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Background: Based on the results of observations made in September 2022-December 2022 in the medical record storage room of the Tk. IV Dr. R. Ismoyo Kendari, there were 427 inpatient medical records and 254 (59%) inpatient medical records that suffered damage caused by physical, chemical and biological factors. The purpose of this study was to determine the causes and types of damage to the medical records of inpatients due to physical, chemical and biological factors in the medical record storage room of the Tk Army Hospital. IVDr. R. Ismoyo Kendari.Methods: This study used a qualitative analytic descriptive design, especially the cross sectional type. The sample in this study consisted of 4 medical record officers, namely 1 Head of Medical Records, 1 Secretary of Medical Records, 1 registration officer and 1 filling officer in the medical record storage room of the Tk Army Hospital. IV Dr.R.Ismoyo Kendari and 254 medical records of inpatients in September 2022 - December 2022 who were damaged. The research instrument used observation, checklists, and interview guidelines. Results: The results of this study indicate that physical factors, chemical factors, and biological factors cause damage caused by negligence of officers, exposure to sunlight, dust, ink, rust, mold, and insects. Conclusion:The conclusion of this study found forms of damage such as torn, detached/missing medical record forms, and yellow to brown in color as a result of physical factors, chemical factors, and biological factors.

Background: Medical records at Udayana Denpasar Level II Hospital that exceed capacity are caused by double medical records, misfiles occur during the implementation of retrieval, the retention process has not run optimally and the increasing number of patient visits. The purpose of this study was to determine the impact of medical record storage overload on the response time of medical record provision. Methods: The research design used is a quantitative method with a cross sectional approach. The data analysis used is the Chi Squere test. With a total sample of 16 medical record officers and medical record documents contained in 30 medical record storage shelves where each shelf consists of 5 sections.   Results: The results of the Chi Squere test show that the p value is 0.002, the value is less than 0.05. So it can be concluded that there is an impact of overload of medical record storage on the response time of providing medical records, thus impacting the quality of hospital services, the services provided become long because they wait for medical records to be delivered to the polyclinic. Based on these results, it is necessary to transfer media by scanning medical records then stored in sharing folders and uploaded to the interface system. This media transfer is expected to provide a solution in dealing with the overload of medical record storage so that it can be more efficient in providing medical records.       Conclusion: The conclusion in this study is that there is an impact of overloaded medical record storage on the response time of medical record provision, which has an impact on the quality of hospital services, the services provided will be long because they wait for medical records to be delivered to the polyclinic, so that doctors experience problems in patient examinations because they cannot see the patient's previous examination history.

Electronic Medical Records (EMR) is one of the health IT applications that is becoming a trend around the world. EMRs are considered to improve the overall quality of care and have an impact on patient safety. EMRs can also help reduce costs, improve accessibility, and improve the quality of hospital services. Therefore, the preparedness analysis of the implementation of EMR with the DOQ-IT approach (Doctor's Office Quality-Information Technology) is the goal of this research. This research uses a type of quantitative descriptive research with a cross sectional approach. The samples were taken from all the officers who were in direct contact with the medical records at AMC Aisyiyah Clinic. Sampling technique using a total sampling of eight officers. Primary data collection is done with a questionnaire. The method of analysis used is descriptive analysis of frequencies, percentages, graphs and tables. From the results of analysis using the DOQ-IT method obtained a total score of 104.75 belongs to category III which shows that human resources, organizational work culture, governance and leadership, IT infrastructure AMC Aisyiyah Clinic is ready to take advantage of EMR as well as overcome the potential challenges for successful adoption of the EMR.

