PAPER

"RECORDING AND REPORTING IN HOSPITALS"

Lecturer: Desy Natalia, M.Pd

Arranged by :
Group 2
Bella Azsaria 2018.C.10A.0960
Mewan Tony 2018.C.10A.09
Leonardo 2018.C.10A.0975
Jekicen 2018.C.10A.09
Oktavia Marentase 2018.C.10A.09
Trisia Vironika 2018.C.10A.0990

FOUNDATION STIKES EKA HARAP PALANGKA RAYA

INSTITUTE OF HEALTH SCIENCE
S1 NURSING STUDY PROGRAM
ACADEMIC YEAR 2019/2020

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 Foreword

Praise and gratitude to the author of the presence of God Almighty, for the
abundance of His grace and gifts, so that the author can complete a paper with the title
"Recording and Reporting in the Hospital". This paper contains information systems for
recording and reporting in hospitals.
So hopefully this paper can be an additional reference for nursing students. We are
aware that our paper is far from perfect. Therefore, we expect constructive criticism and
suggestions so that in making the next paper can be more perfect.
Finally, we hope that this report can be useful for many people. thanks.

Palangka Raya, 11 April 2020

Author

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 TABLE OF CONTENTS

FOREWORD ...................................................................................................
TABLE OF CONTENTS ......................................................................... ... ii
CHAPTER I INTRODUCTION……………………….…………………………….......
A. Background………………………………………………………………...
B. Formulation of the problem………………………………………………………..........
C. Writing purpose…………………………………………………………........
CHAPTER II DISCUSSION …………………………………………. ………… ......
A. Definition of Recording and Reporting ..................................... ... ........ .................
B. Recording and Reporting Functions .......................... ... .. ......... .. ... ........... .........
C. Types of Recording and Reporting .............................................. ..........................
D. Processing of Reporting Pata in Hospitals ............................................ .........
CHAPTER III CLOSING…………………………………………………………….....
A. Conclusion………………………………………………………………….....
B. Suggestions ………………………………………… .. …………………………… .....
BIBLIOGRAPHY…………………………………………………………......

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 CHAPTER 1
PRELIMINARY
A. Background
The need for data and information is currently growing very rapidly, in terms of both
quality and quantity. With the enactment of Law Number 14 Year 2008 regarding
Openness of Public Information (KIP), the availability of data and information is
absolutely needed especially by public service bodies such as hospitals and other health
services. At this time the hospital is a very important health service center in the
community, that is, performing services must be based on a health approach and
implemented according to applicable laws and regulations. Hospitals are also required to
carry out their duties and functions properly. A hospital's quality can affect the image of
the hospital.
Improvement in hospital services is not only influenced by the development of health
science, but is supported by improved services by implementing information technology
advancements as contained in the Law of the Republic of Indonesia Number 44 Year 2009
concerning Hospitals which states that "Hospitals are health care institutions for a society
with its own characteristics that is influenced by the development of health science,
technological advancements and the socio-economic life of the community which must
continue to be able to improve higher quality services that are affordable by the community
in order to realize the highest degree of health. And in Law No. 44 of 2009, CHAPTER XI
Regarding recording and reporting, in article 52 (1) it is stated that: "Every hospital is
required to record and report on all hospital operations in the form of a Hospital
Management Information System", so the need for a Hospital Information System
(SIMRS) is mandatory. In this modern era, hospitals are required to follow the
developments that have existed, in this case, the managerial hospitals that develop
strategies, one of which is the role of management information systems in hospitals.

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B. Formulation of the problem
Based on the background stated above, the problems in this paper can be formulated:
1. What does recording and reporting mean?
2. What is the function of recording and reporting at the hospital?
3. What type of hospital records and reporting?
4. What is the reporting data processing in the hospital?

C. Writing purpose
The purpose of making this paper are:
1. To know understanding of recording and reporting?
2. To know Registration and Reporting River?
3. To find out the typerecording and reporting?
4. To find out anythingrecording and reporting?

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 CHAPTER 2
LITERATURE REVIEW

A. Definition of Recording and reporting at the Hospital

Recording here is intended to document all a patient's medical information in the

medical record. Patient data can be grouped into two groups, namely social data and
medical data. To get good medical data, there are a number of things that can be
considered by doctors and other health experts, namely recording in a timely, up to date,
accurate and complete manner, trustworthy and in reality related to the problem and its
subject matter, so that it does not long-winded, subjective so as to create a clear
impression. This recording activity involves all service units in the hospital that provide
services or actions to patients.

