Alfiansyah, Gamasiano
Department of Health Information Management, Politeknik Negeri Jember, Jember

Published : 2 Documents Claim Missing Document
Claim Missing Document
Check
Articles

Found 2 Documents
Search

Design of Dental Clinic Medical Record Form at a Community Health Center Yuliastin, Shafira; Alfiansyah, Gamasiano; Wijayanti, Rossalina Adi; Vestine, Veronika

Publisher :

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33846/sf170204

Abstract

Dental medical records are essential documents in dental healthcare services, as they contain comprehensive information regarding patients’ medical conditions and all treatments provided. Several studies indicate that dental clinics commonly use general outpatient forms rather than specific dental medical record forms. This study aimed to design a dental medical record form that can be implemented in healthcare services to achieve standardization in dental documentation. This study employed a literature review method, selecting 27 articles based on predefined inclusion criteria. In designing the dental medical record form, the researchers considered user needs identified in previous studies and developed the form in accordance with form design principles and the 2015 Dental Medical Record Guidelines. The results of this study present a dental medical record form design based on three aspects: physical, anatomical, and content aspects. The physical aspect includes paper material (80 gsm HVS paper), size (F4), shape (portrait-oriented rectangular format), and color (white paper with black ink). The anatomical aspect consists of components such as the heading (including title, form identification, date of issue, and issuance number), introduction, instructions, body, and closing section. The content aspect includes patient identity, odontogram, treatment table, and supporting attachments. This study suggests that the developed dental medical record form design may be considered for implementation in dental clinics at community health centers to enhance the completeness and standardization of patient medical record information.Keywords: form design; medical record; dental medical record
Strengthening Medical Record Management Through Training, Monitoring, Tracer Implementation, and Standard Operating Procedures to Reduce Delays in Outpatient Medical Record Returns Wijianto, Ahdan Setyo; Alfiansyah, Gamasiano; Rachmawati, Ervina; Rahargiyanto, Angga

Publisher :

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33846/sf170213

Abstract

Timely return of outpatient medical records is an important component of effective health information management in primary healthcare facilities. Proper management of medical records ensures the continuity of patient care and supports administrative and reporting functions. This study aimed to analyze the factors causing delays in the return of outpatient medical records at Community Health Center (Puskesmas) X based on predisposing, enabling, and reinforcing factors. This study employed a qualitative research design involving nine participants, consisting of one operational coordinator of the medical record unit, one medical record officer, and seven polyclinic staff members. Data were collected through in-depth interviews, observations, documentation review, and brainstorming sessions. The data were then analyzed to identify key factors contributing to delayed medical record returns. The results revealed several contributing factors to the delay. Predisposing factors included the presence of medical record staff who did not meet the minimum educational qualification of a diploma in medical record management and limited compliance among nursing staff regarding the required return time. Enabling factors involved the suboptimal use of expedition logbooks and the absence of tracer tools in the medical record borrowing process. Reinforcing factors included the lack of standard operating procedures (SOPs) regulating the return of medical records. Several improvement strategies were identified, including proposing medical record management training, assigning monitoring responsibilities to polyclinic coordinators, developing and implementing tracer systems, applying administrative sanctions such as additional tasks or point-based accountability mechanisms, and establishing formal SOPs for medical record return procedures. In conclusion, strengthening staff capacity, monitoring mechanisms, record tracking systems, and institutional regulations is essential to improve compliance with medical record return timelines and reduce delays in outpatient medical record management.Keywords: delay; medical records; primary healthcare center; health information management; outpatient services