Diarrhea is a condition in which a person has bowel movements with a soft or liquid consistency, it can even be just water and the frequency is more frequent in one day. Diarrheal disease in toddlers is ranked 2 out of the top 10 childhood diseases at the Sadewa Mother and Children Hospital (RSKIA) in May 2022. Knowing the pattern of prescribing diarrhea drugs in toddlers in outpatient care at the Sadewa Mother and Children Hospital for the period January - June 2022. The research conducted was a non-experimental descriptive research with a retrospective method. The study was conducted by taking prescription data from electronic medical records at the Sadewa RSKIA pharmacy and then recording them on a data collection sheet. Data were analyzed using tabulations in the form of percentages (%). The results showed that out of 130 samples, the profile of diarrhea patients under five was dominated by males, 77 children (59%), aged 2-3 years 65 children (50%), and the degree of dehydration of patients without dehydration, 120 children (92%). ). The most widely used drug class was zinc with 120 prescriptions (34.3%), zinc has a protective effect against diarrhea and can reduce recurrence and probiotics with 119 prescriptions (33.8%), probiotic bacteria will help the process of nutrient absorption and prevent disturbances in water absorption. The dominating combination was a combination of 3 drugs namely electrolytes, zinc and probiotics 69 prescriptions (57%), oralit functioned to replace fluids and electrolytes in the body that are wasted during diarrhea, zinc supplementation and probiotics in diarrhea effectively reduced stool output. The rule for using the treatment of diarrhea in toddlers is mostly 1 time a day with a total of 132 drugs (37.7%). The dominating drug was zinc with 117 prescriptions (88.6%) The pattern of prescribing diarrhea drugs in toddlers in this study was dominated by male patients, aged 2-3 years with a degree of dehydration, patients without dehydration. The most widely used drug classes are zinc and probiotic groups. The most common drug combination found is a combination of 3 drugs, namely electrolyte, zinc and probiotic group drugs. The rule for using the treatment of diarrhea in most toddlers is 1 time a day.    

The aim of this research is to determine the factors associated with the incidence of anemia in pregnant women at the Batua Makassar City Health Center. The type of research used in this research is using analytical research methods with a Cross Sectional Study approach. The population of this study was all 180 pregnant women who underwent pregnancy checks in the Batua Community Health Center Working Area, Manggala District. The sampling technique used in this research is purposive sampling, namely where pregnant women who undergo pregnancy examinations who meet the inclusion criteria when conducting research are used as samples. The sample in the study was 35 pregnant women who experienced anemia during pregnancy. The data collection technique in this research is secondary data, namely data obtained from the medical records of the Batua Community Health Center, Manggala District. In the research, the instrument used was an observation sheet made by the researcher based on theory. The data analysis used is univariate analysis and bivariate analysis using SPSS. The results of the research show that based on the chi square statistical results, the Fisher Exact Test value was obtained = 0.027 < α 0.05, which shows that maternal age is a factor related to the incidence of anemia in pregnant women at the Batua Community Health Center, Manggala District, Makassar City, then based on the chi statistical results square, the Fisher Exact Test value was obtained = 0.012 < α 0.05, which indicates that pregnancy spacing is a factor related to the incidence of anemia in pregnant women at the Batua Community Health Center, Manggala District, Makassar City.

The Nutrition Care Center (NCC) is a teaching factory (TEFA) at the Jember State Polytechnic (Polije) which provides assessment and diagnostic services for nutritional problems, comprehensive nutritional assessments, diagnostic services, nutritional counseling, and customized diet plans for clients. Health services, including nutrition, require accurate medical records that include patient identification, examination, treatment, interventions, and other relevant information. However, NCC faces challenges, namely that the medical recording system is still manual paper-based. Medical record numbers do not comply with numbering regulations, age is still used instead of date of birth, the nutritional assessment section is not yet standardized and disease code classification does not yet exist. This manual system is susceptible to damage, loss, and requires dedicated storage time and space. Since it was inaugurated in November 2021, the number of NCC visits has continued to increase both from internal clients and external clients of Polije with initiations with several educational institutions, offices and elderly groups. The use of EMR which is made easier with QR Codes and the application of Whatsapp Bot is the main alternative to build or improve the management of assessment and diagnostic services for nutritional problems according to client needs. Socialization of assistance in implementing Electronic Medical Records (EMR) with QR Code and WhatsApp Bot at NCC aims to make things easier for experts. nutrition to access the client's examination history, allergy history and previous therapy in one view and make it easier for clients to access medical record numbers without a card. This initiative is in line with the Department of Health Research Masterplan 2022 and the development of TEFA services. NCC recognized the need for a more efficient system and proposed implementing EMR with QR Codes and WhatsApp Bots to optimize patient care. This socialization was carried out at the Jember State Polytechnic NCC with the presence of participants from nutritionists, students, the community and administrators from NCC. This socialization obtained results in the form of increasing public understanding of nutritional care, especially in relation to the existence of NCC as a teaching factory at the Jember State Polytechnic, the use of EMR via QR codes and WhatsApp Bot as a solution implemented by NCC in optimizing patient care and increasing the empowerment of partners in using it. and implementation of EMR with QR codes and WhatsApp Bot in patient nutrition care at NCC.

