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Overview of Completeness of Filling Out Inpatient Discharge Summary Form at General Ahmad Yani Hospital Metro in 2021 2021年Ahmad Yani General Hospital Metro住院病人出院汇总表填写完整性概况
Pub Date : 2022-03-11 DOI: 10.37275/oaijmr.v2i2.179
Nielma Aulia, Wiwik Viatiningsih, Nanda Aula Rumana, Puteri Fannya
Medical records are the property of hospitals that must be maintained because they are useful for patients, doctors, and hospitals. Medical record documents are very important in carrying out the quality of medical services provided by hospitals and their medical as well as accurate evidence in court, doctors, nurses, and other health workers who treat patients are required to complete medical records following applicable regulations. This study aims to describe the completeness of filling out inpatient discharge summary form at General Ahmad Yani Hospital Metro in 2021. This study used a descriptive research method. The research location is the Medical Record Unit of General Ahmad Yani General Hospital Metro Lampung. This research was conducted in October 2021. Of the 100 samples of medical records, the completeness of the inpatient discharge summary form was completed. There are 80% complete and 20% incomplete, where the completeness value of 100% is found in the patient identity filling item, and there are no scribbles. Meanwhile, 20% incompleteness is found in important note items (5%) and authentication (15%). In conclusion, standard operating procedures for completeness of medical records already exist and the implementation of completeness of medical record files has been carried out according to applicable standards, but it can be seen that the steps in the SOP are not detailed and less thorough.
医疗记录是医院必须保存的财产,因为它们对病人、医生和医院都很有用。医疗记录文件对于医院提供高质量的医疗服务以及在法庭上提供准确的证据非常重要,医生、护士和其他治疗病人的卫生工作者必须按照适用的规定填写医疗记录。本研究旨在描述2021年Ahmad Yani General Hospital Metro住院患者出院汇总表填写的完整性。本研究采用描述性研究方法。研究地点是南榜阿末亚尼将军总医院的病历部。这项研究是在2021年10月进行的。在100份病历样本中,完成了住院出院汇总表的完整性。有80%完整和20%不完整,其中在患者身份填写项中发现完整性值为100%,并且没有乱写。同时,重要笔记项(5%)和认证项(15%)的不完整性占20%。综上所述,病历完整性的标准操作程序已经存在,病历文件完整性的实施也已经按照适用的标准进行,但可以看出SOP中的步骤不够详细,不够彻底。
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引用次数: 1
Overview of the Implementation of Medical Record Maintenance at Tarakan Hospital Jakarta in 2021: A Qualitative Study 2021年雅加达塔拉干医院病历维护实施概况:一项定性研究
Pub Date : 2022-03-11 DOI: 10.37275/oaijmr.v2i2.181
Tiara Noviliana, Siswati, Puteri Fannya, Wiwik Viatiningsih
A medical record is a file that contains notes and documents about patient identity, examination, treatment, actions, and other services that have been provided to patients. Medical records in carrying out maintenance and protection so that medical records are protected from damage and can facilitate the service process. This study discusses the process or activities of maintaining medical records at the Tarakan Hospital, Jakarta. The purpose of this study was to find out what factors could trigger the occurrence of damage or dangers to the medical record unit and to find out the preventive actions taken by the hospital in protecting medical records. This type of research uses a qualitative descriptive method, which describes the implementation of the maintenance of medical record files in the filing room in 2021. The implementation of medical record maintenance by medical record unit officers, it does not follow the SOP that has been set by Tarakan Hospital Jakarta. Constraints in maintaining medical records are seen from biological, chemical, environmental, and security factors. These obstacles are often the factors that cause damage to medical records such as dust, fire/coal on cigarettes, pests/insects, and chemical liquids and maintenance of medical records at the Tarakan Hospital.
