KESESUAIAN DIAGNOSIS PADA BERKAS REKAM MEDIS DAN EHR PASIEN INSTALASI GAWAT DARURAT DI RUMAH SAKIT AKADEMIK UNIVERSITAS GADJAHMADA YOGYAKARTA
Background: All health care facilities are required to organize the manufacture and maintenance of medical records. Generally medical records contain administrative data and clinical data. Contains administrative data social data of patients, whereas clinical data contains data relating to the clini...
| Main Authors: | , |
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| Format: | Thesis |
| Published: |
[Yogyakarta] : Universitas Gadjah Mada
2014
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| Subjects: |
| _version_ | 1797035170366226432 |
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| author | , DANIK LESTARI , Nuryati, S.Far. MPH. |
| author_facet | , DANIK LESTARI , Nuryati, S.Far. MPH. |
| author_sort | , DANIK LESTARI |
| collection | UGM |
| description | Background: All health care facilities are required to organize the manufacture and
maintenance of medical records. Generally medical records contain administrative
data and clinical data. Contains administrative data social data of patients, whereas
clinical data contains data relating to the clinical state of the patient. All forms of
treatment and given the patient should be well documented in the medical record.
Given the importance of documenting the process, now comes the a variety of
advanced technologies in the field of medical records one of which is the system
Electronic Health Record (EHR). However, for processes EHR implementation is
perfect, the medical record file manually too still needed in the documentation.
Medical record file manually and electronic medical records should be integrated in
the process documentation. So the medical records of patients had two, one in
and another form of manuals in electronic form.
Objective: To determine the implementation documentation of the diagnosis on file
medical records and EHR, knowing the percentage of conformance documentation
diagnosis, determine the causes and effects of mismatch documentation of a
diagnosis and finding out if an attempt is made to ensure appropriate documentation
of the diagnosis.
Method: The type of research used in this study is descriptive study with a
qualitative approach, and study design cross sectional. The subject of research in
the form of the entire EHR doctors Emergency amounted to fifteen people and the
entire medical record personnel numbered four people, and the object of research in
the form of the entire patient medical record file EHR January to November 2013,
amountingto 2837 files.
Results: Implementation of documenting the patient's diagnosis is done by doctors
write the diagnosis on the patient's medical record file first after completion then
write the diagnosis on the EHR. writing the diagnosis Among the medical record file
with the appropriate EHR as much as 89 % and the not appropriate as much as 11
%. Diagnosis of the causes of nonconformities writing medical record file with the
EHR is 1. been no specific legislation set about writing a diagnosis in the medical
record file and EHR, 2. physician must write the diagnosis two times, 3. Posting
diagnosis in two document (file medical records and EHR) are not effective, 4. term
diagnosis in Terms EHR and ICD-10 diagnosis in difficult equated. While efforts are
performed to ensure documentation of the diagnosis in both documents The suit is a
direct check a doctor writing a diagnosis between file with the EHR, medical records
clerk check writing diagnosis between medical record file with EHR and medical
records Installation hold socialization and appeals to the EHR doctors |
| first_indexed | 2024-03-13T23:24:41Z |
| format | Thesis |
| id | oai:generic.eprints.org:129398 |
| institution | Universiti Gadjah Mada |
| last_indexed | 2024-03-13T23:24:41Z |
| publishDate | 2014 |
| publisher | [Yogyakarta] : Universitas Gadjah Mada |
| record_format | dspace |
