmatism. Whole-rock Sm-Nd, Rb-Sr, and Lu-Hf data in zircon, along with ages reported for the studied igneous and inherited zircon from the CPB; together with isotopic data and ages from the detrital zircon found in the Carboniferous accretionary complex of Chile, indicate that the source of the Permian parental magma in this region was a heterogeneous continental crust mainly formed by Devonian and Carboniferous rocks, related probably to a magmatic arc. However, some contribution from the Carboniferous accretionary complex of Chile to the parental magma should be consider.

Intraperitoneal Onlay Mesh Repair (IPOM) versus Intraperitoneal Onlay Mesh Repair with Closure of Fascia Defect (IPOM Plus) for Ventral Hernias: Retrospective Analysis of Postoperative Outcomes

Background: Intra-peritoneal onlay mesh (IPOM) repair, a type of Laparoscopic Ventral Hernia Repair (LVHR), comprises bridging the defect from the peritoneal side with a composite mesh. Recently, IPOMPlus has become the recommended type of LVHR in which the defect in the fascia is sutured before placing the mesh. Materials and Methods: This study is a retrospective cohort study conducted at Dharan Hospital, Salem. Patients who had undergone IPOM-Plus or IPOM during January 2020 to June 2021 were selected. Data regarding demographics, intra-operative and post-operative outcomes were collected from medical record section. Patients were followed up for 6 months. Data analysis was performed using SPSS version 26.0 taking a p-value of <0.05 as statistically significant. Results: A total of 74 patients were included in this study, out of which 34 patients had undergone IPOM (Group A) and 40 patients underwent IPOM-Plus (Group B). In both the groups, there was no statistical difference in demographic variables except more number of umbilical hernia in both the groups compared to epigastric and paraumbilical hernia. Hernia defect size and mean operative time were varied significantly (p-value < 0.05) in both groups. More number of seroma formation (p=0.021), pseudosac at first OPD visit (p=0.020) and pseudosac at 6 months (p=0.027) in Group A compared to Group B. Conclusions: IPOM plus repair is safe with possible advantages over a standard IPOM repair in patients with ventral hernia in term of postoperative outcomes. Keywords: Ventral hernia, IPOM, IPOM Plus, Laparoscopy

Identify Characteristics Patient Chronic Kidney Failure at Dr. R. Soetijono Hospital Blora

Background research based on the Global Burden of Disease (GBD) study shows that chronic kidney failure has been shown to be the main cause of death in the world. Kidney failure is one of the four diseases that can cause a high financial burden. Purposes is to know description of a case of chronic renal failureat Dr. R. Soetijono Hospital Blora for the period January 2021 to December 2022. Research methods used is the Retrospective Descriptive method using secondary data in the form of medical records / patient status stored in the Medical Records section of Dr. R. Soetijono Hospital Blora, period January 2021 to December 2022. Research result in the period January 2021 to December 2022, there were 221 cases of Chronic Kidney Failure, most of whom were adults and seniors, the gender was predominantly female, which is suspected to be the influence of kidney estrogen, as for the factors causing Chronic Kidney Failure, most of the patients had a history of Diabetes Mellitus with Hemodialysis therapy, and There was an increase in the number of cases by 27% from 2021 to 2022. Implications: The increase in the number of cases of Chronic Kidney Failure will have an impact on the readiness of health services in preparing facilities, resources, costs and technology to overcome problems that occur in CKF patients. Conclusion research that promotive and preventive efforts are very necessary in dealing with cases of Chronic Kidney Failure in adults with a history of Diabetes Mellitus.

Quality Indicators of Colonoscopy: Are we meeting the standards in Nepal?