HIS has a major role in managing health data and information applied through Electronic Medical Records (EMR). EMR facilitates the analysis of health data in patients, decision-making by health care providers, disease mapping, helps identify disease patterns, and maps the spread of the disease. HIS supports the creation of telemedicine services through the concept of telemedicine.  This study uses the Narrative Literature Review (NLR) method on the concepts of Health Information Systems (HIS) and Telemedicine. Integrating HIS and Telemedicine provides promising opportunities for healthcare improvement, offering data accessibility, and efficient remote consultation. However, addressing privacy, security, infrastructure, and regulatory challenges is critical to the successful implementation of such integrations. Collaborative efforts between healthcare providers, policymakers, and technology developers are critical to ensuring the ethical and effective implementation of integrated systems.

Shrinkage is the reduction of medical records on storage shelves by moving inactive medical records to a different room from the active shelf seen from the last patient visit. The purpose of this study was to determine the implementation of shrinkage at the Kembangan Regional General Hospital. This research method uses a qualitative descriptive method by means of interviews and observations in the medical records unit. So it can be concluded from the results of the study that the Kembangan Regional General Hospital already has SOP related to shrinkage which is divided into SOP sorting, media transfer and destruction. In the implementation of shrinkage, officers carry out the process of sorting, transferring and transferring media every day. But officers do not conduct an assessment based on use value. The destruction process is carried out when the number of medical records has reached 2 tons by using a third party to make medical records in the form of pulp. The main obstacles to the implementation of shrinkage are officers who do not have a decree on duties and teams so that officers often delay the implementation of shrinkage, paper quality that makes it difficult for officers to see medical record sheets in the past year and scan machines that heat up quickly due to continuous use. Therefore, the Kembangan Regional General Hospital should complete the SOP related to shrinkage, make a decree of duties and conduct an assessment stage so that the implementation of shrinkage is carried out properly, and add a scan machine so that the implementation of media transfer is not delayed.

Breasts are organs that play a role in the lactation process. In men, this organ does not develop and does not have a function in the lactation process like in women. According to. cancer is characterized by the growth of abnormal cells beyond normal limits and can attack adjacent parts of the body or metastasize to other organs which can result in death for the sufferer. Cancer is also called malignant tumor and neoplasm. Breast cancer sufferers often find out about their disease too late, so they come to the hospital when it is in the final stage. Early detection is very necessary so that breast cancer sufferers can be treated more quickly. The prevalence of cancer in Bali Province in 2018 was 2.3 per 1000 population. This incidence increased compared to the 2013 Riskesdas results of 2.0 per 1000 population (Riskesdas, 2018). The total number of breast cancer cases recorded in the Medical Records Installation at Sanglah General Hospital Denpasar for the period 1 January – 31 December 2022 and which met the inclusion criteria was 70 people with a monthly average of 5.83%, around 6 patients. Inclusion criteria are breast cancer patients with stage II-IV and who have had a mastectomy. Based on a report from the Bali Province Integrated Disease Survey, it was found that the incidence of breast cancer in 2019 was 437 cases. especially in Denpasar City, the incidence of breast cancer was 293 cases. Denpasar City is an area that has the highest incidence of breast cancer in Bali.

