Literatur Review Management Analysis of Medical Record Management System in Puskesmas

Authors

  • M. Yusuf Kohar Health Information Management Study Program, Politeknik Kesehatan Kesuma Bangsa, Bandar Lampung, Indonesia

DOI:

https://doi.org/10.56778/rjhs.v1i4.244

Keywords:

Medical record, system management, Puskesmas

Abstract

The medical record management system at the community health center level is the same as the hospital medical record management system. This study aims to determine the management of the medical record system in health centers. This study is a literature review using methods of traditional review to seek, identify, evaluate, and interpret theoretical references relevant to the management of medical record systems in public health centers. The numbering system used in the health center is the Unit Numbering System, The medical record naming system uses a direct naming system, a centralized medical record document storage system at the health center, and a medical record document alignment system at the health center, namely a direct number alignment system and alignment system per region area. According to alphabetical order, assembly activities have not been carried out properly because there is no standard operating procedure for their implementation. The coding implementation at the community health centers did not use the ICD-10 book as a guideline for providing disease codes, the community health centers did not have a fixed retention schedule, so the retention and destruction of medical record documents at the community health centers had not been implemented. Conclusion: The numbering and naming system implemented at the community health centers is inappropriate, and the implementation of the medical record data processing system at the community health centers has not been optimal.

References

Akyar, I. (2012). Standard Operating Procedures (What Are They Good For ?). In I. Akyar (Ed.), Latest Research into Quality Control. InTech. https://doi.org/10.5772/50439

Antameng, R. F., Sy. Effi Daniati, & Sivia Sumarda. (2022). Implementasi Standar Operasional Prosedur (SOP) Di Puskesmas Simpang Tiga Pekanbaru Tahun 2021. Jurnal Rekam Medis (Medical Record Journal), 1(3), 271–286. https://doi.org/10.25311/jrm.Vol1.Iss3.377

Beam, K. S., Lee, M., Hirst, K., Beam, A., & Parad, R. B. (2021). Specificity of International Classification of Diseases codes for bronchopulmonary dysplasia: An investigation using electronic health record data and a large insurance database. Journal of Perinatology, 41(4), 764–771. https://doi.org/10.1038/s41372-021-00965-3

Blasini, R., Buchowicz, K. M., Schneider, H., Samans, B., & Sohrabi, K. (2023). Implementation of inclusion and exclusion criteria in clinical studies in OHDSI ATLAS software. Scientific Reports, 13(1), 22457. https://doi.org/10.1038/s41598-023-49560-w

Golpira, R., Azadmanjir, Z., Zarei, J., Hashemi, N., Meidani, Z., Vahedi, A., Bakhshandeh, H., Fakharian, E., & Sheikhtaheri, A. (2021). Evaluation of the implementation of International Classification of Diseases, 11th revision for morbidity coding: Rationale and study protocol. Informatics in Medicine Unlocked, 25, 100668. https://doi.org/10.1016/j.imu.2021.100668

Hanauer, D. A., Mei, Q., Vydiswaran, V. G. V., Singh, K., Landis-Lewis, Z., & Weng, C. (2019). Complexities, variations, and errors of numbering within clinical notes: The potential impact on information extraction and cohort-identification. BMC Medical Informatics and Decision Making, 19(S3), 75. https://doi.org/10.1186/s12911-019-0784-1

Harahap, N. C., Handayani, P. W., & Hidayanto, A. N. (2022). Barriers and facilitators of personal health record adoption in Indonesia: Health facilities’ perspectives. International Journal of Medical Informatics, 162, 104750. https://doi.org/10.1016/j.ijmedinf.2022.104750

Kwame, A., & Petrucka, P. M. (2021). A literature-based study of patient-centered care and communication in nurse-patient interactions: Barriers, facilitators, and the way forward. BMC Nursing, 20(1), 158. https://doi.org/10.1186/s12912-021-00684-2

Masud, J. H. B., Kuo, C.-C., Yeh, C.-Y., Yang, H.-C., & Lin, M.-C. (2023). Applying Deep Learning Model to Predict Diagnosis Code of Medical Records. Diagnostics, 13(13), 2297. https://doi.org/10.3390/diagnostics13132297

