ELECTRONIC MEDICAL RECORD OUT PATIENT IN UNIVERSITAS SEBELAS MARET (UNS) HOSPITAL

Abstract

The implementation of medical record recording at Universitas Sebelas Maret Hospital (UNS) is still manual so that there are problems in terms of management delays caused by the cumulation in the polyclinic, causing the document to not be immediately managed further after completion of the examination. The type of research carried use the method of taking observation and interview data using a cross sectional approach. The subjects in this study were the head of the medical record and outpatient officers, while the objects studied include medical records at the UNS Hospital. System development methods using the System Development Life Cycle (SDLC). Electronic medical records are obtained from the process of inputting patient data, doctor data, nurse data, polyclinic data, diagnostic data, action data, general consent data, physician assessment data, initial doctor assessment data, cppt data, patient transfer data to igd, distinctive assessment data urology, and the initial geriatric assessment that will be led into the database table. Then the data will be processed to be entered in the electronic medical record and produce an outpatient medical record form report.