MEDICAL RECORD AND TECHNOLOGY

LECTURER :
Km Tri Sutrisna Agustia, SSI.,M.Hum
BY :
Ni Luh Sri Sukasih (18120901053)

STUDY PROGRAM :

PEREKAM DAN INFORMASI KESEHATAN 2B

UNIVERSITAS DHYANA PURA
2018/2019
 Electrinic Medical Record

EMR (Electronic Medical Record) is a form of information technology development in health

services. There are types of data that can be stored in EMR. Many benefits from
implementing EMR. In this implementation there are also policies in accordance with digital
procedures.

There are serveral types of data that can be stored in electronic medical records. Inthe form
text in the form of code,narration and reprts. In the form images in the form of computer
graphics,scanning results and digital x-rays. In the form sound,for example heart sounds or
lung sounds. In the form videos,for example the operating process or other medical actions.

There are many benefits of applying electronic medical records. Because it can search and
send information easily. Can be linked to information outside the hospital. For storage to be
more concise,data can be displyaed quickly as needed. Easier and automatic reporting.
Quality and standard data can be controlled. And, can be integrated with decision support
software.

In this implementation there are also policies in accordance with digital procedures. Every act
of consultation carried out on the patient, must be directly entered into the patient file on the
computer because if delayed, the possibility will be forgotten. All records made by doctors or
other health workers must be given an identity code, this is a substitute for initials or
signatures which are usually done if using a manual medical record system. Every deletion or
change of information must be done by using an interested PIN and must be known by the
head of the medical record, because it is feared that the engineering will occur. The use of
digitally recorded medical forms is represented by each type of patient activity, namely in the
outpatient, inpatient, and emergency groups. Each has been arranged according to their needs,
just like the manual form is just the form in the computer.

Electronic medical record is a form of medical record activity that is formed because of the
development of computer technology for the purpose of efficiency, effectiveness and in order
to improve the quality of service and organization of hospital activities.
 Important Role of Information Technology

In The Field of Medical Record

Information technology has a major role in improving health services. Its role can be seen
from the administrative aspect. Its role is also very in the documentation aspect. And, there
are some tangible benefits that can be obtained.

Its role can be seen from the administrative aspect. The use of medical records is currently
very necessary because we can see the treatmen process and the actions given to a patient.
Now can be accessed directly by the authorized part of the inspection. Then processing
computerized data will also make it easier for all authorities. In this case the administrative
officer in a health service agency can immediately find out the details of the costs to be
incurred by the patient as long as the patient is undergoing treatment at the hospital.

Its role is also very important in the documentation aspect. Among others are medical record
files that have documentation value. Because the contents concern memory resources that
must be documented and used as material for hospital accountability and reports. The
development of knowledge and information technology can be applied in the implementation
and management of medical records that are quite effective and efficient. Documentation of
patient medical data can be done easily and effectively in accordance with established rules
and procedures.

There are some tangible benefits that can be obtained. First, Medical Records information
technology can make medical record data integrated so that patients do not need to bring
medical record documents from one doctor to another doctor or from the laboratory to the
doctor concerned. Second, the diagnosis process is better because it is supported by complete
patient history data, both medical actions have been given, even knowledge (best practices)
that can be considered. Third, management of inpatient room services can be done easily and
quickly. Fourth, prescriptions and documentation of drugs with unclear doctor prescription
information becomes clearer because drug choices are available without the need to contact
the doctor again to ensure clarity of prescription. The last, bill payments to patients can be
done quickly and the payment option are desired by the patient.
So, the use of information technology at the Hospital will make the service at the Hospital be
effective, efficient and productive in improving health services. Especially can be seen from
the administrative aspects,documentation aspects and some tangible benefits obtained.