Discovery and Analysis of Documentation Systems and Medical Record Service Procedures at Hospital Nacional Guido Valadares
DOI:
10.29303/jppipa.v9iSpecialIssue.6207Published:
2023-12-25Issue:
Vol. 9 No. SpecialIssue (2023): UNRAM journals and research based on science education, science applications towards a golden Indonesia 2045Keywords:
Documentation System, Medical Record, Service ProceduresResearch Articles
Downloads
How to Cite
Downloads
Metrics
Abstract
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.
References
Abidin, Z., & Yunengsih, Y. (2021). Pengaruh Pelepasan Informasi Rekam Medis dalam Menjamin Aspek Hukum Kerahasiaan Rekam Medis di Rumah Sakit FMC Bogor. Journal of Innovation Research and Knowledge, 1(5), 705–712. https://doi.org/10.53625/jirk.v1i5.463
Agustin, D. W., Wijayanti, R. A., & Permana, G. N. (2020). Identifikasi Faktor Penyebab Ketidaksesuaian Pelaksanaan Retensi Dokumen Rekam Medik Inaktif di RS Husada Utama Kota Surabaya. J-REMI: Jurnal Rekam Medik Dan Informasi Kesehatan, 2(1), 57–63. https://doi.org/10.25047/j-remi.v2i1.2156
Apriliani, E. D., Muflihatin, I., & Muna, N. (2020). Analisis Pelaksanaan Retensi dan Pemusnahan Berkas Rekam Medis di Rumkital dr Ramelan Surabaya. J-REMI: Jurnal Rekam Medik Dan Informasi Kesehatan, 1(4), 564–574. https://doi.org/10.25047/j-remi.v1i4.2012
Aregay, A., O’Connor, M., Stow, J., Ayers, N., & Lee, S. (2023). Palliative care in rural and regional health care settings: A qualitative study of enabling factors and implementation challenges. https://doi.org/10.21203/rs.3.rs-2581074/v1
Ayaad, O., Alloubani, A., ALhajaa, E. A., Farhan, M., Abuseif, S., Al Hroub, A., & Akhu-Zaheya, L. (2019). The role of electronic medical records in improving the quality of health care services: Comparative study. International Journal of Medical Informatics, 127, 63–67. https://doi.org/10.1016/j.ijmedinf.2019.04.014
Bohr, A., & Memarzadeh, K. (2020). The rise of artificial intelligence in healthcare applications. In Artificial Intelligence in healthcare (pp. 25–60). Elsevier. https://doi.org/10.1016/B978-0-12-818438-7.00002-2
Dewi, F. D., & Agustina, K. (2017). Analisis Sistem Pelayanan Rekam Medis Rawat Inap di RSUP Dr. Kariadi Semarang Tahun 2016. Jurnal Vokasi Indonesia, 5(2), 2017. Retrieved from https://core.ac.uk/reader/230545480
Enaiz an, O., Zaidan, A. A., Alwi, N. H. M., Zaidan, B. B., Alsalem, M. A., Albahri, O. S., & Albahri, A. S. (2020). Electronic medical record systems: Decision support examination framework for individual, security and privacy concerns using multi-perspective analysis. Health and Technology, 10, 795–822. https://doi.org/10.1007/s12553-018-0278-7
Fennelly, O., Cunningham, C., Grogan, L., Cronin, H., O’Shea, C., Roche, M., Lawlor, F., & O’Hare, N. (2020). Successfully implementing a national electronic health record: a rapid umbrella review. International Journal of Medical Informatics, 144, 104281. https://doi.org/10.1016/j.ijmedinf.2020.104281
Harjanti, H., & Wariyanti, A. S. (2020). Penerapan Kartu Indentitas Berobat (Kib) Dalam Pelaksanaan Family Numbering System. Prosiding" e-Health". Retrieved from https://publikasi.aptirmik.or.id/index.php/prociding/article/view/10
Husnina, N., & Sutrisno, T. A. (2021). Literature Review : Aspek Keamanan Dan Kerahasiaan Dokumen Rekam Medis Di Rumah Sakit. Indonesian Journal of Health Information Management, 1(1), 36–42. https://doi.org/10.54877/ijhim.v1i1.6
Imam, C. W., Sigit, N., & Rahayu, R. P. (2021). Penggunaan Kartu Indeks Berobat Pada Fasilitas Pelayanan Kesehatan. SELAPARANG: Jurnal Pengabdian Masyarakat Berkemajuan, 5(1), 1042–1046. https://doi.org/10.31764/jpmb.v5i1.7524
Kikoba, B. R., Kalinga, E., & Lungo, J. (2019). Integrating electronic medical records data into national health reporting system to enhance health data reporting and use at the facility level. Information and Communication Technologies for Development. Strengthening Southern-Driven Cooperation as a Catalyst for ICT4D: 15th IFIP WG 9.4 International Conference on Social Implications of Computers in Developing Countries, ICT4D 2019, Dar Es Salaam, 532–543. https://doi.org/10.1007/978-3-030-18400-1_44
Lee, D., & Yoon, S. N. (2021). Application of artificial intelligence-based technologies in the healthcare industry: Opportunities and challenges. International Journal of Environmental Research and Public Health, 18(1), 271. https://doi.org/10.3390/ijerph18010271
Lindawati, L., & Rudiansyah, R. (2018). Analisis Pelaksanaan Sistem Penomoran Rekam Medis Rawat Jalan. JUPERMIK (Jurnal Perekam Medis Dan Informasi Kesehatan), 1(2). Retrieved from https://shorturl.asia/qsmH0
Lindskou, T. A., Mikkelsen, S., Christensen, E. F., Hansen, P. A., Jørgensen, G., Hendriksen, O. M., Kirkegaard, H., Berlac, P. A., & Søvsø, M. B. (2019). The Danish prehospital emergency healthcare system and research possibilities. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 27(1), 100. https://doi.org/10.1186/s13049-019-0676-5
Mammadova, M., & Jabrayilova, Z. (2019). Electronic medicine: formation and scientific-theoretical problems. Baku:" Information Technologies" Publishing House. Retrieved from https://shorturl.asia/Wbpty
Mardiawati, D., Srimayarti, B. N., Handayuni, L., Sari, D., Putra, H. N., Fariza, A. S., & Dinda, A. D. (2021). Sosialisasi Pentingnya Kartu Kunjungan Berobat Pasien di Puskesmas Ulak Karang Padang. Jurnal Abdidas, 2(6), 1269–1275. Retrieved from https://www.abdidas.org/index.php/abdidas/article/view/345
Marpaung, Y. N. M., & Irwansyah, I. (2021). Aplikasi Kesehatan Digital Sebagai Konstruksi Sosial Teknologi Media Baru. Jurnal Komunikasi Dan Kajian Media, 5(2), 243–258. https://doi.org/10.31002/jkkm.v5i2.2501
Nursikuwagus, A. (2020). E-Health as a Service Software of Medical System in UML Modeling. Retrieved from https://repository.unikom.ac.id/67427/
Purba, H. H. (2008). Diagram fishbone dari Ishikawa.
