| Summary: | Background : According to the KARS ( 2012) as for 7 ( seven ) standard
on each service consists of : Philosophy and Objectives , Administration
and Management , Staff and Chief , Facilities and Equipment , Policies
and Procedures , Staff Development and Education Program , and
Evaluation and Quality Control . Based on observations , it is known that
RSA Gadjah Mada University is heading the accreditation process , but at
RSA Medical Record Installation UGM not have the SPO regarding the
conduct of Electronic Health Record ( EHR) .
Objective : had designed standard operating procedures (SOP)
ambulatory care admissions and coding in the implementation of
Electronic Health Record in the Gadjah Mada University Academic
Hospital.
Design Process : Results of interviews and observations are used as a
basis for making the procedure a step in the manufacture of SPO
ambulatory care admissions and coding . Results SPO made designer , to
verify the Admissions officers and officers approved coding after SPO
results that have been designed filed with the chief medical records .
Results : The draft Standard Operating Procedures (SOP]) have been
proposed to admissions officers who then carried out the verification , then
made improvements on said KIUP SPO into the form provided , then the
order of the patient's existing print cards at the end of the groove , be
finished after officers noted the identity patients in the EHR . Draft
Standard Operating Procedures (SOP) have been proposed to the officer
Encoding encoding , then verification . After that , improvements include :
add views No , Time , Code , Diagnosis , No. RM , unit and status .
Furthermore , the addition of data related to units which include : ER ,
Inpatient , Haemodialysis Installation , One Day Care Unit .
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