Sevia Maysa Shabira, Fadil Ahmad Junaedi
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摘要

misfile是经常发生在医疗机构的储藏室里的事情。努力避免错档事件需要控制病历文件。Mangkubumi保健中心还没有医疗记录文件控制系统。E-Puskesmas NG应用程序还没有控制医疗记录的功能。本研究旨在分析并设计一套综合病历文件控制系统在E-Puskesmas NG应用中的应用。这类研究采用FOCUS PDCA方法进行定性分析。如何通过访谈和观察收集数据。使用内容分析进行数据分析。病历文件控制流程从病人来就诊登记开始,到病人去综合诊所时发给病人病历,由综合诊所人员填写病历,填写完整后返回存储单元。病案文件管控存在的问题有:因病历归还延迟、检查结果归档延迟导致病案丢失、散落、没有SOP作为工作流程指导、没有制作远征记录、没有带病案毕业生的病案人员。建议的病历文件控制系统设计是一个提醒系统(警报),在E-Puskesmas NG应用程序中填写病历文件,供综合诊所人员在完成对病人的服务后,立即填写病历文件,防止病历文件散落。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
PERANCANGAN SISTEM PENGENDALIAN DOKUMEN REKAM MEDIS DI PUSKESMAS MANGKUBUMI KOTA TASIKMALAYA
Missfile is something that often happens in the storage room of a health care facility. Efforts to avoid missfile events need to control medical record documents. The Mangkubumi Health Center does not yet have a medical record document control system. The E-Puskesmas NG application does not yet have a feature that can control medical records. This study aims to analyze and design an integrated medical record document control system in the E-Puskesmas NG application. This type of research is qualitative with a FOCUS PDCA approach. How to collect data using interviews and observation. Data analysis using content analysis. The flow of medical record document control starts from the patient coming and being registered, the patient is given a medical record when going to the polyclinic, the medical record is filled out by the polyclinic officer and returned to the storage unit when it is completely filled out. Problems in controlling medical record documents are medical records are lost and scattered due to delays in returning medical records and delays in documenting examination results, there is no SOP as a workflow guideline, expedition records are not made, and there are no medical record personnel with medical record graduates. The proposed medical record document control system design is a reminder system (alert) for filling out medical record documents in the E-Puskesmas NG application which is intended for polyclinic officers when they finish providing services to patients so that they immediately complete documentation and prevent medical record documents from being scattered.
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