| Summary: | Background: The Electronic Health Record is the latest technology that can
facilitate the performance of personnel medical recorders and other health
personnel. Yet many who have to implement the latest technology in the
medical record installation in Indonesia. One that has been implemented
EHR are UGM Academic Hospital.
Objective: To determine the implementation of EHR systems, as well as
identify existing constraints on the EHR in Medical Record Installation
UGM Academic Hospital.
Methods: The study was a descriptive study with a qualitative approach
to data collection in phenomenology. Techniques of data collection by
interview, observation, and documentation. Subjects in this study were
medical records officer installation and IT officer, while the object of this
study is the EHR system at UGM Academic Hospital.
Results: Implementation Review of the medical records held at the
outpatient registration, emergency care and hospitalization with entry
social data, sub visit, sub service, then sub internal reference and
synchronized directly to the computer doctor with the advent of
notification. Encoding has also been implemented well and is easy to entry
EHR diagnosis and the desired code appears. In addition to the newly
implemented reporting RL 1.1 and RL 4.b for external, internal, while the
hospital daily reports, visit reports, statements diagnosis list, reports of
nursing actions and patient every doctor report. Problems were
encountered in the implementation of the EHR is not the policy of the
encoding delay, lack of data retrieval system development related to the
implementation of reporting and the lack of manual books in the
implementation of EHR systems.
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