BACKGROUND Colonoscopy is an important tool for management of colorectal disorders. Performance of quality colonoscopy requires a trained endoscopist, adequate resources, preparation and evaluation parameters for good outcomes. We conducted this study to emphasize the importance of quality practice in colonoscopy in our country as there is lack of standardization. METHODS This is a retrospective observational study done at a referral center in Western Nepal. All the colonoscopies were done without sedation with two sachets of peglec powder 137.15 grams, each containing polyethylene glycol (118grams) dissolved in 2 liters of clean water each. Data of 1052 colonoscopies done during three years were retrieved from colonoscopy record section and analysed for important quality measures in use. Data entry and analysis was done in Microsoft Excel. RESULTS A total of 1052 colonoscopies were included in this study. Pain abdomen (70.6%) was the commonest indication for colonoscopy and majority were male patients (53.4%). Good bowel preparation was achieved by split dosing of commercially available polyethylene glycol. Cecal and ileal intubation was achieved in 98% and 96% colonoscopies respectively, meeting the current recommendations set by the gastroenterology societies. No major complications occurred during the procedure. CONCLUSION Important quality indicators could be achieved with colonoscopy done without sedation in resource limited settings also. Screening colonoscopy should be promoted for early detection and management of colorectal cancers in low-income countries like Nepal. Quality should be standardized and practiced in routine colonoscopy examination taking into consideration of patient comfort.

Ultrasound evaluation of scar thickness for prediction of uterine dehiscence in term women with previous caesarean sections.

To determine the role of ultrasound in evaluation of scar thickness for prediction of uterine dehiscence. This retrospective cross-sectional study was conducted in the Radiology department of Aga Khan University Hospital from 1st July to 31st December 2021 after approval from the University Ethic Committee. In this study pregnant women 18 to 40 years with a live singleton fetus with vertex presentation, at term, with history of prior caesarean section and availability of medical record were included. Using a curvilinear ultrasound transducer with optimally distended urinary bladder, the myometrial thickness was measured in the sagittal plane. The intraoperative visual findings of the lower uterine segment outcome at the time of C-section were recorded and categorized into two groups i.e., with and without dehiscence for statistical analysis. A total of 126 women were included. The mean age of the study participants was 29.8±4.1. The median gestational age was 35 (34-37) weeks. The highest AUC 0.58 was recorded for the scar thickness of ≤2.5mm with a sensitivity, specificity, PPV and NPV of 80.9%, 36.4%, 36.3% and 80.8% respectively. Similarly, the AUC for the scar thickness of ≤2mm was 0.55 with a sensitivity, specificity, PPV and NPV of 93%, 18.2%, 18.2% and 93% respectively. Transabdominal Sonography is a safe technique to determine the LUS thickness during antenatal ultrasound at term. A cutoff value of ≤2mm showed a high sensitivity and negative predictive value of 93% for evaluating the risk of uterine dehiscence.

Improving Basic English Skills in Health Workers, Especially in the Medical Records Section at the Kuranji Health Center, Padang City

Improving Basic English Skills in Health Workers, Especially in the Medical Records Section at the Kuranji Health Center, Padang City

Analisis Pengetahuan, Sikap Dan Motivasi Kepatuhan Dokter Spesialis Dengan Pengisian Rekam Medis Pasien di Instalasi Rawat Inap RS X Jakarta

Completeness in filling of medical record files by doctors will be able to facilitate other health workers in providing action or treatment to patients, and can be used as a source of data in the Medical Record section in data management and reports that will be used as useful information for hospital management in determining evaluation and development of health services. At this time at RS X based on the Quality of Medical Records, the completeness of filling in the Medical Records of inpatients for the period January –Desember 2023 is still 59%. The purpose of this study was to analyze the compliance analysis of doctors filling out patients Medical Records at the inpatient installation of RS X Jakarta in 2023.The study was conducted with a cross sectional design, using a sample of 60 specialist doctors at RS X. Data were analyzed by Chi Square. Sources of Data This research is primary data collected by the method of distributing questionnaires as a research instrument.The results of the study concluded that there was a significant relationship between age, gender, knowledge, attitudes and motivation of doctors with compliance in filling out medical records with p-value ˂ 0.05. There is no significant relationship between tenure and compliance in filling out medical records with p-value = 0.452 ˃ 0.05. The most dominant relationship in physician compliance in filling out medical records is Doctor's Knowledge and Motivation with p-value = 0.000 ˂ 0.05. Dominance of knowledge and motivation of doctors in filling out medical records. The suggestion is that the knowledge and motivation of doctors really need to be a concern and the hospital management should consider things related to improving the quality of doctors in filling out medical records. Knowledge improvement in regulatory updates, SOPs and procedures for filling out medical records is very important. The use of electronic medical records can provide great benefits for health services such as hospitals.