Hospital reporting is a health service activity in a hospital that has the task of
collecting data, processing data, and presenting data into information.
B. Function Recording and Reporting at the Hospital
As a support for achieving administrative standards in an effort to improve health
services in hospitals. This must be supported by the organization of a good and
correct medical record. Directive administration is one of the determining factors in
the efforts of health services in hospitals.
C. Types of Recording and Reporting in Hospitals
1. Report Internal Home Hospital Internal hospital reports namely outpatient
and inpatient reports made by the hospital itself where this report will be
disseminated to every unit / service section in the hospital. In making hospital
internal reports both for outpatient and outpatient care the hospital has no specific
provisions or requirements from the Health Department or the Ministry of Health
regarding the form of the reporting form because in preparing reports for internal
hospitals must adjust to the hospital itself.
2. Report Monthly, Quarterly and AnnualIn the manufacture of hospital reports
we can make the hospital report system per month, quarterly and annually. The final
count of the form of hospital service analysis can be transferred or transferred to the
hospital service analysis form. Other statistical sources for this report include
monthly data on the therapeutic and diagnostic sections (surgical, clinical and

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 pathology laboratories, x-rays, physical therapy, etc.) and daily censuses. Monthly,
quarterly and annual reports made by the patient discharge data service provide the
hospital with numerous and varied reports. The administrative summary includes
patient demographics, hospital performance indicators (rates related to patient
admission, death, occupancy, length of stay), expected source of payment, and other
relevant data. operation and index doctor too was made.
Home sick which develops its own system produces reports made by medical
records officers. In designing its own system, hospitals have a greater amount of
flexibility in designing reports from data collected. In hospital systems, abbreviated
data from medical records are more readily available with financial data to make
reports that show the impact of clinical practice on hospital costs.

3. Report External Hospital

Hospital external report is a report made by the hospital where the report can later be
used by the Directorate General of Health Efforts, in this case the DEPKES, DKK,
the Regent / Mayor, and other agencies.

D. Data Processing at the Hospital

Data processing in Hospital Information System starting from Hospital Activity Data
(Form RL 1) to Nosocomial Infection Data (Form RL 6) is done in 2 ways, namely:
a. Processing in a manner Manual. Processing with this manual is done by
recapitulating the data that has been collected in the data processing unit to be made a table
or graph that suits your needs. in a manner This computerization of processing is
done by inputting / entering data, both from a medical record that contains a doctor's coded
notes / diagnoses. And will be processed by the computer in accordance with their
respective programs, so that reports will appear in the form of RL 2a and RL 2b, and RL
2a1 and RL 2b1. Or from the registration of outpatients, where if the patient after treatment
can be entered in the data, so that reports will come out about the number of visits to the
patient's clinic or emergency room or each doctor. Data can also come from the input of
the laboratory, radiology and diagnostics which later after being processed by the computer
will produce data about the number of examinations for each part.
1. Data Home Activities Sick (RL1) Daily reports of hospital activities from each
room, both from the inpatient room in the form of a daily inpatient census, or other forms
that have been filled out by their respective sections. The report is processed by the data

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processing department so that the report is in accordance with the need to complete the RL
and the hospital, this processing is carried out in a manner manual.
2. Data kHospital Inpatient Morbidity (RL 2a) and Hospital Outpatient Morbidity
(RL2b) Daily reports derived from medical record files that are codified based on ICD-10,
recapitulated weekly and then made monthly and reported quarterly . This is done both
manually and computerized through an index process for each type of disease grouped
according to DTD as contained in forms RL 2a and 2b.
3. Hospital Integrated Patient Morbidity Inpatient Data (RL2a1) and Hospital Integrated
Patient Morbidity Situation Data (RL2b1) Data can be obtained from RL reports 2a and 2b
which are communicable diseases that are routinely monitored and reported monthly. . To
present data from RL 2a1, it can be ranked in which infectious diseases are highest, report
forms can be in the form of tables or graphs, according to the hospital's needs.
4. Individual Morbidity Data for Inpatients in General Patients (RL 2.1), Individual
Morbidity Data for Inpatients for Obstetric Patients (RL 2.2) and Individual Morbidity for
Patient Data Take care Inap Patient Perinatal (RL2.3)
This data can be obtained from the filling in the doctor who handles the patient in each
sampling period written in the left column and the right column filled by the Medical
Record officer based on the doctor's treating in the left column. The period is only for
patients going home on 1-10 every February, May, August and November. Henceforth, if
you need data about RL 2.1, 2.2, 2.3, recapitulation can be made for example by making
data based on the patient's illness, so that from the period 1-10 can be known which disease
that more Lots suffered patient.5. Data Status Immunization (RL2c)
This report is part of RL 2a, especially those included in the causes of illness in DTD
035,012,00,000,000.00.9, 014, 015, 028 and DTD 037-038.9 and also has to do with the
immunization status of patients in RL 2a affected by a disease such as DTD mentioned
above, so it can be seen in RL 2a and 2b, where the cause of the patient's illness can be
adjusted to the patient's immunization status.Basic Home Sick (RL3) Namely data on
the number of TT available in hospitals and outpatient / polyclinic facilities that provide
specialist / sub-specialist services to treat patients. Data can be presented about the
development of beds in the hospital or can also about the data services specialist or sub-
specialist what is in the hospital. 7) Data Energy Home Sick (RL4) For data RL 4, it
is presented the amount of all personnel on duty at the hospital, both doctors, nurses and
other officers. With this data you can present the number of health care workers.
Presentation of data about health workers in a hospital can be taken from RL 4 data about

