Proceeding International Conference on Medical Record最新文献

{"title":"The Completeness and Accuracy of Hepatoma Coding for Medical Procedure Based on ICD-9 CM at Public Hospital in Padang","authors":"Sayati Mandia","doi":"10.47387/icmr.v2i1.150","DOIUrl":"https://doi.org/10.47387/icmr.v2i1.150","url":null,"abstract":"Background: Hepatoma  or  hepatocellular  carcinoma  (KHS)  is  a  primary  malignant  tumor  of  the  liver originating from hepatocytes and the 3rd cause of death from cancer in the world. The history of a hepatoma patient can be seen based on the patient's medical record. The filling of medical record is done by doctors, nurses and medical record personel. However, in medical record  filling, incompleteness  is often found and cause inaccurate information. Accuracy coding important for financial of hospital.Methods: Type  of  research  is  quantitative  descriptive,  which  is  to  determine  the  completeness  and accuracy of  the  medical  records  for  hepatoma  cases and procedure code using criteria  for  document  quantitative  analysis in a public hospital, Padang. The study  design  used  a  retrospective  analytical  approach. The variables in the study were completeness of discharge summary and accuracy of hepatoma procedure based on ICD-9 CM. The population in this study were inpatient medical record documents for Hepatoma cases at a public hospital, Padang from June to August 2019, which were 45 medical record documents (discharge summary form) of hepatoma inpatients.Results: From 45 hepatoma patient medical record documents, filling of item name, medical record number, date of admission, indication of the patient being treated, history, physical examination, diagnostic examination, procedures, medications given, medicines used at home, PPBS doctor's signature, DPJP doctor's hand is complete 100% . Highest incompleteness of filling was found  at code ICD (47%) and address item (43%). From 45 discharge summary , accuracy procedure code at hepatome case shows 100 % accurate in ultrasonoggrafi abdomen and ultrasonografi thorax. While that EKG 98% accurate and 95 % rontgen thorax.Conclusions: In general, item data of discahrege summary for hepatoma medical record are completenes; highest incompleteness of filling was found  at code ICD (47%) and address item (43%); Accuracy of code procedure more than 90% in each code procedure.","PeriodicalId":185869,"journal":{"name":"Proceeding International Conference on Medical Record","volume":"49 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2022-01-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"115212750","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Analysis and Design of Inpatient Daily Cense Information System in Bhayangkara Bengkulu Hospital","authors":"Ismail Arifin, Niska Ramadani, I. Duri","doi":"10.47387/icmr.v2i1.156","DOIUrl":"https://doi.org/10.47387/icmr.v2i1.156","url":null,"abstract":"Background: Progressing technology in the world need to fast and accurate information in the hospital agencies as the basis for appropriate making decision. The inpatient daily census reporting of system Bhayangkara Hospital Bengkulu don't have utilized the Inpatient Daily census system electronically and still uses a manual system, so that the processing of report data is less than optimal. There are still a lot of inputting errors, inaccurate data, and inefficient time and energy. This study to aim design system information inpatient daily census reporting application at the Bhayangkara hospital to existing problems solving.Methods: The method used in designing and making this application is by utilizing software development methods, namely the waterfall method which includes identification, analysis, design or design, implementation and maintenance of the system.Results: The results this study is creation of an application to facilitys the processing of data into an inpatient daily census report that is needed and to overcome the problems that arise because of the report processing system manually. Design and Creation of Inpatient Daily Census Applications with Visual Basic 6.0 Programming at Bhayangkara Bengkulu Hospital have been made with the results of an analysis of existing systems and according to the method used, and the design of the forms that have been made in accordance with the manual form or home party needs sick and can simplify filling out forms and processing the data.Conclusions: At Bhayangkara Bengkulu Hospital still uses a manual inpatient daily census system, and not on time for reporting daily cencus patient data. The data structure contained in the ledger consists of patient identity, patient diagnosis, and others. There are three processes in the stage of analyzing the needs of the inpatient daily census system, namely the data input process, data processing and data output processes. ledger, patient data consisting of patient identity, doctor's name, patient diagnosis, treatment room, and treatment class. In designing the daily inpatient census system at Bhayangkara Bengkulu Hospit consists of patient data forms, incoming patients, outgoing patients, and patients moving. The implementation of the daily inpatient census system at the Bhayangkara Bengkulu Hospital  has carried out socialization and discussions about the user interface design to officers or users of the electronic daily census system. And the maintenance of the daily inpatient census system is carried out in several stages (1) corrective, by correcting design and errors in the program, (2) adaptive, by