| spelling | oai:generic.eprints.org:1293982016-03-04T07:54:14Z https://repository.ugm.ac.id/129398/ KESESUAIAN DIAGNOSIS PADA BERKAS REKAM MEDIS DAN EHR PASIEN INSTALASI GAWAT DARURAT DI RUMAH SAKIT AKADEMIK UNIVERSITAS GADJAHMADA YOGYAKARTA , DANIK LESTARI , Nuryati, S.Far. MPH. ETD Background: All health care facilities are required to organize the manufacture and maintenance of medical records. Generally medical records contain administrative data and clinical data. Contains administrative data social data of patients, whereas clinical data contains data relating to the clinical state of the patient. All forms of treatment and given the patient should be well documented in the medical record. Given the importance of documenting the process, now comes the a variety of advanced technologies in the field of medical records one of which is the system Electronic Health Record (EHR). However, for processes EHR implementation is perfect, the medical record file manually too still needed in the documentation. Medical record file manually and electronic medical records should be integrated in the process documentation. So the medical records of patients had two, one in and another form of manuals in electronic form. Objective: To determine the implementation documentation of the diagnosis on file medical records and EHR, knowing the percentage of conformance documentation diagnosis, determine the causes and effects of mismatch documentation of a diagnosis and finding out if an attempt is made to ensure appropriate documentation of the diagnosis. Method: The type of research used in this study is descriptive study with a qualitative approach, and study design cross sectional. The subject of research in the form of the entire EHR doctors Emergency amounted to fifteen people and the entire medical record personnel numbered four people, and the object of research in the form of the entire patient medical record file EHR January to November 2013, amountingto 2837 files. Results: Implementation of documenting the patient's diagnosis is done by doctors write the diagnosis on the patient's medical record file first after completion then write the diagnosis on the EHR. writing the diagnosis Among the medical record file with the appropriate EHR as much as 89 % and the not appropriate as much as 11 %. Diagnosis of the causes of nonconformities writing medical record file with the EHR is 1. been no specific legislation set about writing a diagnosis in the medical record file and EHR, 2. physician must write the diagnosis two times, 3. Posting diagnosis in two document (file medical records and EHR) are not effective, 4. term diagnosis in Terms EHR and ICD-10 diagnosis in difficult equated. While efforts are performed to ensure documentation of the diagnosis in both documents The suit is a direct check a doctor writing a diagnosis between file with the EHR, medical records clerk check writing diagnosis between medical record file with EHR and medical records Installation hold socialization and appeals to the EHR doctors [Yogyakarta] : Universitas Gadjah Mada 2014 Thesis NonPeerReviewed , DANIK LESTARI and , Nuryati, S.Far. MPH. (2014) KESESUAIAN DIAGNOSIS PADA BERKAS REKAM MEDIS DAN EHR PASIEN INSTALASI GAWAT DARURAT DI RUMAH SAKIT AKADEMIK UNIVERSITAS GADJAHMADA YOGYAKARTA. UNSPECIFIED thesis, UNSPECIFIED. http://etd.ugm.ac.id/index.php?mod=penelitian_detail&sub=PenelitianDetail&act=view&typ=html&buku_id=69789 |
| spellingShingle | ETD , DANIK LESTARI , Nuryati, S.Far. MPH. KESESUAIAN DIAGNOSIS PADA BERKAS REKAM MEDIS DAN EHR PASIEN INSTALASI GAWAT DARURAT DI RUMAH SAKIT AKADEMIK UNIVERSITAS GADJAHMADA YOGYAKARTA |
| title | KESESUAIAN DIAGNOSIS PADA BERKAS REKAM MEDIS DAN EHR PASIEN INSTALASI GAWAT DARURAT DI RUMAH SAKIT AKADEMIK UNIVERSITAS GADJAHMADA YOGYAKARTA |
| title_full | KESESUAIAN DIAGNOSIS PADA BERKAS REKAM MEDIS DAN EHR PASIEN INSTALASI GAWAT DARURAT DI RUMAH SAKIT AKADEMIK UNIVERSITAS GADJAHMADA YOGYAKARTA |
| title_fullStr | KESESUAIAN DIAGNOSIS PADA BERKAS REKAM MEDIS DAN EHR PASIEN INSTALASI GAWAT DARURAT DI RUMAH SAKIT AKADEMIK UNIVERSITAS GADJAHMADA YOGYAKARTA |
| title_full_unstemmed | KESESUAIAN DIAGNOSIS PADA BERKAS REKAM MEDIS DAN EHR PASIEN INSTALASI GAWAT DARURAT DI RUMAH SAKIT AKADEMIK UNIVERSITAS GADJAHMADA YOGYAKARTA |
| title_short | KESESUAIAN DIAGNOSIS PADA BERKAS REKAM MEDIS DAN EHR PASIEN INSTALASI GAWAT DARURAT DI RUMAH SAKIT AKADEMIK UNIVERSITAS GADJAHMADA YOGYAKARTA |
| title_sort | kesesuaian diagnosis pada berkas rekam medis dan ehr pasien instalasi gawat darurat di rumah sakit akademik universitas gadjahmada yogyakarta |
| topic | ETD |
| work_keys_str_mv | AT daniklestari kesesuaiandiagnosispadaberkasrekammedisdanehrpasieninstalasigawatdaruratdirumahsakitakademikuniversitasgadjahmadayogyakarta AT nuryatisfarmph kesesuaiandiagnosispadaberkasrekammedisdanehrpasieninstalasigawatdaruratdirumahsakitakademikuniversitasgadjahmadayogyakarta |