Preliminary

Information is the core life of a health information presentation system. Medical records that are
made either in the form of forms or sheets, must contain medical information that describes in
detail all aspects of patient care that occur (information that is ready to use)

Record = the mark or impression of something said or written

Medical Records (broadly) = records and data as a result of direct or indirect relationship with all
activities in the hospital related to patient treatment. This includes records from the support units,
the implementation of a diagnostic index and supervision of staff associated with the activity

Medical record (briefly) = as case notes for each patient treated in the hospital

Forms of medical records  painting, writing both on paper, walls, earth, walls, stone, wood, cloth,
sculpture

Medical Record: a collection of marks / impressions of something that was said / written <> the state
of the patient from time to time.

Nature: Confidential, the information contained therein can only be given or issued based on
confidentiality legislation in force in the medical profession or under state provisions.

MEDICAL RECORD TERMS

 Medical document

 Medical notes

 Medical record

 Health record

Onn Personnel health record

 Family health record

 Medical report

Medical Records:

the handwriting of doctors, medics and other health professionals about a patient's medical
condition. Has the value of confidentiality while in the supervision and authority of the designated
health workers.

Medical Documents:

doctor's letter regarding a brief medical history from someone who is temporary in accordance with
the time period stated in the statement. Medical documents can be provided to patients, companies
/ offices requesting a residence (eg immigration, place of work / place of application for
employment). The value of confidentiality cannot be accounted for because it is open to non-health
parties

MEDICAL RECORDER OWNER

Health care institutions that make them and at the same time protect the interests of patients,
health institutions and health workers who do the recording

PHYSICAL:

▪ Medical Records

▪ Health Record

▪ HR Health Information

▪ Medical Records

▪ RMIK experts

▪ Health Information Administrator

▪ Health Information Management Expert / MIK UNIT WORK

▪ Medical Records

▪RMIK

▪MIK (Health Information Management)

MEDICAL RECORDS

Form R M → painting, writing both on paper, wall, earth, wall, stone, wood, cloth, stone carving,
body organ model made of clay, plastic, etc. Records can also be produced by means of manual or
electronic stationery (telex, fax, computer print, telegram, video, film, laser, optical disc, etc.).
Includes examination results issued by medical devices such as: Radiology, (negative x-ray film
examination film)

Graph printout: Heart rate recorder: ECG / ECG = Electro Cardiogram, Muscle (EMG =
ElectroMusclegram), Brain (Electro Encephalogram), Ultrasound (Ultra Sonogram), Scanning, etc.

HEALTH RECORD

Personal Health Record or Family Health Record contains the understanding that the doctor in
charge of the patient provides a record of the patient's or family's personal health to take home.
Furthermore, the value of confidentiality is very dependent on the holder. The contents of the two
types of records are not as complete as the original left at the service provider. Means that are given
to patients and their families are only in the form of the original form. Examples of Baby Cards, KMS
Cards, Pregnant Women Cards, etc.
ELECTRONIC MEDICAL RECORD / ELECTRONIC HEALTH RECORD a. is the activity of computerizing the
contents of the health record and the processes associated with it. (PORMIKI Professional Standards,
2007)

HEALTH INFORMATION SERVICE / MEDICAL RECORD is a professional support service activity

oriented to the health information needs of health service providers, administrators and
management of health service facilities as well as other interested institutions based on medical
record technology knowledge (synthesis of social science, epidemiology, medical terminology ,
biostatistics, medical legal principles and information technology). (PORMIKI Professional Standards,
2007)

EXPERT OF HEALTH INFORMATION MANAGEMENT = ADMINISTRATOR OF HEALTH INFORMATION

(MEDICAL RECORDER)

is a profession that focuses its activities on health service data and management of health service
information sources by describing the nature of the data, structure and translating it into various
forms of information for the advancement of health and health services for individuals, patients and
communities

ELECTRONIC DOCUMENTS (UU ITE / 2008)

is any Electronic Information that is made, transmitted, sent, received, or stored in analog, digital,
electromagnetic, optical, or the like, which can be seen, displayed and / or heard through a
Computer or Electronic System, including but not limited to writing , sounds, pictures, maps, designs,
photographs or the like, letters, signs, numbers, Access Codes, symbols or perforations that have
meaning or meaning or can be understood by people who are able to understand it

