Perencanaan Implementasi Rekam Medis Elektronik Dalam Pengelolaan Unit Rekam Medis Klinik Pratama Romana

Abstract

Background: Medical records are files that contain identity, history, physical, laboratory, diagnosis and medical treatment of a patient recorded both in writing and electronically. The system for administering medical records starts from recording as long as patients get medical services, followed by organizing, storing and issuing medical record files from storage to serve requests / loans by patients or for other purposes. Currently health facilities are trying to replace manual medical record management into electronics. Klinik Pratama Romana Deli Serdang is one of the clinics in the Deli Serdang area that has management planning to change the implementation of a manual medical record unit that has been running into an electronic medical record. The research objective was to design an electronic medical record concept for the Pratama Romana Clinic. This type of qualitative descriptive researched with informants as many as 5 people. Data were collectioned through observation and interviews. The results of the study showed that the management of medical records required qualifications of officers with a background in D4 management of health information, make procedures from registration to reporting and coding according to the ICD and establishing record access rights. The conclusion was that the management of Pratama Romana Clinic already had high support in the implementation of electronic medical records until the application of the concept can be carried out in stages in accordance with the standards and needs.

Digitalisasi Pencatatan Data Rekam Medis Balita dan Upaya Pencegahan Stunting

“…Rekam medis mempunyai pengertian yang sangat luas, tidak hanya sekedar kegiatan pencatatan, akan tetapi mempunyai pengertian sebagai suatu sistem penyelenggaraan rekam medis yaitu mulai pencatatan selama pasien mendapatkan pelayanan medik, dilanjutkan dengan penanganan berkas rekam medis yang meliputi penyelenggaraan penyimpanan serta pengeluaran berkas dari tempat penyimpanan untuk melayani permintaan atau peminjaman apabila dari pasien atau untuk keperluan lainnya (Silalahi & Sinaga, 2019). Seperti halnya layanan kesehatan lainnya, Posyandu juga mempergunakan sejenis rekam medis yang diberi nama Kartu Menuju Sehat (KMS).…”

Pengaruh Citra Rumah Sakit, Kualitas Layanan Terhadap Kepuasan dan Loyalitas Pasien BPJS Rawat Inap

“…Bahkan di Indonesia juga telah berdiri beberapa rumah sakit bertaraf intenasional. Kemajuan teknologi dan ketatnya persaingan baik rumah sakit dalam maupun luar negeri menyebabkan pihak rumah sakit menawarkan pelayanan yang terbaik dan menggerakkan pemasaran aktif (Silalahi & Sinaga, 2019).…”

Information Retrieval for Early Detection of Disease Using Semantic Similarity

“…The notation 𝑁 is the total number of documents weighted. Furthermore, the 𝑡𝑓 𝑖,𝑗 and 𝑖𝑑𝑓 𝑖 values obtained are used to calculate the weight of words or terms in each document as shown in equation (2).…”

“…The search was obtained from a massive collection of medical and clinical record data [1]. The medical record is a file containing notes and documents about patient identity, examination, treatment, actions and other services for patients in health facilities that are carried out manually or electronically [2]. The growth in the number of medical record data that continues to grow can be used as information material and a decision-support tool in making a diagnosis.…”