Proceeding International Conference on Medical Record最新文献

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Analysis of Medical Procedures Codes Accuracy Based on ICD-9 CM Cases of Bacterial Infection at Hospital X in Padang 巴东市X医院基于icd - 9cm病例细菌感染的医疗程序代码准确性分析

Proceeding International Conference on Medical Record Pub Date : 2021-02-15 DOI: 10.47387/ICMR.V1I1.17

Yastori

{"title":"Analysis of Medical Procedures Codes Accuracy Based on ICD-9 CM Cases of Bacterial Infection at Hospital X in Padang","authors":"Yastori","doi":"10.47387/ICMR.V1I1.17","DOIUrl":"https://doi.org/10.47387/ICMR.V1I1.17","url":null,"abstract":"Background: Based on a preliminary survey at X Padang hospital, the writing of a diagnosis code for a procedures medical caused by a bacterial infection found a discrepancy between the diagnosis in cases of bacterial infection and the written code. In 15 samples of medical record files at hospital X in Padang, only 33.33% of the code writing was correct. Based on the Decree of the Minister of Health Number 377/MenKes/SK/III/2007 concerning Professional Standards for Medical Recorders and Health Information, it states that one or the competencies that a medical recorder must have is the classification and coding of diseases, problems related to health and actions medical. Medical recorders are capable of defining disease and action codes precisely according to the international classification of diseases and medical practices in health care and management. The impact of losses from inaccurate clinical data codes has an effect on the financing of health services, such as submitting financing claims to health insurers. The aim of this study was to determine the accuracy of the medical procedure code based on ICD-9 CM at Hospital X in Padang.Methods: The kind of this research is a descriptive study with the retrospective method. The variables is the accuracy of the medical procedures codes bacterial infection. The population is all medical records of bacterial infection inpatients in January 2019 and the sample with sampling techniques saturated is 33 documents. The collection of data is interviews and observation in July 2020 at Hospital X in Padang.Results: Accurate medical procedures codes based on the ICD-9 CM is 22 (66.66%), and an inaccurate 11 (66.66%) of 33 diagnoses in the medical record file.Conclusions: The coding inaccuracy at Hospital X in Padang was partly due to the inaccuracy in selecting sub-category for determining the causes of bacterial infection.","PeriodicalId":185869,"journal":{"name":"Proceeding International Conference on Medical Record","volume":"82 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":"132902956","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}

引用次数: 1

Relationship of Nurse's Knowledge Concerning Medical Recording With Nursing Care Document Completeness 护士病历知识与护理文件完整性的关系

Proceeding International Conference on Medical Record Pub Date : 2021-02-15 DOI: 10.47387/ICMR.V1I1.11

Dewi Mardiawati, Linda Handayuni, Ririn Afrima Yenni, Fitria Septi Aryani

引用次数: 0

Literature Review of Online Registration System Based On SMS Gateway 基于短信网关的在线报名系统的文献综述

Proceeding International Conference on Medical Record Pub Date : 2021-02-15 DOI: 10.47387/ICMR.V1I1.16

Oktamianiza, Deni Maisa Putra, Yulfa Yulia, Yulia Fitriani

{"title":"Literature Review of Online Registration System Based On SMS Gateway","authors":"Oktamianiza, Deni Maisa Putra, Yulfa Yulia, Yulia Fitriani","doi":"10.47387/ICMR.V1I1.16","DOIUrl":"https://doi.org/10.47387/ICMR.V1I1.16","url":null,"abstract":"Background: Online registration is a patient or patient's family registering to get an examination from a health care facility by utilizing remote technology facilities, for example a patient registering by using telephone, SMS, WhatsApp, web, and others. Because often there are problems with SIMRS which are caused by several factors. The purpose of this study is to describe the SMS gateway-based online outpatient registration systemMethods: This research method was carried out by conducting a literature review. with the literature study method. Sources of data in this study were obtained from several published journals with attention to inclusion and exclusion categories. Meanwhile, data analysis was carried out by paying attention to aspects of similarity, inequality, views, comparisons and summaries.Results: The results obtained are based on a review of several journals with literature studies related to the online registration system, namely the discovery of the advantages and disadvantages of the SIM-RS implementation system in hospitals in terms of online registration, including from the aspect of system users, low user satisfaction, utilization. technology that is still limited and the quality of information is still inaccurate. Besides, the stipulation and implementation of SOPs is not optimal.Conclusions: It is necessary to establish SOP that is more measurable and can be implemented appropriately","PeriodicalId":185869,"journal":{"name":"Proceeding International Conference on Medical Record","volume":"15 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":"117110752","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}

引用次数: 0

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