![]() ![]() ![]() Item Type:Įlectronic Medical Record, Regulation, Medical Malpractice. For this reason, a normative legal research with a comparative approach was conducted to compare the legislation in other countries as a recommendation for the establishment of electronic medical record regulation in Indonesia in accordance with the rules for establishing legislation, so that they can be used as valid evidences in medical malpractice courts. Terbitan: (2013) FAKTOR-FAKTOR KETERLAMBATAN PENGEMBALIAN REKAM MEDIS PASIEN RAWAT INAP DI RUMAH SAKIT DKT DR. fill out medical record files, especially medical resume forms. In practice, electronic medical record can be categorized as valid evidence in a medical malpractice case court is only based on the judge's conviction. yang belum lengkap, sehingga rekam medis banyak dikembalikan ke ruang perawatan. Various lawsuits against health services or known as malpractice involve evidence in the form of medical records which are opened by court order. ![]() Agar pengisian Rekam Medis lebih optimal, dan untuk menyegarkan kembali cara pengisian Rekam Medis secara benar, maka perlu disusun buku pedoman pengisian Rekam Medis. Legislation in the form of a regulation of the minister of health only regulates medical records in general and there is no standardization and legislation regarding electronic medical record. Banyak lembaran-lembaran yang tidak terpakai atau masih kurangnya pengisian form-form Rekam Medis yang mengakibatkan pemborosan. Currently, there is no specific legal regulation that regulates the implementation of electronic medical record in Indonesia. Staf yang berperan untuk menjalankan fungsi ini bertugas untuk. untama untuk menginputkan data yang akan dipergun akan pada SI ReMis. In the case of medical malpractice in Indonesia, medical records play an important role in the evidence in court. Proses assembling memiliki fungsi yang sangat penting di dalam pelayanan dan pengelolaan rekam medis, yakni: Penyusun formulir rekam medis, Peneliti isi data rekam medis, Pengendali dokumen rekam medis yang tidak lengkap, Pengendali penggunaan nomor dan formulir rekam medis. Form Data Dokter pa da gambar 11 dan Form Rekam Medis pada gambar 12merupakan form. Various health facilities such as hospitals in big cities in Indonesia already use electronic medical records. 1) Jam diisi berdasarkan waktu kedatangan pasien ke ruang gawat. Formulir IGD adalah formulir yang digunakan pada saat pemeriksaan. The results showed that the incomplete completion of authentication on the discharge patient summary form carried out by the author obtained a percentage of the completeness of the discharge patient summary form filling of 73.2% and the incomplete filling of 26.8% from October and November with a total sample of 87 discharge patient summary forms.Medical records are a form of administrative service provided by health facilities to patients that must be carried out by health workers who provide services. PETUNJUK TEKNIS PENGISIAN FORMULIR REKAM MEDIS RSUD. Data collection techniques in research include: observation, interviews, documentation and literature study.Based on research at the Pindad General Hospital, Bandung already has a Standard Operating Procedure, but in its implementation it has not been in accordance with the standards set by the hospital. Gizi Rawat Inap Terhadap Kelengkapan Pengisian Dokumen Rekam. This study aims to determine the incomplete description of filling in the doctor's authentication on the summary form of discharge patients at the medical record installation of inpatients at the Pindad General Hospital, Bandung.The research method used is descriptive research method. Based on a preliminary study from February 8 to March 8, 2021, the authors found that the number of medical records on the summary form of discharged patients at the inpatient medical record installation were incomplete, such as the signature and full name of the doctor that were not filled out, out of 225 medical record files in the form summary of patients returning home, only 155 forms were completed and 70 forms were incomplete. ![]() Incomplete medical resume is a problem because medical resumes can provide detailed information about what has happened while the patient was hospitalized so that it has an impact on the quality of medical records and services provided by the hospital. ![]()
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