modifying the system according to user needs, (3) perfective, namely processing census data computerized.","PeriodicalId":185869,"journal":{"name":"Proceeding International Conference on Medical Record","volume":"19 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2022-01-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"123542962","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Accuracy and Validity Outpatient Diagnosis Code Base On ICD-10 at Imogiri I Health Center Bantul Yogyakarta","authors":"Hendra Rohman","doi":"10.47387/icmr.v2i1.151","DOIUrl":"https://doi.org/10.47387/icmr.v2i1.151","url":null,"abstract":"Background: Analysis of accuracy and validity fill code diagnosis on medical record document is very important because if diagnosis code is not appropriate with ICD-10, will cause decline in quality services health center, generated data have this validation data level is low, because accuracy code very important for health center such as index process and statistical report, as basis for making outpatient morbidity report and top ten diseases reports, as well as influencing policies will be taken by primary health center management. This study aims to analyze accuracy and validity diagnosis disease code based on ICD-10 fourth quarter in 2020 Imogiri I Health Center Bantul.Methods: Descriptive qualitative approach, case study design. Subject is a doctor, nurse, head record medical and staff. Object is outpatients medical record document in Imogiri I Health Center Bantul. Total sample 99 medical record file. Obtaining data from this study through interviews and observations.Results: Number of complete accurate diagnosis codes is 60 (60,6%), incomplete accurate diagnosis codes is 26 (26.3%) and inaccurate diagnosis codes is 13 (13.1%). Inaccuracies include errors in determining code, errors in determining 4th character ICD-10 code, not adding 4th and 5th characters, not including external cause, and multiple diseases.Conclusions: Inaccuracy factors are not competence medical record staff, incomplete diagnosis writing and no training, no evaluation or coding audit has been carried out, and standard operational procedure is not socialized.","PeriodicalId":185869,"journal":{"name":"Proceeding International Conference on Medical Record","volume":"19 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2022-01-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"128391108","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Study of Incompleteness Medical Records of Inpatient in Appendicitis Cases at Dr. Reksodiwiryo Hospital Padang","authors":"N. Nasution","doi":"10.47387/icmr.v2i1.153","DOIUrl":"https://doi.org/10.47387/icmr.v2i1.153","url":null,"abstract":"Background: Incomplete filling of medical record files for inpatients at Dr. Reksodiwiryo hospital medical records will be describe health services and the quality of medical record services. Medical record quality services include the completeness of medical record files, accuracy in providing diagnosis and diagnosis codes, as well as speed in providing service information. The requirements for quality medical records must be accurate, complete, reliable, valid, timely, usable, common, comparable, guaranteed, and easy.Methods: This research method is a descriptive with a retrospective approach or looking at existing data. This study was carried out in September 2021. The population was 70 files cases of inpatient digestive surgery. Samples were taken from 27 files of inpatients with appendicitis cases.Results: From the research that has been done, the highest percentage of incomplete identification components is found on the gender item about 81.48%, the highest percentage of incomplete important report components is obtained on the medical resume and informed consent items about 11.1%. The highest percentage of incomplete authentication components was obtained in the nursing degree about 96.3%. The highest percentage of the components of the recording method was obtained by 59.3%, there are several blank sections about 16 files. The percentage of incomplete diagnostic codes and procedures is 100%  Conclusions: the researcher suggested that the hospital can have an Operational Standart on filling out the completeness of medical records files","PeriodicalId":185869,"journal":{"name":"Proceeding International Conference on Medical Record","volume":"35 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2022-01-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"129007190","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Relationship Between Waiting Time on Patient Satisfaction at Baloi Permai Batam Puskesmas Year 2021","authors":"R. E. Putri, Veggi Klawdina, Fani Farhansyah","doi":"10.47387/icmr.v2i1.157","DOIUrl":"https://doi.org/10.47387/icmr.v2i1.157","url":null,"abstract":"Background: Medical records are an important part in assisting the implementation of service delivery to patients in hospitals. This research aimsMethods: Quantitative with survey research, a quantitative approach is used to find out how effective the relationship between waiting time and patient satisfaction is at the Baloi Permai Health Center.Results: The results of the chi square statistical test showed that the p-value of 0.001 was less than 0.050, so it can be said that there is a significant relationship between waiting time and patient satisfaction. The odds ratio for the relationship between waiting time and patient satisfaction is 7.263 with 95% CI between 2.143- 24.614. Patients with long waiting times