Overview of Completeness of Operation Report in Medical Records Surgical Patient Electronics

Abstract

Medical information is confidential, so when releasing information to a second party health facilities are responsible for protecting health information contained in medical records. The impact that can arise if the release of medical information does not comply with applicable legal standards or provisions is that sanctions such as fines, license revocation and even prison sentences will be imposed. The aim of this research is to find out an overview of the implementation of releasing electronic medical record information at RSUP Prof. Dr. I.G.N.G. Ngoerah. Type of research uses quantitative research with descriptive approach. The results of this research, some files have correctly recorded identity information, both the applicant's identity is 93.2% and the patient's identity is 100%. Authentication, most of the files have met the necessary authentication requirements, such as research or lending permits 94.5%, ethical clearance and integrity facts 95.9% and incomplete 4.1%. Recording, the majority of files have correctly recorded information related to the release of medical information, such as the applicant's name 93.2%, origin/agency, destination, and patient medical record number 100%. From this research it can be concluded that the completeness of identification, authentication and recording is good in supporting the release of electronic medical record information at RSUP Prof. Dr. I.G.N.G Ngoerah.