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All Journal Jurnal Pengabdian Ilmu Kesehatan Aspirasi : Publikasi Hasil Pengabdian dan Kegiatan Masyarakat
Mei Sryendang Sitorus
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Agriculture, Biological Sciences & Forestry Humanities Economics, Econometrics & Finance Education Engineering Health Professions Public Health

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Sosialisasi Pengisian Kelengkapan Dokumen Rekam Medis Rawat Inap Pada Pasien Diabetes Mellitus Di Rsu Imelda Medan Ali Sabela Hasibuan; Ratna Dewi; Hamonangan Damanik; Esraida Simanjuntak; Mei Sryendang Sitorus
Jurnal Pengabdian Ilmu Kesehatan Vol. 3 No. 2 (2023): Juli : Jurnal Pengabdian Ilmu Kesehatan
Publisher : Pusat Riset dan Inovasi Nasional

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.55606/jpikes.v3i2.2591

Abstract

This service aims to find out the number of incomplete medical records for inpatient diabetes mellitus patients at Imelda Hospital, Medan. This service uses a descriptive method, namely a research method carried out with the main aim of finding out the number of incomplete filling in inpatient medical records for Diabetes Mellitus patients. From the results of the service, it was found that the number of incomplete filling out of the integrated record form was found to be 17.40%, initial assessment was 15, 22% of medical resumes were 9.79% and informed consent was 17.40%, the doctor's name was 21.74% and the doctor's signature was 8.70%, while for patient identification, anesthesia records and the operation report is filled out completely. The suggestions from the author are: (1) the permanent procedure for analyzing incompleteness in filling out inpatient medical records needs to be revised so that all forms are analyzed, and continuous socialization needs to be carried out.
Sosialisasi Perancangan Redesain MAP Rekam Medis di Puskesmas Bestari Theresia Hutasoit; Mei Sryendang Sitorus
ASPIRASI : Publikasi Hasil Pengabdian dan Kegiatan Masyarakat Vol. 1 No. 6 (2023): November : Publikasi Hasil Pengabdian dan Kegiatan Masyarakat
Publisher : Asosiasi Periset Bahasa Sastra Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.61132/aspirasi.v1i6.50

Abstract

A medical record folder is a thick paper cover that unites all of a patient's sheets so that they become one complete history, protects the medical record files inside so that they are not easily damaged and makes it easier to store, search and transfer medical record files (Heltiani, 2020). Designing a medical record folder has physical aspects, anatomical aspects and content aspects. The physical aspect consists of materials: Ivory paper, the shape resembles a rectangular book, there are folds to increase the capacity to store medical record forms accompanied by color coding. Anatomical aspects include the Header, which contains the logo, name, address and telephone number, Introduction, Instructions, which contains confidential information from the medical record folder, Body contains the Name and Medical Record Number. Register Number and Year of Visit, Font using Time New Roman, form title size 40, patient identity and year of visit size 12, while Arial font size 14 is used for instructions, Ruler has a ruler on the medical record folder to limit the heading and body of the map, Border there is a border in the medical record folder. Content aspects include the identity of the health service facility, the identity of the name of the health service facility, the patient's name, the medical record number, the year of the last visit and the row available in the year of the last visit in the medical record folder. Socialization is given to medical record officers using discussion, lecture and question and answer methods. It is hoped that the results of this socialization will be for the Bestari Community Health Center to redesign the medical record folder which refers to three aspects, namely: anatomical aspects, physical aspects and content aspects so that the medical record forms are not damaged or scattered.
Co-Authors Damanik, Hamonangan Esraida Simanjuntak Ratna Dewi Sabela Hasibuan, Ali Theresia Hutasoit