are 7,263 or 7 times more likely to have a low level of satisfaction compared to patients whose waiting times are not too long.Conclusions: Based on the results of the study, it can be concluded that there is an effect of patient waiting time on outpatient satisfaction. The staff of the Baloi Perma Batam outpatient unit should further improve services, especially for waiting time for outpatients. Based on the results of the study, it can be concluded that there is an effect of patient waiting time on outpatient satisfaction. The staff of the Baloi Perma Batam outpatient unit should further improve services, especially for waiting time for outpatients.","PeriodicalId":185869,"journal":{"name":"Proceeding International Conference on Medical Record","volume":"54 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2022-01-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"122252371","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Public Perceptions About Covid-19 Prevention Measures in Ganting Parak Gadang Village, Padang Timur District","authors":"Anne Rufaridah, Wuri Komalasari, Ridholla Permata Sari","doi":"10.47387/icmr.v2i1.155","DOIUrl":"https://doi.org/10.47387/icmr.v2i1.155","url":null,"abstract":"Background: The dominant factors that influence Covid-19 prevention behavior can be divided into three domains; knowledge, attitude and action. Knowledge is the result of knowing after people have sensed certain objects. Attitude describes whether a person like or dislike towards an object. Action is a response to a stimulus that is active and observable.Methods: This study aims to determine the public's perception towards Covid 19 Prevention in Ganting Parak Gadang Village, East Padang. The type of research used is the Winshield Survey. The sample used 24 families by random sampling at TNI AD Ganting Parak Gadang dormitory, RW: 08 consists of RT 01,02,03,04,05,06.Results: The results of this research showed that the respondents' perceptions of 100% considered the current situation is seriously in dangerous and should not be considered as trivial cases, 62% of handling COVID-19 carried out preventive behaviors such as maintaining immunity, 71% of people's behavior in worshiping choosing to worship at home, as much as 75% did not go to planned events. Knowledge of respondents 84% still doubted and did not know about the symptoms of covid 19 and as much as 23% did not know about OTG covid 19 is 62% knew from social media.Conclusions: The conclusion in this study are attitude and the highest percentage of preventive actions in the good category compared with the lower percentage of prevention knowledge. The suggestion in the study is that the public is expected to maintain health protocols by continuing to follow government recommendations in efforts to prevent Covid-19.","PeriodicalId":185869,"journal":{"name":"Proceeding International Conference on Medical Record","volume":"461 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2022-01-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"125811786","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Readiness of Application of Electronic Medical Records in Health Services (Literature Study)","authors":"Lilis Masyfufah, M. Sriwati, Amiri Ali, Bambang Nudji","doi":"10.47387/icmr.v2i1.148","DOIUrl":"https://doi.org/10.47387/icmr.v2i1.148","url":null,"abstract":"Background: Information and Communication Technology is advancing rapidly and has a major impact on all life, especially in the health sector, especially medical records. This is manifested in the Electronic Medical Record (EMR), which has now been further developed into an Electronic Health Record (EHR). This technology is used to replace or complement paper medical records. The purpose of this literature study is to determine the readiness to apply electronic medical records in health services.Methods: This study uses a literature study obtained from searching scientific research articles from the 2010–2020 range. Keywords used in this study is readiness and DOQ-IT. The database used comes from Google Sholar, Garuda, Neliti, and One Search. The search found 130 articles, then a critical appraisal process was carried out to produce 10 suitable manuscripts.Results: Various literatures found that the readiness to apply electronic medical records using the DOQ-IT method was influencedby 4 factors including the readiness of human resources, orgnizational culture, insfrastructure, and leadership governance. It can be concluded that the readiness for the application of  electronic medical recors in health services with the very ready category is 30%, the moderately ready category is 50%, then the unready category is 20%.Conclusions: From the discussion above, it can be concluded that EMR readiness in health services is categorized as quite ready (50%), very ready (30%), and not ready (20%).","PeriodicalId":185869,"journal":{"name":"Proceeding International Conference on Medical Record","volume":"30 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2022-01-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"121908425","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Cases of Dispute and Pending Claims in Hospitals in the Era of National Health Insurance","authors":"Mrs. Yastori","doi":"10.47387/icmr.v2i1.152","DOIUrl":"https://doi.org/10.47387/icmr.v2i1.152","url":null,"abstract":"Background: Indonesia began to implement a National Health Insurance System based on the National Social Security System in 2014 with the support of government regulations which states that Indonesia requires every citizen to have access to comprehensive and quality health services so that can continue their life through the National Health Insurance. Pending and dispute claims are problems that often occur in the era of national health insurance that can affect hospital budget allocation and planning policies, increasing the high cost burden for hospitals which will affect the quality of health services provided. The purpose of this study was to determine pending cases and dispute claims in hospitals in the Era of National Health Insurance.Methods: The study used a descriptive method with a qualitative approach. The data collection technique used is the observation method, namely directly to the e-claim file at several hospitals. 