UPT Karanganyar Health Center Karanganyar Regency is a type urban non-inpatient health centers, so they only serve outpatient care and emergency. Based on the results of the survey and introduction of researchers, at UPT Karanganyar Health Center found a medical record document missfile. The Missfile was due to a lack of non-RMIK officers in the filing department careful in returning medical record documents in place, and amount the medical record staff in the filing is inadequate. This research aims to find out the medical record document storage system at UPT Puskesmas Karanganyar.This type of research uses descriptive research methods, with approach. The subjects in this study were medical record filing officers. The object of this study is a medical record document storage system in UPT Karanganyar Health Center. This research instrument uses guidelines interviews and observations. Data processing by collecting, editing, and data presentation.The result of this research is based on record numbering system medical uses UNS (Unit Numbering System) with Family Numbering, for alignment using SNF (Straight Numerical Filling) and storage using centralization with personal folders. Factor the cause of the missfile is the inaccuracy of the clerk in returning the document medical records to the filing rack, the impact of the missfile is service delays and duplication of medical records efforts made namely socialization with color coding.The author suggests that a tracer should always be used when retrieval of medical record documents, so that they are stored again medical record documents faster, and avoid missfiles. It is necessary control by medical record officers when non medical record officers put DRM back on the shelf. Conduct HR recruitment with competence and qualifications from D3 Medical Records.  

Medical records are files that contain records of documents regarding patient identity, examinations, treatment, actions and other services provided to patients. Medical records contain written or recorded information containing identity, anamnesis, support, diagnosis, services and medical actions that will be given to patients and treatment whether inpatient, outpatient or receiving emergency services (Permenkes RI No. 269 of 2008) . Increasing the effectiveness of recording medical record data accurately and quickly can take advantage of current technological advances through Electronic Medical Records (RME). Electronic Medical Records are Medical Records created using an electronic system intended for the maintenance of Medical Records

Cephalopelvic Disproportion (CPD) is a condition that describes a discrepancy between maternal and fetal pelvic capacity caused by maternal pelvic abnormalities (pelvic bone size and architecture) or abnormalities in the fetal head (size or presentation) or a combination of both. The dominance of sectio caesarea surgery for cephalopelvic disproportion according to the Basic Health Research Survey in Indonesia in 2010 was quite high at 4.40% of all childbirths. Factors affecting cephalopelvic disproportion can be influenced by both mother and baby. Factors of the mother include body height less than 145 cm, and, the size of the outer and inner pelvis is below normal that the baby is unable to pass through whereas factors in the baby is that the large baby size. Previous studies on pregnant women found that the majority of those who experienced cephalopelvic disproportion were mothers with short postures or a body height of less than 145 cm. Objective : To determine the relationship between maternal height and the incidence of cephalopelvic disproportion at the General Hospital in Mandau Subdistrict, Bengkalis Regency period 1 January - 31 December 2017.  Method : This type of research is analytic observational with cross sectional design. The sampling technique used is simple random sampling. The sample in this study amounted to 253 respondents. Data for height and incidence of CPD using medical record records of Mandau District Hospital Bengkalis Regency period 1 January - 31 December 2017. The data obtained will then be analyzed using the Spearman correlation test. Results : There was a significant relationship between the height of pregnant women with the incidence of CPD in the District Hospital of Mandau, Bengkalis Regency, period 1 January - 31 December 2017 with a p value of 0.00 (p <0,01) and correlation coefficient (r=-0,737) with strength relationship is very strong and negative direction. Conclusion : There is a significant relationship between the height of pregnant women with the incidence of CPD in the District Hospital of Mandau, Bengkalis Regency, period 1 January - 31 December 2017.

Latar Belakang: Lymph node cancer in the case of Hodkin's Lymphoma is a type of cancer. Lymphoma is a solid tumor of the immune system. Hodgkin lymphoma (HL) accounts for about 10% of all lymphomas. The Intensity Modulated Radiation Therapy (IMRT) technique is one of the cancer treatment techniques in Hodgkin's Lymphoma cases. The aim of this research is to determine the procedure and reasons for using the IMRT technique in lymph node cancer in Hodkin's Lymphoma cases.Metode: This research is qualitative research with a case study approach using retrospective data. The research time is from 24 to 30 May 2023 and the research location is in the Department of Radiation Oncology, RSUP Dr. Hasan Sadikin Bandung. The research subjects consisted of Radiation Oncologists, Medical Physics, Radiotherapists. Researchers collected data from patient medical records, made interview transcripts and carried out data reduction and processed it using open coding, and provided it in the form of quotations and then drew conclusions.Hasil: The procedure for irradiating Hodgkin's Lymphoma using the IMRT technique at the RSHS Department of Radiation Oncology begins with positioning the patient on the examination table with a fixation device and arranging the patient according to the reference point of the CT Simulator and making a thermoplastic mask then carrying out verification and irradiation. The IMRT technique has the advantage of using MLC so that the radiation is modulated according to the contour of the target and the disadvantage of precise dose distribution in limiting the radiation dose to organs at risk.Kesimpulan: In the case of the Department of Radiation Oncology, Dr. Hasan Sadikin Hospital, Bandung, the IMRT technique was used with consideration, namely that the IMRT technique already uses MLC which creates individual blocks automatically according to the projections depicted on the TPS.  