A Retrospective Study of Imaging of Invasive Rhino-Orbital-Cerebral Mucormycosis in the COVID-19 Pandemic in a Tertiary Care Center.

Aim The study aims to analyze the imaging findings of invasive rhino-orbital-cerebral mucormycosis (ROCM) in patients who had COVID-19. Materials and methods This retrospective descriptive study was done on confirmed (culture and histopathology) patients who had a COVID-19 infection. The data was collected from the record section from May 2021 to June 2021. Imaging data were analyzed, and findings were tabulated according to statistical methods. Results Radiological evaluation, including CT and MRI, was done in 48 cases. The ethmoid sinus was the most common sinus involved in 60.41% of cases, followed by the maxillary sinus (52.09%). Unilateral pansinusitis was observed in 21 cases (43.75%). Among periantral extensions, retroantral fat involvement was the most common finding, seen in 24 cases (50%). Lamina papyracea and the walls of the maxillary sinus were involved in eight cases (16.67%). A total of 38 cases (79.17%) exhibited involvement of the extraconal compartment, while 32 cases (66.67%) showed involvement of the intraconal compartment. In intracranial involvement, infarct was noted in 13 cases (27%), and cavernous sinus involvement in nine cases (18.75%). Conclusions ROCM is a life-threatening fungal infection in immunocompromised patients, especially diabetics. Imaging of ROCM plays a pivotal role in early diagnosis, the extent of disease, surgical planning, prognosis, and the response to treatment. Radiologists must know the imaging features and patterns of extension of ROCM.

Long-Term Outcomes Associated With β-Lactam Allergies

β-lactam (BL) allergies are the most common drug allergy worldwide, but most are reported in error. BL allergies are also well-established risk factors for adverse drug events and antibiotic-resistant infections during inpatient health care encounters, but the understanding of the long-term outcomes of patients with BL allergies remains limited. To evaluate the long-term clinical outcomes of patients with BL allergies. This longitudinal retrospective cohort study was conducted at a single regional health care system in western Pennsylvania. Electronic health records were analyzed for patients who had an index encounter with a diagnosis of sepsis, pneumonia, or urinary tract infection between 2007 and 2008. Patients were followed-up until death or the end of 2018. Data analysis was performed from January 2022 to January 2024. The presence of any BL class antibiotic in the allergy section of a patient's electronic health record, evaluated at the earliest occurring observed health care encounter. The primary outcome was all-cause mortality, derived from the Social Security Death Index. Secondary outcomes were defined using laboratory and microbiology results and included infection with methicillin-resistant Staphylococcus aureus (MRSA), Clostridium difficile, or vancomycin-resistant Enterococcus (VRE) and severity and occurrence of acute kidney injury (AKI). Generalized estimating equations with a patient-level panel variable and time exposure offset were used to evaluate the odds of occurrence of each outcome between allergy groups. A total of 20 092 patients (mean [SD] age, 62.9 [19.7] years; 12 231 female [60.9%]), of whom 4211 (21.0%) had BL documented allergy and 15 881 (79.0%) did not, met the inclusion criteria. A total of 3513 patients (17.5%) were Black, 15 358 (76.4%) were White, and 1221 (6.0%) were another race. Using generalized estimating equations, documented BL allergies were not significantly associated with the odds of mortality (odds ratio [OR], 1.02; 95% CI, 0.96-1.09). BL allergies were associated with increased odds of MRSA infection (OR, 1.44; 95% CI, 1.36-1.53), VRE infection (OR, 1.18; 95% CI, 1.05-1.32), and the pooled rate of the 3 evaluated antibiotic-resistant infections (OR, 1.33; 95% CI, 1.30-1.36) but were not associated with C difficile infection (OR, 1.04; 95% CI, 0.94-1.16), stage 2 and 3 AKI (OR, 1.02; 95% CI, 0.96-1.10), or stage 3 AKI (OR, 1.06; 95% CI, 0.98-1.14). Documented BL allergies were not associated with the long-term odds of mortality but were associated with antibiotic-resistant infections. Health systems should emphasize accurate allergy documentation and reduce unnecessary BL avoidance.

