Develop Medical Record in Fm

7/28/2019 Develop Medical Record in Fm

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Insi Farisa Desy Arya dr.,M.SiDepartement of Public Health

Faculty of MedicineUniversitas Padjadjaran


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1. What is the Definition about Medical Record?

2. Mention the function of medical record ?3.

Mention the component of POMR ?


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REKAM MEDIS YANG BAIK ADALAHWUJUD DARI KEDAYAGUNAAN DAN

KETEPATGUNAAN PERAWATAN PASIEN


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Undang-Undang Praktik Kedokteran Nomor29 Tahun 2004, psl. 46 dan 47: salah satuunsur utama dalam sistem pelayanankesehatan yang prima adalah tersedianyapelayanan rekam medis oleh dokter Kendala utama : dokter tidak menyadarisepenuhnya manfaat dan kegunaan rekammedis, baik pada sarana pelayanan kesehatanmaupun pada praktik perorangan.


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Pasal 46 ayat (1) UU Praktik Kedokteran: rekammedis adalah berkas yang berisi catatan dandokumen tentang identitas pasien, pemeriksaan,pengelolaan, tindakan dan pelayanan lain yang

telah diberikan kepada pasienPermenkes no.749a/Menkes/Per/XII/1989:berkas yang berisikan catatan dan dokumententang identitas pasien, pemeriksaan,

pengobatan, tindakan dan pelayanan lain kepadapasien pada sarana pelayanan kesehatan .


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Struktur dan isi rekam medisKeseragaman dalam penggunaan simbol,

tanda, istilah, singkatan dan ICD/ICPC(International Classification of Primary Care)Kerahasiaan dan Keamanan data

LOKAKARYAREKAM MEDIS


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a. To communicate with yourself Organize and remember information

Document patients complains and physical findings Document clinical reasoningDocument course of illness

b. To communicate with other health professionalsTeam members involved in care of patient

ConsultantsPhysicians covering for youTransferring patient care to another physician

c. Used for quality assurance within health care systemd. Used for researche. Patient may want to see recordf. Used as a legal document


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1. Problem ListMedical and social problems

2. Background information(Sex, date of birth, family history, immunisations)

and changing information (marital status, job,address, screening tests)

3. Progress notes (SOAP)S ubjective the patients observations O bjective the Doctors observations and tests A nalysis the Doctors understanding of the

problemP lans Goals, action, advice etc.


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1. Data base (information)Includes history, physical examination, labs, x-rays, special

tests2. Problem list

Includes biological, psychological, social, and demographicproblems

3. Plans (intentions)numbered and titled by problemincludes diagnostic, therapeutic, and patient education

plans4. Progress notes (follow up)

numbered and titled by problemrelated back to planscollect more data, move through process of clinicalreasoning, generate new hypotheses, make new plans


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1. Patient Identification/Chief Complaint usually one sentence, often with the chief complaint in the patients own words

2.History of Present Problems (s) narrative3. Past Medical History outline form

Childhood illnessesAdult medical illnessesSurgeriesTraumas


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4. Medications/Habits & Risk Factorsa. Medications (including over the counter and

complementary/alternative medicines)b. Allergiesc. Habits/risk factors:

TobaccoAlcoholDrug useDiet, exerciseHIV risk factorsOccupational exposure and travel

Gynecological history (women only)Menstrual historyObstetric historySexual history (men and women)


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Health maintenanceImmunizationsCancer screening testsDomestic violenceFirearms

5. Family Medical HistoryOutlineGenogram

6. Social History narrative7. Review of Systems checklist or outline8. Physical Examination9. Laboratory/ X-rays/ Special Tests10. Diagnostic Holistic11.Management12. Prognosis


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Many patients are unaware of the medicalhistories of their relatives

And many health professionals underused thisinformation in advising patients about how tomaintain good health


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ANYQUESTION ?


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The students will be divided into 4 OR 5groups.Interactive learning will be conducted byanalizing the case, develop and implementthe medical records


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Develop/Create a template of medical records!

30 minutesTask 1

Implement the case into thetemplate of medical recordsthat student develop/createfrom the case given

45 minutes

Task 2


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OK

LESTSTART

WORKING!


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ALL GROUP SHOULD PRESENTATIONEACH GROUP HAVE 10 MINUTES TO PRESENT


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Mr. Yunus is a 45-years-old male presents to the clinic

complaining of having 10 episodes of watery, no bloody diarrheathat started last night. He vomited twice last night but has been ableto tolerate liquids today. He has had intermittent abdominal crampsas well. He reports having muscle aches, weakness, headache, andlow-grade temperature. He is here with his daughter, who startedwith the same symptoms this morning. On questioning, he statesthat he has no medical history, no surgeries, and does not take anymedications. He does not smoke cigarettes, drink alcohol, use anyillicit drugs, and has never had a blood transfusion. He and hisfamily return to Bandung yesterday, following a week-long vacationin Bali.

He works as government employee and lives with his wife and 1son and 1 daughter in Padjajdajaran street no.9 Bandung.