The aim of this research is to analyze the handling of medical record archives that runs at Bhakti Kartini Hospital and is the subject of research discussion. This research uses a qualitative method with a descriptive approach, the subjects of this research are the medical records staff at Bhakti Kartini Hospital, totaling 4 people. From the results of the research conducted, Management of medical record archives includes creating, handing over and destroying medical record archives. Maintenance of medical record archives is carried out by medical record staff and maintenance of equipment that supports the archives is carried out by hospital cleaning staff, however, the equipment facilities that support medical record archives are still inadequate, hampering employee activities and performance that are less than optimal. Meanwhile, the storage of medical record archives at Bhakti Kartini Hospital uses a decentralized system where active archives and inactive archives are stored in different storage locations, active archives are less than 5 years old while inactive archives are more than 5 years old, and for the record archive alignment system medical devices use a digit terminal system.    

Serotinus is one of the obstetric complications that needs to be watched out for and there is a high risk of caesarean section during delivery. These complication will be made worse if the mother experiences anemia which can cause uterine atony, post partum bleeding and even lead to maternal death. According to WHO (2021), the Maternal Mortality Rate (MMR) is 329,000 per 100,000 live births, data from the Brebes Health Office in 2022 is 105 cases, and data from the Paguyangan Community Health Center (2021) is 4 cases. Researchers implemented comprehensive midwifery care using Varney and SOAP documentation. This research uses a qualitative descriptive method with a case study approach. Data collection used interview methods, observation, physical examination, supporting examinations, medical records, KIA books and other literature. The main informant is Mrs. A, while additional informants were midwives, general practitioners, obstetricians, nutrition officers, laboratory officers, husbands and families. Based on the results of pregnancy, childbirth, newborn, postpartum and family planning care, there were only problems in pregnancy at the age of 29+1, namely breech and oblique presentation and mild anemia with HB 9.6 g/dL and at the gestational age of 31+3, namely underestimation of fetal weight.

Coronavirus is an infectious human disease caused by Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2). D-dimer affects the mortality rate of COVID-19 patients due to an impaired immune system and an excessive inflammatory process that leads to tissue damage, leading to death conditions. The increase in COVID-19 severity correlates with an elevation in D-dimer levels. Elevated D-dimer levels have become an important marker in monitoring the condition of severe COVID-19 patients, as they are associated with worse outcomes and increased mortality in severe COVID-19 cases. To determine the relationship between D-dimer levels and mortality in severe COVID-19 patients.This research used a descriptive and analytical study with a cross-sectional design to determine the correlation between D-dimer levels and mortality in severe/critical COVID-19 patients. Data were obtained from secondary sources of medical records of confirmed severe/critical COVID-19 patients at Dr. Pirngadi Regional General Hospital. There is a correlation between D-Dimer levels and mortality in confirmed severe COVID-19 patients with moderate severity. A significant association exists between elevated D-Dimer levels and mortality in confirmed COVID-19 patients with moderate severity. This study also indicated that there are more male COVID-19 patients compared to females. Older individuals (elderly) in this study, aged over 45 years, are more likely to be infected with COVID-19 compared to those under 45 years of age.