The response of ostracod faunal assemblages to hydrology, lake level, and carbon cycling in a Jamaican marl lake: a palaeolimnological investigation

Abstract. Ostracod taxa from shallow freshwater lakes are sensitive to a range of limnological factors including temperature, hydrological habitat, lake level, and the distribution of aquatic plants. Ostracod assemblages preserved in Quaternary lake sediments can be used to reconstruct limnological change and are therefore potentially valuable palaeoenvironmental proxies. However, lack of autecological information about some taxa may limit the validity of such reconstructions. We use fossil ostracod assemblages recovered from radiocarbon-dated late Holocene sediments from Wallywash Great Pond, a small, shallow freshwater lake in southwestern Jamaica, to reconstruct limnological change over the past ∼ 1800 years. We circumvent ongoing taxonomic and ecological uncertainties associated with the identification of fossil ostracod taxa by drawing on observations of the ecology of ostracods found living in Jamaican water bodies. By combining this information with limnological data from the extant lake, and with sedimentological and isotopic data from the lake sediments, we show that a published interpretation of ostracod assemblages for the late Quaternary of Wallywash Great Pond is simplistic, at least for the late Holocene section of the sediment record. We conclude that changes in ostracod assemblages are linked to variations in the input of undersaturated groundwater to the northern part of the lake from which the core was recovered. These variations, which were driven by changes in the precipitation / evaporation ratio (effective moisture), also controlled sedimentation, with reduced effective moisture and a decline in undersaturated groundwater input favouring marl precipitation, whereas organic sediments are linked to increased effective moisture and enhanced groundwater input. Our findings suggest that the dramatic shifts in ostracod assemblages at this site are a complex response to changes in hydrology, sedimentology, and carbonate saturation rather than being a simple indicator of lake-level change. Combining ostracod assemblage data with the results of other palaeolimnological analyses also allows more detailed reconstructions to be made for this lake, and such a multiproxy approach is recommended for similar lakes elsewhere.

Traumatic spinal spondyloptosis presenting in a tertiary care unit in central Nepal

Introduction Traumatic spinal spondyloptosis, though rare, harbingers a high risk of mortality as well as permanent and disabling neurological deficits. They invariably become socially aloof and marginalized in most parts of our subcontinent owing to the lack of dedicated rehabilitation units amid their poor economic status. There is a paucity of studies pertaining to such rare epiphenomenon within our region. Materials ad Methods A retrospective study of 16 patients presenting with spinal spondyloptosis in a tertiary care center in Nepal was undertaken. The clinical records of the patients were retrieved from the hospital record section to study the demographic variables, modes of injury, American Spinal Injury Association (ASIA) grades, salient radiological characteristics, management strategies, and the resultant clinical outcomes. Result The mean age of the cohorts in our study was 40 years with an age range of 25-80 years. Most of the patients presented in ASIA ‘A’ neurological grade (75%). The cervical spine was involved in the majority (68.75%) of cases. 8 (50%) patients left against medical advice, 2 (12.5%) were managed conservatively, and 6 (37.5%) were operated. The posterior-only approach was undertaken in 4(66.67%) cases. Tracheo-oesophageal fistula occurred in 2 (33.33%) patients. And cerebrospinal fluid (CSF) leak occurred in 2 (33.33%) patients. The overall hospital mortality was 3(37.5%). Conclusion Traumatic spinal spondyloptosis on our center mostly involved cervical spine (68.75%). 75% of the patients presented with ASIA ‘A’ neurological grade. 50% of them left against medical advice. 37.5% were operated. The overall hospital mortality was 37.5%. This study emphasizes the implementation of a national spinal trauma data bank and the systematic implementation of dedicated neuro-rehabilitation units. This will thereby help improve the clinical outcome among these ‘socially aloof’ and marginalized subsets of neurosurgical patients.

