Evaluasi Penyelenggaraan Rekam Medis Elektronik pada Rumah Sakit Gigi dan Mulut Universitas Sumatera Utara

Abstract

Medical records contain files, notes, and documents regarding identity, examination, treatment procedures, and other services provided to patients. Electronic medical records represent the use of information technology systems in medical recording. Since electronic medical records are important, this research was conducted to examine to what extent medical staff use electronic medical records effectively in Universitas Sumatra Utara Dental and Oral Hospital. This study employed the qualitative descriptive method to reveal events, facts, and situations during the research and to present them as they are. The results of the present study show that in the hospital: 1) the patient registration process is done according to the standard because it requires patient identity; 2) the distribution of electronic medical record data complies with the standard; 3) the clinical information input complies with the standard because it is done by the doctors; 4) the management of medical record information does not meet the standard, 5) the input of hospital bill claim is conducted in accordance with the standard and the Regulation of the Ministry of Health; 6) the medical record data is stored in cloud, so it complies the standard; 7) the quality assurance of the electronic medical records does not comply with the standard because the hospital still hires a vendor to secure the privacy of patient data; and 8) the electronic medical record transfer does not comply with the standard. In general, the Dental dan Oral Hospital of Universitas Sumatra Utara does not comply with the Regulation of the Ministry of Health standards, and it is expected that the quality of services can be improved.