Respiratory tract infections are one of the causes of high mortality and morbidity in children, especially in children under the age of 5 years whose immune system is still susceptible to various diseases. The purpose of this study was to determine the rationality of giving antibiotics for acute respiratory tract infections (ARI) to toddlers at the Jamanis Health Center. The type of research used is descriptive research, the sampling method is purposive sampling and data collection is carried out retrospectively. Then data analysis was carried out and compared with references from MTBS guidelines. This research was conducted at the Jamanis Health Center when the research was conducted in March-May 2023. The population used in this study was all ARI patients at the Jamanis Health Center for the January-December 2022 period. Based on the data obtained, the number of medical records of ARI patients in toddlers at the Jamanis Health Center for the 2022 period is 1121 people. The results of the study of the most widely used antibiotic drug were amoxicillin with 82 cases (89.13%). The results of rationality of drug administration based on the criteria of Right diagnosis that is equal to 100% (Rational), Right indication that is equal to 65.21% (Not Rational), Right drug that is equal to 65.21% (Not Rational), Right patient that is equal to 100% (Rational), Right dose that is equal to 100% (Rational)

Assessment of the quality of service in hospitals can be done by determining the completeness of filling in medical record documents through quantitative analysis. Quantitative analysis of medical record documents is the study or review of certain parts of the contents of medical records with the aim of finding specific deficiencies related to recording medical records. Quantitative analysis of medical records includes four review components, namely identification review, recording review, reporting review, and authentication review. Rumah Sakit Umum Hidayah Boyolali has implemented electronic medical records since January 2023 in accordance with the mandate of the Republic of Indonesia Minister of Health Regulation Number 24 of 2022 concerning medical records. The aim of PkM activities is to increase the knowledge and abilities of medical record officers regarding quantitative analysis of medical records and electronic medical records at Rumah Sakit Umum Hidayah Boyolali. The PkM implementation method includes material presentation, discussion, clinic and evaluation. The target of PkM consists of 13 medical record officers with the results of PkM being to increase the knowledge and ability of officers in analyzing the completeness of filling in medical records and electronic medical records.  

Background: Hyperthermia is a condition where the body temperature is higher than normal because the body is unable to dissipate excess heat in the body, which threatens to cause fever. The results of the medical records of the children's inpatient room at Dr Socratno Gemolong Hospital, the number of children treated at the Anggrek ward who experienced fever, namely preschool aged children in the last 4 months, was 116 patients. Efforts to reduce fever can use Water Tepid Sponge. Water Tepid Sponge is a warm compress action using wipes and blocks not only in one place. Objective: The aim is to find out the results of the implementation of giving Water Edged Sponge to body temperature due to fever. Methods: using a case study design, subjects were 2 pre-school aged children who were treated in the orchid children’s room at dr. Soeratno Gemolong hospital. The instrument used to measure body temperature is a thermometer. Application of water tepid sponge was carried out for 3 days. Findings: water tepid sponge is able to reduce body temperature in pre-school aged children (1-3 years) with hypertermia. Implication: there are dfferences in the develoment of decreased body temperature in pediatric patients with hypertermia before and after the application of the water tepid sponge. So that the action of water tepid sponges can be used as a non-pharmacological technique to reduce body temperature in pre-school aged children (1-3 years) with hyperthermia.

Anemia in pregnancy is characterized by a condition in which the body has few red blood cells or the cells cannot carry oxygen throughout the body. it is estimated that the prevalence of anemia in pregnant women in Indonesia in 2019 is 48.9%. Bananas are the best food because they contain vitamins needed by pregnant women. Bananas are sufficient to meet the substance intake of anemic patients. The aim of the study was to determine the relationship between Ambon Banana Administration and Hemoglobin Levels in Pregnant Women with Mild Anemia in the First Trimester. This research was carried out using quantitative analytic research with a cross sectional approach by collecting secondary data from medical records. from April 2021 to June 2022 . This research was conducted at TPMB Susi in Dolok Merawan District, Serdang Bedagai Regency in February 2023. The sampling technique used total sampling with a total sample of 42 pregnant women in the first trimester with mild anemia who met the inclusion and exclusion criteria. Analysis using the Chi Square statistical test shows that the p value is 0.000 (<0.05). So that the hypothesis can be accepted, then there is a "Relationship between Giving Ambon Bananas and Hemoglobin Levels in Pregnant Women with Mild Anemia in the First Trimester. The results of this study indicate that there is a relationship between giving Ambon bananas and hemoglobin levels of pregnant women after being given Ambon bananas. Giving ambon bananas can be suggested as an alternative complement of vitamins to increase hemoglobin levels.