A prospective audit on adult thromboprophylaxis and therapeutic anticoagulation prescribing and administration practices in Galway University Hospitals

Abstract Introduction Anticoagulants are high-alert medications that can cause significant patient harm if used inappropriately.[1] These preparations have been identified as a significant medication safety concern in Galway University Hospitals and are one of the most frequently reported medication incidents in Ireland.[2] A key performance indicator agreed by the local Medication Safety Subgroup and Drugs and Therapeutics Committee was to conduct an anticoagulation audit against local guidelines to identify patterns and develop quality improvements. Methods A prospective audit was conducted over six weeks from September to November 2022 by five interprofessional data collectors using a data collection tool and accessing drug records and clinical notes. Development of the tool was guided by national[1] and local guidelines as well as design input from local expert specialist doctors and pharmacists. Adult inpatients on all wards receiving thromboprophylaxis (after 24 hours of admission) or therapeutic anticoagulation were included. Paediatrics and psychiatry were excluded. The protocol and tool were approved by the local Clinical Audit Committee, piloted with three inpatients, and communicated to all data collectors prior to commencement. Generated data were anonymous and securely stored. Data analysis was carried out by two independent researchers to confirm reliability of results. Results A total of 242 inpatients were audited on 26 wards: -Patients prescribed thromboprophylaxis (52%; 126/242). -Patients prescribed therapeutic anticoagulation (26%; 63/242) -Patients not prescribed anticoagulants (22%; 54/242) Most patients (92%; 216/234) did not have a thromboprophylaxis risk assessment form completed/signed. Nineteen patients (35%; n=54) not prescribed thromboprophylaxis or therapeutic anticoagulation should have been prescribed anticoagulation. High compliance with guidelines (>80%) included: i) anticoagulants prescribed in correct section of drug record, ii) appropriate agents prescribed, iii) correct dose and frequency, iv) few dose delays and omissions, and v) indication mostly documented. Low compliance with guidelines (<35%) included: -Patient height and weight not documented: unable to calculate creatinine clearance to determine accurate dose. -Incorrect administration times for once daily therapeutic dosing (should be in morning to facilitate surgery next day) and twice daily dosing (mostly 8am and 10pm = gap of 14 hours and 10 hours). Conclusion Results have identified varying levels of compliance with local anticoagulation guidelines. To date, there has been continuous targeted education and training on appropriate anticoagulation use for doctors, nurses, and pharmacy staff inclusive of the development and implementation of a new bespoke eLearning module for high-alert medications (which includes the appropriate use of anticoagulants specific to Galway University Hospitals). High leverage strategies, such as electronic prescribing, is a current consideration to standardise practices. Strengths include study robustness, interprofessional collaboration, and transferability to other hospitals. Perhaps reducing the scope in a re-audit which will be conducted in 2024 to identify any improvements in medication safety and patient care with these agents may allow for further in-depth analysis.

