The Influence of Knowledge and Perceptions of Doctors on the Quality of Medical Records

Ismawati, Nining Dwi Suti; Supriyanto, Stefanus; Haksama, Setya; Hadi, Cholicul

doi:10.4081/jphr.2021.2228

Cited by 6 publications

(7 citation statements)

References 13 publications

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“…Then in CHAPTER III, in the second part, also contains things that are no less important, namely those relating to sanctions. Article 42, paragraph (1) to paragraph (3) states that "The Minister in carrying out guidance and supervision can impose administrative sanctions on Health Service Facilities that violate the provisions referred to in Article 3. (2) Imposition of administrative sanctions by the Minister as referred to in paragraph (1) implemented through the Director General.…”

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Medical Record Digitization Policy: Overview of the Health Minister Regulation Number 24 of 2022

Asyfia¹,

Zaid

Mahendika

et al. 2023

JHSP

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Objective: This study aims to examine the Regulation of the Minister of Health Number 24 of 2022 concerning Medical Records, which regulates electronic medical records. Methods: This research is juridical research with a statutory approach. Thus, this study only analyzes the rules and regulations related to legal or policy issues related to the digitization of medical records. Results: The obligation of the Electronic Medical Record (EMR) in Indonesia has legal certainty with the ratification of the Regulation of the Minister of Health of the Republic of Indonesia Number 24 of 2022 concerning Medical Records. This obligation has administrative consequences in the form of a written warning and/or recommendations for revocation or revocation of accreditation status for Health Service Facilities that commit violations. The provisions of this policy must go into effect no later than December 31, 2023. Conclusion: Three new things are regulated in the Regulation of the Minister of Health of the Republic of Indonesia Number 24 of 2022: the electronic system of electronic medical records, activities for organizing electronic medical records, security, and protection of electronic medical record data.

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Section: Discussionmentioning

confidence: 99%

“…2 Medical records are a reflection of the quality of medical services provided. 3 Medical records have been widely used in developed and developing countries on a limited basis. 4 However, the traditional (paper-based) medical record system is a waste of time (inefficient) and hinders providing the best care to patients.…”

Section: Introductionmentioning

confidence: 99%

Medical Record Digitization Policy: Overview of the Health Minister Regulation Number 24 of 2022

Asyfia¹,

Zaid

Mahendika

et al. 2023

JHSP

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“…This suggests that while knowledge training is valuable, it might not be adequate on its own to drive consistent and accurate record-keeping behaviours. Organizational success often requires a work environment that empowers personnel to align with the organization’s goals 19 . This aligns with the broader literature, indicating that attitude is a crucial factor influencing medical record completeness, as observed in this study 20 , 21 .…”

Section: Discussionmentioning

confidence: 99%

Factors affecting completeness of anaesthetic record: a cross-sectional study

Limpoon,

Seangrung,

Nimmankiatkul

2023

Annals of Medicine &Amp; Surgery

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Background: Anaesthesia Information Management Systems (AIMS) are of critical importance for ensuring the comprehensive recording of anaesthesia data. This study aimed to investigate the factors influencing the completeness of anaesthetic records created by various healthcare professionals including anesthesiologists, nurse anaesthetists, residents/fellows, and anaesthetic nurse trainees. Methods: Employing an online Google Forms questionnaire, this descriptive research focused on understanding the factors contributing to the completeness of anaesthetic records. The survey was distributed to all anaesthesia personnel in the department, comprising a total of 165 participants. The questionnaire encompassed three primary aspects:(1) personal information, (2) knowledge related to recording anaesthetic records, and (3) concerns related to achieving high-quality record-keeping. To assess completeness, anaesthetic record forms were evaluated based on the 2020 Medical Record Audit Guideline of Thailand’s National Health Security Office, with a completeness rate exceeding 80% deemed acceptable. Spearman’s rank correlation was employed to analyze the connections between the associated factors and completeness of anaesthetic records. Results: From August to October 2021, 165 records were examined, indicating a completeness rate of 89.7%. Several factors exhibited significant correlations with the completeness of anaesthetic records. These included age (r = −0.223; P=0.004), job position (r = 0.44; P<0.001), years of anaesthesia experience (r = −0.208; P=0.007), experience in anaesthetic record training/teaching (r = 0.181; P=0.02), and attitude emphasizing high-quality record-keeping (r = 0.167; P=0.032). Conclusion: While personal attributes emerged as pivotal factors influencing record completeness, continuous training and a collaborative attitude were identified as critical for maintaining sustainability and achieving record-keeping goals.

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“…This happens because doctors have a high workload, and lack of support from hospitals and lack of communication. (17) The existence of incomplete medical resumes at X Hospital requires supervision from the Head of Health Services Division and the medical committee.…”

Section: The Process Ofmentioning

confidence: 99%

Dispute Analysis of Claims for Patients With Covid-19: A Case Study at Hospital X Class B in Bantul Regency

Putri

Hafidz²,

Hendrartini³

2023

J INDO HEALTH POLICY ADM

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The Indonesian Government established referral hospitals for COVID-19 as an effort in combating the pandemic. Referral hospitals for COVID-19 submit their services’ claims to the Ministry of Health. Hospital X in Bantul experienced challenges in submitting COVID-19 claims and underwent claim disputes which caused delays in payment process. This research aimed to explore the factors that led to the disputes over the COVID-19 claims. This descriptive research was conducted with a qualitative approach, using in-depth interviews and observations. The additional descriptive analysis used secondary data COVID-19 claim dispute file reports from 2020. The results showed that the highest criteria of disputed claims at Hospital X were the criteria for non-compliant guaranteed participants, incomplete claim files, non-compliant comorbid diagnoses, and identities that did not comply with the provisions. The causes of the disputes over claims for patients with COVID-19 included inaccurate history taking, differences in regulation perceptions between the provider and payer, PCR results were not provided, and doctors had a lack of understanding regarding the technical guidelines for COVID-19 claims. In addition, there were technical problems faced by the hospital during the process of submitting claims, including regulations were changed frequently, errors in applications, incomplete medical resumes, and unreadable doctors’ writings. Disputed claims did not affect the hospital cash flow, yet delayed the payment process to health workers, which might harm the quality of services.

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The Influence of Knowledge and Perceptions of Doctors on the Quality of Medical Records

Cited by 6 publications

References 13 publications

Medical Record Digitization Policy: Overview of the Health Minister Regulation Number 24 of 2022

Medical Record Digitization Policy: Overview of the Health Minister Regulation Number 24 of 2022

Factors affecting completeness of anaesthetic record: a cross-sectional study

Dispute Analysis of Claims for Patients With Covid-19: A Case Study at Hospital X Class B in Bantul Regency

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