Putri, R. S. E., Putri, W., & Windharti, C. (2022). Edukasi Kepada Pasien Pentingnya Membawa KIB Sebagai Upaya Percepatan Pelayanan Kesehatan. (PRIMA) Portal Riset Dan Inovasi Pengabdian Masyarakat, 2(1), 90–94. https://doi.org/10.55047/prima.v2i1.467
Rohman, H., & Marsilah, M. (2022). Pemanfaatan Sistem Pendaftaran Online Melalui Aplikasi WhatsApp di Rumah Sakit Umum Daerah. Indonesian of Health Information Management Journal (INOHIM), 10(1), 18–26. https://doi.org/10.47007/inohim.v10i1.397
Sheikh, A., Anderson, M., Albala, S., Casadei, B., Franklin, B. D., Richards, M., Taylor, D., Tibble, H., & Mossialos, E. (2021). Health information technology and digital innovation for national learning health and care systems. The Lancet Digital Health, 3(6), e383--e396. https://doi.org/10.1016/S2589-7500(21)00005-4
Sinta, S., Juanita, J., Aulia, D., Santosa, H., & Zulfendri, Z. (2022). Sistem Rujukan dan Utilisasi Rumah Sakit Studi Kasus di Rumah Sakit Haji Medan Tahun 2019. Journal Of Healthcare Technology And Medicine, 7(2). https://doi.org/10.33143/jhtm.v7i2.1790
Strich, F., Mayer, A.-S., & Fiedler, M. (2021). What do I do in a world of artificial intelligence? Investigating the impact of substitutive decision-making AI systems on employees’ professional role identity. Journal of the Association for Information Systems, 22(2), 9. https://doi.org/10.17705/1jais.00663
Suryani, F. (2018). Penerapan Metode Diagram Sebab Akibat (Fish Bone diagram) dan FMEA (Failure Mode and Effect) dalam Menganalisa Resiko Kecelakan Kerja di PT. Pertamina Talisman Jambi merang. Journal Industrial Servicess, 3(2). https://doi.org/10.36055/jiss.v3i2.3171
Thorsen-Meyer, H.-C., Nielsen, A. B., Nielsen, A. P., Kaas-Hansen, B. S., Toft, P., Schierbeck, J., Strøm, T., Chmura, P. J., Heimann, M., Dybdahl, L., & others. (2020). Dynamic and explainable machine learning prediction of mortality in patients in the intensive care unit: a retrospective study of high-frequency data in electronic patient records. The Lancet Digital Health, 2(4), e179--e191. Retrieved from https://www.thelancet.com/journals/landig/article/PIIS2589-7500(20)30018-2/fulltext
Tsai, C. H., Eghdam, A., Davoody, N., Wright, G., Flowerday, S., & Koch, S. (2020). Effects of electronic health record implementation and barriers to adoption and use: a scoping review and qualitative analysis of the content. Life, 10(12), 327. https://doi.org/10.3390/life10120327
Wager, K. A., Lee, F. W., & Glaser, J. P. (2021). Health care information systems: a practical approach for health care management. John Wiley & Sons.
Author Biographies
Anabela Markes, Program Studi Magister Manajemen Rumah Sakit Fakultas Kedokteran Universitas Brawijaya Malang
Alberto Alberto, Hospital Nacional Guido Valadares Dili Timor-Leste
Tita Hariyanti, Program Studi Magister Manajemen Rumah Sakit Fakultas Kedokteran Universitas Brawijaya Malang
License
Copyright (c) 2023 Anabela Markes, Alberto Alberto, Tita Hariyanti
This work is licensed under a Creative Commons Attribution 4.0 International License.
Authors who publish with Jurnal Penelitian Pendidikan IPA, agree to the following terms:
- Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a Creative Commons Attribution 4.0 International License (CC-BY License). This license allows authors to use all articles, data sets, graphics, and appendices in data mining applications, search engines, web sites, blogs, and other platforms by providing an appropriate reference. The journal allows the author(s) to hold the copyright without restrictions and will retain publishing rights without restrictions.
- Authors are able to enter into separate, additional contractual arrangements for the non-exclusive distribution of the journal's published version of the work (e.g., post it to an institutional repository or publish it in a book), with an acknowledgment of its initial publication in Jurnal Penelitian Pendidikan IPA.
- Authors are permitted and encouraged to post their work online (e.g., in institutional repositories or on their website) prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work (See The Effect of Open Access).