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health workers only, then sorted into sections or classified according to medical, nursing,
pharmaceutical and others such as those in RL 4 pages 1 to 1 4. Can also be compared with
other RL. For example nurses compared with the number of patients treated every day.8.
Data Individual Energy (RL4a) For RL 4a data, it is made for the benefit of the
Ministry of Health itself about individual workforce data, especially in vertical hospitals.
Equipment Medical Home Sick (RL5) This report contains the
number, age, capacity, conditions and operational permits as well as calibration of
equipment in the hospital. With this RL 5 format, it's enough to judge whether a tool is
feasible or not to be used .10. Data on Nosocomial Infection
RL 6 can be presented about nosocomial infections that may occur during the period of
treatment originating from the hospital ward. From daily reports can be made monthly
reports. From these data it can be processed how high / the number of infections that occur.
You do this by clarifying each infection that occurs during treatment at the hospital and
sequencing nosocomial infections where that most often occur.2. Data
Processing in Directorate General Service Medical data collected is primary data
obtained from all hospitals in Indonesia with a predetermined period for each type of
Reporting Form consisting of Hospital Activity Data (Form RL 1) to Hospital Nosocomial
Infection Data (Form RL 6 ) by processing the same. As for data processing consists of 2
ways, namely:
a. Processing in a manner Manual The manual processing process is as follows:
1) Registrationdata processing received in advance is recorded at the registration of
processing for each hospital and the type of form in accordance with the owner such as:
Ministry of Health Regional Government, TNI Polri, Dep Other / BUMN and Private
2) Correction Data data is corrected beforehand the truth of data that has been received
from the hospital before it is entered to computer.
3) Correction listbalancingCorrecting the results of balancing from a computer to the
original / original data.
b. Processing in a manner Computerized The computerized processing process is as
follows:
1) Entry data. Enter / enter data that has been corrected according to the reporting
format.
2) List balancing.
Removing the balancing list from the results of data that has been entered.

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3) Balancing data Reentry of data according to the results of the correction (Up date, Deel,
Insert).
4) Print Data Results net data that has been balancing, presented as needed.

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 CHAPTER III
CLOSING
A. Conclusion
Data processing in Hospital Information System starting from Hospital Activity Data
(Form RL 1) to Nosocomial Infection Data (Form RL 6) is done in 2 ways namely
Manually Processing and Computerized Processing. Hospital Activity Data (RL 1)
this processing is done manually, for report data from RL 2 to RL 6 is done both
manually and computerized. Data processing at the Directorate General of Medical
Services is done in 2 ways, namely manual processing, namely processing
registration, data correction and list balancing correction. For computerized
processing, namely, data entry, list balancing, data balancing and print data.
Presentation of Data in the Hospital can be presented in the form of narrative or
descriptive, table or graphic. Presentation of data on hospital activities (RL 1),
namely hospital efficiency, BAP recapitulation (Bed Occupancy Rate) every quarter,
delivery in the inpatient room, radiology examination, diagnostic examination and
family planning participants. Presentation of data in RL 2a, 2b and 2c namely,
ranking of the top 10 inpatient and outpatient diseases, immunization status and
hospital personnel data. Presentation between tables in Hospital Activity data (RL 1),
namely utilization of laboratory examinations. And the presentation of several RL
namely, Patients with cases of Dengue Haemorragic Fever (DHF), Nursing and
Medical personnel and Number of Visits of Outpatients and Inpatients.
There are 2 types of hospital reporting, namely internal reporting and external
reporting. Reports are scheduled on the 15th of each month.
B. Suggestion
From the whole of this paper the authors suggest that in writing the paper "Recording
and Reporting at the Hospital" there are still many shortcomings, the authors expect
suggestions and criticisms from readers (lecturers, semester sisters and classmates) are
highly expected to authors of the refinement of the next paper or the future.

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 BIBLIOGRAPHY

 Directorate General of Medical Services Development, (2005) Manual for Filling,

Processing and Presentation of Hospital Data, Jakarta; MOH RI
 Aptirmik, (2013) Indonesian Journal of Health Information Management Vol 1 No
2
 Permata Indonesia Health Polytechnic, (2013) Permata Indonesia Journal Vol 4 No
1
 Law of the Republic of Indonesia Number 44 of 2009 concerning Hospitals
 Law Number 14 of 2008 concerning Public Information Openness
 Law No. 44 of 2009, CHAPTER XI Regarding recording and reporting
 http://depkes.go.id/
 http://buk.depkes.go.id/
 http://202.70.136.52/sirs/login.php