On examination, he is not acute distress. His Blood pressure is

110/70 mmHg, his pulse is 94 beats/min; his respiratory rate is 16breath/min, and his temperature 36, 5C. His mucosa membrane isdry. His bowel sound hyperactive and his abdomen are mildly tenderthroughout, but there is no rebound tenderness and no guarding. Arectal examination and his stool is guaiac negative. The remainderof his examination is unremarkable.

The diagnosis is Acute gastroenteritis, next step: Order stoolfor fecal leucocytes, with the treatment only replacement fluids andelectrolytes. Prevention by hand washing and avoid contaminatedfood and water.


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Ms. Agnes 26-year-old women presents to your office complaining of progressingnervousness, fatigue, palpitation, and the recent development of a resting hand tremor. Shealso states that she is having difficulty concentrating at work and has been more irritable withher coworkers. The patient also notes that she has developed a persistent rash over her shinsthat have no improved with the use of tropical steroid creams. All of her symptoms have comeon gradually over the past few month and continue to get worse. Review of system also revealsan unintentional weight loss of about 3 kg, insomnia, and amenorrhea for the past two months(the patients menstrual cycles are usually quite regular). The patients past medical history isunremarkable and she takes no oral medications. She is currently not sexual active and doesnot drink alcohol, smoke, or use any illicit drugs. On examination, she is afebrile. Her pulse

varies from 70-110 beats per minutes. She appears restless and anxious. Her skin is warm andmoist. Her eyes show evidence of exophthalmoses and lid retraction bilaterally, althoughfunduscopic examination is normal. Neck examination reveals symmetric thyroid enlargement,without any discrete palpable masses. Cardiac examination reveals an irregular rhythm. Herlungs are clear to auscultation. Extremity examination reveals an erythematous, thickened rashon both shins. Neurological examination is normal except for a fine resting tremor in herhands when she attempts to hold out her outstretched arms. Initial lab tests include a negativepregnancy test and an undetectable level of thyroid-stimulating hormone (TSH). Thediagnosis Hyperthyroidism secondary to Graves disease, the suggestion of laboratory nuclearmedicine thyroid scan with uptake. And definitive non surgical treatment is Thyroid ablationwith radioactive iodine.

She lives in Sukajadi Street no. 10 Bandung with her parent and one brother; her fathershave a hypertension and her mom have a diabetic. She works as administration staff ingarment factory.


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Mr. Pandu, 54-year-old male is bought to the emergency department complaining of chest discomfort for about 90 minutes. He has had occasional symptoms for a month, but itworse today. Todays symptom began while he was walking his dog and decreased slightly withrest, but have not resolved. He describes the feeling as a pressure sensation in he leftsubsternal area of his chest associated with shortness of breath and mild diaphoresis. He doesnot have any radiation of the discomfort today, but has experienced radiation on the left upperextremity in the past. The patient denies any health problems, but his wife reports that he hasnot seen a physician in years. His wife made him come in because his younger brother hadattack 6 month ago. He is a vice president of a bank lives with his wife and 3 daughters. Hesmoked 1.5 packs of cigarettes per day for more than 30 years and denies drinking alcohol orany drug use.

On physical examination he is an anxious, obese gentleman who appears pale and has amoist brow. His temperature 36,5C, his pulse 105 beat/min, his respiration is 18 breaths/min,his blood pressure is 190/95 mm Hg, his height is 180 cm, and his weight 110 kg. Cardiacexamination reveals regular rhythm without murmur, but he has a gallop. Lungs are clear toauscultation. Neck is without caroted bruits or jugular venous distantion. Abdomen is normal.He does have a right femoral bruit. Extremities reveal trance edema but no clubbing orcyanosis. He has 2+ pulses in radial and dorsal pedies arteries. Rectal examination has nomasses or tenderness with normal prostate, and guaiac negative.

Most likely diagnosis: unstable angina pectoris; next diagnostic step: CBC, BUN,creatinine, protombin time (PT), partial protombine time (PTT), glucose, EKG, and chest x-ray.Next step therapy : MONA therapy: Morphine, Oxygen, Nitroglycerine, Aspirin.


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TEMPLATE OF MEDICAL RECORD.docx MEDICAL RECORD Case 1.docx MEDICAL RECORD case 2.docx
http://localhost/var/www/apps/conversion/tmp/scratch_4/TEMPLATE%20OF%20MEDICAL%20RECORD.docxhttp://localhost/var/www/apps/conversion/tmp/scratch_4/MEDICAL%20RECORD%20Case%201.docxhttp://localhost/var/www/apps/conversion/tmp/scratch_4/MEDICAL%20RECORD%20case%202.docxhttp://localhost/var/www/apps/conversion/tmp/scratch_4/MEDICAL%20RECORD%20case%202.docxhttp://localhost/var/www/apps/conversion/tmp/scratch_4/MEDICAL%20RECORD%20Case%201.docxhttp://localhost/var/www/apps/conversion/tmp/scratch_4/TEMPLATE%20OF%20MEDICAL%20RECORD.docx

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