COMPUTER-BASED PATIENT RECORD (CPR):

Electronic patient medical records contained in a system specifically designed to help users by being
able to access data completely and accurately, alerting, supporting clinical decisions, relating to
medical knowledge, and other aids.

a. Electronic Medical Record (EMR) is broader with a system based on document imaging or a
system that has been implemented in a doctor's office

b. Electronic Health Record (EHR) terms used by IOM (Institute of Medicine) and the US Department
of Health and Human Services (HHS) since July 2003

c. EHR Standards are developed based on HL7 (Health Level Seven), namely Standards Development
Organization in collaboration with IOM (Appendix B)

USE MEDICAL RECORDS

1. Patient Care Management

▪ Record the condition of the disease & treatment

▪ Communication between doctors and other health service providers.

▪ Provide information → Continuation

2. Quality Review: evaluating appropriate & adequat service.

3. Financial Reimbursement: collect the cost of health care for patients / institutions. 4. Legal Affairs:
Provide data u. protect the interests of patients, doctors and health service institutions.

  5. Education: Provide actual case studies for health professional educators.

6. Research: providing data in developing penget.medis.

7. Public Health: Identifying existing diseases, can be the basis for improving national / world health.

8. Planning and Marketing: identifying important data to select and promote services from existing
facilities.

RM users:

▪ all individuals who fill out, verify, correct, analyze and obtain information from the medical record
either directly or indirectly.

1. PATIENT

2. PARTICIPANTS OF HEALTH SERVICES (PROVIDERS)

3. FOR MANAGEMENT OF PATIENT SERVICES (MEDICAL COMMITTEE)

4. FOR SUPPORTING SERVICES

5. FOR PAYMENT AND PARTIES

REIMBURSEMENT

6. EDUCATORS

7. RESEARCHERS

8. REGULATION

9. DECISION MAKER

10. Industry Side

FUNCTION OF RM

Store data and information from care

patient, on condition:

1. Accessibility → 24 hours

2. Quality → depends on the design of

primary data collection system and process

3. Security

4. Flexibility

5. Connectivity

6. Efficiency

RESPONSIBILITIES FOR RM

Governing Board - CEO - Medical Staff is officially (legally) and morally responsible for the quality of
care provided to patients. a. CEO b Head of Medical Records (Inf. Health) c. Doctors who treat d.
Medical Staff

Centralization

Centralization is all information about a patient stored in one file, both outpatient, inpatient and
emergency information.

Or more clearly, centralized storage

adlh:

1. All records of services provided to patients are in one file / folder.

2. Stored in one location.

3. Managed by one work unit of RM.

ALL INFORMATION ON TTG SOMEONE PATIENTS WILL BE STORED IN A DLM, ONE COVER, ONE
PLACE.

The Goodness Of The Decentralized System

1. Information is in one file / folder, one place, and is open to the profession of care / health
services.

2. Reducing information duplication & RM.

3. The number used by this RM is different from that of other patients in the hospital.

4. Reduce the amount of costs for equipment & space.

5. Work procedures & regulations regarding recording are easily standardized.

6. Improved work efficiency of storage officers.

7. Easy file control.

8. Easy to retrieval.
Weaknesses of the decentralized system

1. Officers become busier because they handle all outpatient, inpatient & emergency services.

2. Work within 24 hours continuously.

Decentralization

Separation of storage place / location between outpatient & inpatient RM. Can be with 1 unit
number / with a different number.

This method requires a strict policy so that it can be managed under one RM work unit.

Kind :

• Time efficiency so that patients get faster service.

• Officer workloads are lighter.

Deficiency :

• There was a duplication in making RM.

• Cost for equipment & more space.

In theory, centralization is better than decentralization, but in practice it depends on the conditions
& situation of the hospital, a.l. :

• Lack of skilled workers especially those who manage RM.

• Hospital funding capability.

• In hospitals with separate buildings / wards, it is possible for a certain level of decentralization to
facilitate the provision and access to RM units.

• In large hospitals where demand for RM is constant, the way to centralize & RM in one file can only
be unprofitable.