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All Journal COVID-19 : Journal of Health, Medical Records and Pharmacy
Liem, John Barker
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Chemistry Health Professions Immunology & microbiology Medicine & Pharmacology Nursing Public Health

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Review of the Completeness of the Medical Resume Form Based on the Assessment Elements of Mirm 15 National Hospital Accreditation Standards (SNARS) at Imelda Pekerja Indonesia Hospital Medan 2021 Liem, John Barker; Rifhan, Zanurul; Simanjuntak, Marta; Sitorus, Mei Sryendang; Alna, Jihan
COVID-19 : Journal of Health, Medical Records and Pharmacy Vol. 2 No. 01 (2024): COVID-19 : Journal of Health, Medical Records and Pharmacy
Publisher : CV. Devitara

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Abstract

Incompleteness in filling out a medical resume will greatly affect the hospital's accreditation assessment listed in the MIRM 15 SNARS standard sub-group Issue 1.1. This study aims to determine the completeness of filling out the resume form based on the assessment elements of MIRM 15 SNARS Edition 1.1 at Imelda Pekerja Indonesia Hospital in Medan. This study uses quantitative and qualitative methods, with a population of 1,355 medical resume forms at Imelda Pekerja Indonesia Hospital Medan in November-December 2021 and a sample of 93 medical resumes which are completed into 100 medical resume forms. Based on the results of the study, it was found that 76 medical resume forms were filled (70%) and 30 medical resume forms were incomplete (30%). score Based on the assessment of SNARS Edition 1.1, the number of complete medical resume forms was 76% with a score of 5 (partially fulfilled) because the achievement range was 29%-79%. The highest completeness on the medical resume form at Imelda Pekerja Indonesia Hospital is found in the patient history component, diagnostic examination, therapeutic procedures and actions, drugs given and drugs when the patient leaves the hospital, the patient's health condition (current status) and follow-up instructions (100% ) Medical resume forms and the lowest completeness were found on physical examination (15%) indication of patients being treated (6%), comorbidities (12) and patient/family signatures (24%) of medical resume forms. Researchers suggest that there is a need for socialization that continuously increases knowledge to medical officers about filling out the complete medical resume form according to SNARS at Imelda Pekerja Indonesia Hospital in Medan.
Evaluation of Clinical Pathway Implementation for Acute Appendicitis at Mitra Medika General Hospital, Medan Tanjung Mulia, 2022 Liem, John Barker; Siregar, Rabia Ulfa
COVID-19 : Journal of Health, Medical Records and Pharmacy Vol. 2 No. 02 (2025): COVID-19 : Journal of Health, Medical Records and Pharmacy
Publisher : CV. Devitara

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This study evaluated the implementation of the Clinical Pathway for acute appendicitis at Mitra Medika General Hospital, Medan Tanjung Mulia, in 2022. The objective was to assess the compliance level of healthcare professionals with the established clinical pathway and to identify factors influencing its application in patient management. A descriptive retrospective design was employed, using medical records of acute appendicitis patients treated during the specified period. Data analysis focused on adherence to diagnostic, therapeutic, and postoperative care standards outlined in the clinical pathway. The results showed that overall compliance was high, particularly in preoperative and operative phases, while postoperative follow-up displayed moderate adherence due to variations in discharge planning and documentation. Factors affecting implementation included staff workload, availability of medical resources, and differences in clinical judgment. It was concluded that the clinical pathway was effectively implemented, although improvements are required to enhance consistency in postoperative care. Strengthening monitoring systems and conducting regular training are recommended to improve adherence and optimize patient outcomes.
Co-Authors Alna, Jihan Rifhan, Zanurul Simanjuntak, Marta Siregar, Rabia Ulfa Sitorus, Mei Sryendang