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Dampak Ketidaklengkapan Rekam Medis Rawat Inap Kasus Covid-19 Terhadap Pelayanan di Rumah Sakit Condong Catur Yogyakarta Paskalia Gabrielsa Dehoni; Kori Puspita Ningsih
International Journal of Healthcare Research Vol. 4 No. 1 (2021)
Publisher : Universitas Ahmad Dahlan

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (1326.301 KB)

Abstract

A well-written and complete medical record have many uses, including aspects of administration, legal, finance, research, education and documentation (ALFRED). Therefore, incomplete medical records will have an impact on hospital services. To find out the benefits of medical records from users in RSCC and to know the type of medical record form to claim Covid-19 patients at RSCC. Also, to find out the impact of incomplete inpatient medical records for Covid-19 cases from the aspects of Administration, Legal, Finance, Research, Education, Documentation (ALFRED) at RSCC. This study used a qualitative descriptive method with a case study design. The informants in this study are 11 people consisting of 1 medical record officer, 1 distribution officer, 1 covid-19 claim officer, 1 claim verification doctor, 1 head of medical services, 1 head of medical support, 1 head of ICU officer, 1 head of inpatient care officer, 2 heads of ward officers and 1 head of nursing. The object of this study used 8 inpatient medical records of Covid-19 patients in the period January-March 2021 at RSCC. In addition, the head of RSCC medical record carried out data validation as triangulation. The benefits of medical records for health care workers at the RSCC are knowing the activities of health care providers in treating patients, BPJS/insurance claims and predicting hospital income, as a source of data for research, learning materials about service activities in hospitals, to know about patient medical history and hospital reports. In claiming Covid-19 patients, the RSCC uses medical resumes, Covid-19 screening, laboratory results, isolation certificates, CPPT sheets, medical prescriptions, and inpatient approval sheets. However, the incompleteness of medical records from the administrative aspect causes delays in the administrative process, the financial aspect causes claims to be disputed, and the documentation aspect causes delays in the making of hospital reports. Incompleteness of medical records at RSCC have impacts on administrative aspects, financial aspects, and documentation aspects.
Upaya Mendukung Keberhasilan Implementasi Rekam Medis Elektronik Melalui Digitalisasi Rekam Medis Kori Puspita Ningsih; Endang Purwanti; Suryo Nugroho Markus; Sugeng Santoso; Husin Husin; Muhammad Zaini
Jurnal Empathy Pengabdian Kepada Masyarakat Jurnal Empathy Pengabdian Kepada Masyarakat Volume 3 Nomor 1 Tahun 2022
Publisher : Poltekkes Kemenkes Surakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37341/jurnalempathy.v0i0.107

Abstract

Background: The development of the digital era makes routine and quality data integration an essential component in realizing digital transformation. One data that must be maintained is the Electronic Medical Record (RME). Wates Hospital is currently testing the implementation of RME and requires technical assistance in digitizing medical records in paper to electronic form. Digitization is necessary to ensure the patient's medical history information continuity. The digitization of medical records is expected to support the successful implementation of RME in Wates Hospital. Methods: Solutions are carried out in solving partner problems through training and science and technology substitution. Training activities are carried out by providing counseling, demonstrations, and training to operate scanner equipment. The substitution of science and technology in this PKM is by offering new science and technology to digitize medical records to replace the old science and technology mastery. Results: The activity is divided into 3 stages, starting with providing training related to the procedure for digitizing medical records, then assisting officers during the digitization process of medical records, and ending with accompanying the reflection process to evaluate the success of digitizing medical records. Pre-test and post-test showed an increase in the "Good" category by 58.3% Conclusion: To ensure the success of digitizing medical records, demonstrations were carried out starting from sorting medical record forms that need to be scanned (functional), simulating how to scan, saving files so that they are easy to identify, to importing image files over media on RME.