Analysis of prescription pattern and adverse drug reactions of drugs used in Urinary Tract Infection in reproductive age group (15-44 years) women in a Tertiary Care Hospital in Central India: An observational retrospective study

Background Urinary tract infection is considered a common bacterial infection. Nowadays there is an increase in the irrational and inappropriate use of drugs. Adverse drug reactions have been reported to be a main cause of morbidity, hospital admission, and sometimes death. For this, it is very important to do the analysis of prescriptions and to see the adverse drug reactions due to the prescribed drugs. Objective 1. To determine the prescribing pattern of drugs used in urinary tract infections of the reproductive age group (15-44). 2. To identify adverse reactions due to drugs used for UTI of reproductive age group (15-44). 3. To observe the pattern of combination therapy for urinary tract patients of reproductive age group. 4. To analyze the Fixed Drug Combination. Methods It is a retrospective observational study. Data will be collected from 175 prescription papers. Data will be collected from the medical record section. The study will include prescriptions of UTI for Females of the reproductive age group (15-44 years).

A Research Study on Histopathological Changes that are Seen in Lungs of Victims Who Died of Drowning

Drowning is considered to be the leading cause of death in water and the third most common cause of accidental death worldwide, with the highest drowning rates in developing countries. The WHO defines drowning as the process of experiencing respiratory impairment from submersion/immersion in liquid. For forensic experts, death in water is a multifaceted issue presenting a challenge to them. Since all the circumstances from natural death to homicide are possible in the water, critical examination and interpretation of all abnormal findings found during autopsy are of great importance.Drowning is a diagnosis of exclusion, based on ruling out all other causes of death via complete autopsy and toxicology. Drowning causes hypoxemia, loss of consciousness, apnea and ultimately cardiac arrest. Fluid aspiration results in lung injury and acute respiratory distress syndrome. Acute Respiratory Failure is the main component of drowning pathophysiology. Near drowning results in multiple complications including aspiration pneumonia which is often life-threatening. Hence the histopathological changes in the lungs provide good corroborative evidence of death due to drowning. Nevertheless, for the examined drowning signs, no high diagnostic certainty could be observed. However, these findings can increase their diagnostic value if forensic doctors take influencing factors into consideration.From the central record section of the Department of Forensic Medicine, Siddhartha Medical College, Vijayawada, Andhra Pradesh, about 80 medicolegal postmortem reports of death due to drowning in undecomposed bodies were selected in which one whole lung was sent for histopathological examination during the past two years i.e, 2020 - 2022. Parameters like Age, Sex and Marital Status were also studied. Histopathological examination of drowned lungs showed that congestion was seen in 92% of cases, oedema in 96% cases, dilatation of alveoli in 86% of cases, thinning of septa was seen in 84% of cases rupture of alveoli seen in 64% of cases and hemorrhage is seen in 46% of cases. Mostly males are affected and drowning deaths are seen more in 26 – 40 years age group. The histopathological investigations must be performed on all the organs of non-putrefied bodies with the aim of making the difference between death by drowning and other causes of death. The lung examinations can show over-distension of the alveoli, thinning of the alveolar septa and compression with narrowing of the capillary network.

Time Efficiency, Reliability, and User Satisfaction of the Tooth Memo App for Recording Oral Health Information: Cross-Sectional Questionnaire Study.