15 e-claim files taken in total from April – July 2021.Results: Obtained 13 cases of pending claims and 2 cases of dispute claims. Cases pending claims are caused by not complying with the code with evidence or resources, not in accordance with medical clinical practice guidelines and the rules of the health insurance provider.Conclusions: In coding, it is necessary to match the theory on the ICD-10, update the ICD-10. It is necessary to understand the rules and provisions made by the insurer and the related guidelines and rules. Please be aware of every latest code update.","PeriodicalId":185869,"journal":{"name":"Proceeding International Conference on Medical Record","volume":"138 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2022-01-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"125745032","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Surabaya City Health Office’s Readiness In Facing ‘EHR' Era Through Doq-It","authors":"Lilis Masyfufah, Sendy Ayu Mitra Uktutias","doi":"10.47387/ICMR.V1I1.13","DOIUrl":"https://doi.org/10.47387/ICMR.V1I1.13","url":null,"abstract":"Background: E-Health is an innovation created by the City Government of Surabaya in the realm of health services. E-Health integrates data between Puskesmas (Public Health Center), Hospitals, Dispendukcapil (the Department of Population and Civil Registration), and the City Health Office of Surabaya. E-Health is the latest health service program prior to the Electronic Health Record (EHR). An assessment on its readiness is important and necessary. One way to realize the readiness for implementing the Electronic Health Record (EHR) is by using the EHR Assessment and Readiness Starter Assessment tool by the Doctor's Office Quality - Information Technology (DOQ-IT). This research will analyze the readiness of the Surabaya City Health Office in applying e-Health in order to implement the Electronic Health Record (EHR).Methods: This research is a quantitative-descriptive type of research with cross sectional design. The main subject is the Surabaya City Health Office, and the data collection technique used is interviews. The data are processed through coding and calculating the respondent's answer to be then categorized.Results: The indicators in this research are Organizational Alignment and Organizational Capacity. The results show that the City Health Office and Puskesmas are strong enough to face the challenges of developing the Electronic Health Record (EHR), which is in range III. This indicates their readiness in facing changes towards the Electronic Health Record (EHR) and denotes its success. The indicator smallest value lies in the section of coordination with all related parties which is less optimal.Conclusions: Surabaya City Health Office is ready to implement the Electronic Health Record (EHR). The involvement of all components becomes the key to success towards a more innovative change in Electronic Health Record (EHR).","PeriodicalId":185869,"journal":{"name":"Proceeding International Conference on Medical Record","volume":"100 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2021-02-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"122613717","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Impact of Bullying on Children in the School Environment","authors":"Izky Tussila Diana Putri, Zulia Putri Perdani, Azizah Al Ashri Nainar","doi":"10.47387/ICMR.V1I1.12","DOIUrl":"https://doi.org/10.47387/ICMR.V1I1.12","url":null,"abstract":"Background: School is one of the places where children interact with their peers. Children's behavior in interacting with others has different coping responses due to bullying behavior. The prevalence of this bullying behavior tends to increase in both cyber and school environments.Methods: This study used a cross sectional study design. The research subjects were 128 respondents. Selected through probability sampling. Data were collected using a questionnaire illois bullying scale to measure the incidence of bullying and to determine the coping mechanism using a Ways of Coping questionnaire.Results: As a result of bullying in children, 45 respondents (66.2%) showed ineffective coping behavior. Hypothesis testing using the Chi-Square test with a confidence level of 95% with the result of a p value of 0.00 (p 0.002), with an OR value of 3.14.Conclusions: The impact on children who get bully behavior in the school environment is related to the emergence of ineffective coping mechanisms for children.","PeriodicalId":185869,"journal":{"name":"Proceeding International Conference on Medical Record","volume":"8 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2021-02-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"127370318","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}