Noviliana, T., Siswati, Puteri Fannya, & Wiwik Viatiningsih. (2022). Overview of the Implementation of Medical Record Maintenance at Tarakan Hospital Jakarta in 2021: A Qualitative Study. Open Access Indonesian Journal of Medical Reviews, 2(2), 211–216. https://doi.org/10.37275/oaijmr.v2i2.181

Nowell, L. S., Norris, J. M., White, D. E., & Moules, N. J. (2017). Thematic Analysis: Striving to Meet the Trustworthiness Criteria. International Journal of Qualitative Methods, 16(1), 160940691773384. https://doi.org/10.1177/1609406917733847

Pfaff, E. R., Madlock-Brown, C., Baratta, J. M., Bhatia, A., Davis, H., Girvin, A., Hill, E., Kelly, E., Kostka, K., Loomba, J., McMurry, J. A., Wong, R., Bennett, T. D., Moffitt, R., Chute, C. G., Haendel, M., The N3C Consortium, & The RECOVER Consortium. (2023). Coding long COVID: Characterizing a new disease through an ICD-10 lens. BMC Medicine, 21(1), 58. https://doi.org/10.1186/s12916-023-02737-6

Porzsolt, F., Wiedemann, F., Becker, S. I., & Rhoads, C. J. (2019). Inclusion and exclusion criteria and the problem of describing homogeneity of study populations in clinical trials. BMJ Evidence-Based Medicine, 24(3), 92–94. https://doi.org/10.1136/bmjebm-2018-111115

Rico, J., Echevarría-González De Garibay, L. J., García-López, M., Guardiola-Vilarroig, S., Maceda-Roldán, L. A., Zurriaga, Ó., & Cavero-Carbonell, C. (2021). The interoperability between the Spanish version of the International Classification of Diseases and ORPHAcodes: Towards better identification of rare diseases. Orphanet Journal of Rare Diseases, 16(1), 121. https://doi.org/10.1186/s13023-021-01763-y

Rizki, F., Noor, N. B., Adellia U.A. Mangilep, & Irwandy. (2020). Analysis of Standard Operational Procedures implementation on medical records completion at Stella Maris Hospital in Makassar, Indonesia. Enfermería Clínica, 30, 35–39. https://doi.org/10.1016/j.enfcli.2019.07.023

Sammani, A., Bagheri, A., Van Der Heijden, P. G. M., Te Riele, A. S. J. M., Baas, A. F., Oosters, C. A. J., Oberski, D., & Asselbergs, F. W. (2021). Automatic multilabel detection of ICD10 codes in Dutch cardiology discharge letters using neural networks. Npj Digital Medicine, 4(1), 37. https://doi.org/10.1038/s41746-021-00404-9

Song, Z., Wan, L., Wang, W., Li, Y., Zhao, Y., Zhuang, Z., Dong, X., Xiao, W., Huang, N., Xu, M., Clarke, R., Qi, L., & Huang, T. (2023). Daily stair climbing, disease susceptibility, and risk of atherosclerotic cardiovascular disease: A prospective cohort study. Atherosclerosis, 386, 117300. https://doi.org/10.1016/j.atherosclerosis.2023.117300

Van Kempen, M., Kim, S. S., Tumescheit, C., Mirdita, M., Lee, J., Gilchrist, C. L. M., Söding, J., & Steinegger, M. (2022). Fast and accurate protein structure search with Foldseek. https://doi.org/10.1101/2022.02.07.479398

Vos, J. F. J., Boonstra, A., Kooistra, A., Seelen, M., & Van Offenbeek, M. (2020). The influence of electronic health record use on collaboration among medical specialties. BMC Health Services Research, 20(1), 676. https://doi.org/10.1186/s12913-020-05542-6

Wiseman, V., Thabrany, H., Asante, A., Haemmerli, M., Kosen, S., Gilson, L., Mills, A., Hayen, A., Tangcharoensathien, V., & Patcharanarumol, W. (2018). An evaluation of health systems equity in Indonesia: Study protocol. International Journal for Equity in Health, 17(1), 138. https://doi.org/10.1186/s12939-018-0822-0

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Published

2024-05-29

How to Cite

Kohar, M. Y. (2024). Literatur Review Management Analysis of Medical Record Management System in Puskesmas. RADINKA JOURNAL OF HEALTH SCIENCE, 1(4), 140–148. https://doi.org/10.56778/rjhs.v1i4.244