Digitalizing oral health data through an app can help manage the extensive data obtained through oral health surveys. The Tooth Memo app collects data from oral health surveys and personal health information. This study aims to evaluate the evaluate the time efficiency, reliability, and user satisfaction of the Tooth Memo app. There are 2 sections in the Tooth Memo app: oral health survey and personal oral health record. For the oral health survey section of the Tooth Memo app, different data entry methods were compared and user satisfaction was evaluated. Fifth-year dental students had access to the oral health survey section in the Tooth Memo app during their clinical work. The time required for data entry, analysis, and summary of oral health survey data by 3 methods, that is, pen-and-paper (manual), Tooth Memo app on iOS device, and Tooth Memo app on Android device were compared among 3 data recorders who entered patients' information on decayed, missing, and filled permanent teeth (DMFT) index and community periodontal index (CPI), which were read aloud from the database of 103 patients by another dental personnel. The interobserver reliability of the 3 different data-entering procedures was evaluated by percent disagreement and kappa statistic values. Laypeople had access to the personal oral health record section of this app, and their satisfaction was evaluated through a Likert scale questionnaire. The satisfaction assessments for both sections of the Tooth Memo app involved the same set of questions on the app design, usage, and overall satisfaction. Of the 103 dental records on DMFT and CPI, 5.2% (177/3399) data points were missing in the manual data entries, but no data on tooth status were missing in the Android and iOS methods. Complete CPI information was provided by all 3 methods. Transferring data from paper to computer took an average of 55 seconds per case. The manual method required 182 minutes more than the iOS or Android methods to clean the missing data and transfer and analyze the tooth status data of 103 patients. The users, that is, 109 fifth-year dental students and 134 laypeople, expressed high satisfaction with using the Tooth Memo app. The overall satisfaction with the oral health survey ranged between 3 and 10, with an average (SD) of 7.86 (1.46). The overall satisfaction with the personal oral health record ranged between 4 and 10, with an average (SD) of 8.09 (1.28). The Tooth Memo app was more efficacious than manual data entry for collecting data of oral health surveys. Dental personnel as well as general users reported high satisfaction when using this app.

Overview of The Destruction of Inactive Medical Record Files at The Kencana Serang Level IV Hospital in 2023

Kencana Serang Level IV Hospital has destroyed inactive outpatient and inpatientmedical record files. Kencana Serang Level IV Hospital in carrying out the transfer ofinactive medical records is still united with the medical record room which is still activebut the storage shelves are different. And the Medical Record section of the filingroom already has tools for destroying Medical Record files but they have not beenused for destruction which has resulted in piles of medical record files. The purpose ofthis study was to determine the implementation of the destruction of inactive medicalrecord files at Kencana Serang Level IV Hospital in 2023. The type of research used wasdescriptive qualitative research. The population of this study were all officers whoworked in the medical record unit at Kencana Hospital Level IV Kencana Serang andthe sample of this study were the head of the Medical Record Installation and FilingOfficer for Hospital Level IV Kencana Serang. At Kencana Serang Level IV Hospital, thefacilities and infrastructure used for extermination are computers, scanners, scissorsand cardboard. For paper destruction tools already available but not yet used, MedicalRecords at Kencana Hospital in Serang City which are destroyed in the category ofMedical Records that have no use value or are more than 5 years old, and obstacles todestruction are Lack of Human Resources (HR) and place or room

DESCRIPTION OF MISSFILE EVENT RATE AND CAUSED FACTORS IN MEDICAL RECORD FILLING SECTION AT PUSKESMAS PONTANG

Background: The purpose of this research is to know the description of the Missfile Incidence Rate and its Causes in the Medical Record Filling Section of the Pontang Health Center. The type of research used in this study is descriptive research, which is a research method carried out with the main aim of making an objective description or description of a situation [1] Based on the results of observations and interviews related to the storage system and alignment system at the Pontang Health Center, there is no SOP related to the storage system and alignment system of medicalrecord files. Based on the results of interviews with filling officers of the Pontang Health Center, there is no special officer for the medical record section, especially in the filling section, filling activities at the Pontang Health Center are still carried out by two registration officers. Based on the observations made by the author, the system used at the Pontang Health Center is centralized. Based on the results of observations and interviews, the alignment system of medical record files used at the Pontang Health Center is straight numerical filling (SNF). Based on observations, the means of controlling medical record files in the filling section of the Pontang Health Center uses a shelf made of wood. The results of the recapitulation of the missfile incidence rate above show that the percentage of missfile events is 14.01% with the number of missfile events being 167 medical record files from 1192 medical record files on the storage rack.