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All Journal Buletin Keslingmas Jurnal Amanah Kesehatan Indonesian Journal of Health Information Management Services (IJHIMS) Miracle Get Journal
Oktamianiza
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Computer Science & IT Decision Sciences, Operations Research & Management Environmental Science Health Professions Nursing Public Health Social Sciences

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Journal : Miracle Get Journal

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Overview of Return Times for Inpatient Medical Records at Andalas University Hospital Rahmadhani; Oktamianiza; Ade Puspitasari
Miracle Journal Get Press Vol 1 No 2 (2024): May, 2024
Publisher : CV. Get Press Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.69855/mgj.v1i2.30

Abstract

One supporting element for medical record processing is the prompt return of files belonging to patients who have concluded their inpatient healthcare services. The established standard for the return of these medical records is within a maximum of 48 hours. This research aims to ascertain the timeframe the return of hospitalized patient records at Andalas University Hospital in Padang. The investigation employed a quantitative approach utilizing descriptive methods. The research took place in the storage room at Andalas University Hospital, Padang. The investigation took place starting from May to September 2023. The population of this study was 302 files with a sample of 75 medical record files with data collection time from 20 to 25 September 2023. The research applied the Simple Random Sampling technique. Data gathering involved observation and data processing techniques including editing, coding, processing, and cleaning. The analysis focused on univariate analysis. Results from Andalas University Hospital revealed that 31 files (41.3%) returned accurate medical records, while 44 files (58.7%) were found to have incorrect medical records returned. This indicates that many medical record files were returned after the stipulated timeframe of >48 hours. As a conclusion from the study, it's imperative for the head of the medical records room to assess and supervise the return process of inpatient medical record files. By doing so, this issue can be mitigated and delays in Submitting the medical records of a hospitalized patient anew files can be minimized.
Overview of Incompleteness of Filling Out Summary Forms of in- and Outpatient Medical Records on Hypertension in RSUD Lubuk Basung Yulfa Yulia; Dian Sari; Oktamianiza; Mila Sari; Vitratul Ilahi; Kalasta Ayunda; Gopinda Deska Putra
Miracle Journal Get Press Vol 1 No 2 (2024): May, 2024
Publisher : CV. Get Press Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.69855/mgj.v1i2.37

Abstract

The admission and discharge summary is a medical record form that is used to record a summary of the course of the disease from the time the patient entered the hospital until the patient was discharged. The research used is quantitative research with a descriptive approach. Data collection was carried out at Lubuk Basung Regional Hospital from 27 May to 1 July 2023., and the sample consisted of 88 entry and exit summary forms from the medical records of patients suffering from hypertension. Research through observation with a checklist table. Computerization is used to process data and carry out univariate analysis. The results of the study showed that there were still incomplete filling out of entry and exit forms on patient identification items (40.9%), important patient reports (20.5%), patient permission (12.5%), good record keeping (15.9%) . ), and scribbled and clearly legible (17.05%). The results showed that the summary of admissions and discharges for hypertensive patients was still incomplete. In conclusion, this shows that the summary of admissions and discharges for hypertensive patients is still incomplete. It is recommended to carry out evaluations and reviews, as well as outreach and evaluation with doctors, nurses and other related personnel. It mainly deals with quantitative analysis of incoming and outgoing summaries.
Co-Authors Ade Puspitasari Afridon Aulia Rahmi Cheni Ayu Permata Sari Ayunda Putri, Kalasta Dian Sari Dimas Maulana Syafeli Gopinda Deska Putra Ilahi, Vitratul Kalasta Ayunda Mila Sari Putri, Helmi Mazra Putri, Kalasta Ayunda Rahmadhani Siti Handam Dewi Vitratul Ilahi vitratul ilahi, Vitratul Ilahi Yulfa Yulia Yulia, Yulfa Yulva Yulia