医疗记录是包含关于患者身份、检查、治疗、行动和向患者提供的其他服务的笔记和文档的文件。对医疗记录进行维护和保护,使医疗记录不受损坏,可以方便服务过程。本研究讨论了雅加达塔拉干医院保存病历的过程或活动。本研究的目的是找出哪些因素会引发病案单位的损害或危险的发生,并找出医院在保护病案方面所采取的预防措施。这类研究采用定性描述的方法,描述了2021年档案室病案档案维护的实施情况。由病案单位官员执行病案维护,没有遵循雅加达塔拉干医院制定的SOP。病历保存的制约因素有生物、化学、环境和安全等方面的因素。这些障碍往往是造成医疗记录损坏的因素,如灰尘、香烟上的火/煤、害虫/昆虫、化学液体和塔拉干医院医疗记录的维护。
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引用次数: 1
Diagnosis and Management of Wilms Tumor 肾母细胞瘤的诊断与治疗
Pub Date : 2022-03-11 DOI: 10.37275/oaijmr.v2i2.178
Nicodemus
Wilms Tumor is one of the malignancies frequently found in children under five years old. This tumor is frequently found coincidentally by parents or caregivers who notice a lump in the children’s abdomen. The specific factors of Wilms tumor have not been detected yet. However, it is often associated with specific syndromes as a predisposing factor and a mutation of specific genes. The symptoms caused by this tumor are varied, starting from asymptomatic without any symptom to severe symptoms due to the tumor distribution to the lung. In general, Wilms tumor attacks one of the kidneys (unilateral) with different grades and particular histology. Generally, the management encompasses surgery, chemotherapy, and radiotherapy, depending on the tumor grade. The patients’ recovery rate and managed survival rate were quite high with a low recurrence rate. Therefore, a clinical approach and skepticism of Wilms tumor become one of the diagnoses in children with an abdominal mass.
肾母细胞瘤是常见于五岁以下儿童的恶性肿瘤之一。这种肿瘤经常被父母或看护者偶然发现,他们注意到孩子腹部有一个肿块。Wilms肿瘤的具体影响因素尚未发现。然而,它通常与特定综合征相关,作为易感因素和特定基因突变。该肿瘤引起的症状多种多样,由于肿瘤向肺部分布,可从无症状到严重症状。通常,肾母细胞瘤侵袭一侧肾脏(单侧),具有不同的分级和特殊的组织学。一般来说,治疗包括手术、化疗和放疗,这取决于肿瘤的级别。患者的治愈率和生存率高,复发率低。因此,对Wilms肿瘤的临床诊断和怀疑成为儿童腹部肿块的诊断之一。
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引用次数: 0
Pathophysiological to Clinical Aspects of Head Injury: Narrative Literature Review 脑损伤的病理生理到临床方面:叙事文献综述
Pub Date : 2022-03-04 DOI: 10.37275/oaijmr.v2i2.174
R. Hidayat
Head injury is a change in brain function or brain pathology, caused by external forces on the head. Changes in brain function consist of any period of loss or loss of consciousness, anterograde or retrograde amnesia, neurological deficits, or mental changes following a head injury. A study reported that the highest incidence of head injury was in the Americas, which was 1299 cases per 100,000 population, followed by Europe, which was 1012 cases per 100,000 population. The lowest incidence of head injury occurred on the African continent, which was 801 cases per 100,000 population. Based on these data, the overall incidence of head injuries in the world is 939 cases per 100,000 population with most of them being mild head injuries (55.9 million cases per year) and 5.28 million people experiencing severe head injuries.
头部损伤是由头部外力引起的脑功能或脑病理变化。脑功能的变化包括任何时期的意识丧失或丧失、顺行性或逆行性遗忘、神经功能缺陷或脑损伤后的精神变化。一项研究报告说,头部受伤的发病率最高的是美洲,每10万人中有1299例,其次是欧洲,每10万人中有1012例。头部受伤发生率最低的是非洲大陆,每10万人中有801例。根据这些数据,全世界头部损伤的总发生率为每10万人939例,其中大多数为轻度头部损伤(每年5590万例),528万人遭受严重头部损伤。
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引用次数: 0
The Role of Cell Membranes in Cell Traffic 细胞膜在细胞运输中的作用
Pub Date : 2022-01-13 DOI: 10.37275/oaijmr.v1i6.168
Rara Inggarsih, E. Amalia, Septi Purnamasari
The cell membrane plays an important role in cell traffic because it functions to secrete various molecules. The selective transport system allows the movement of molecules into or out of the cell compartment. By controlling the movement of substances from one compartment to another, membranes exert a strong influence on metabolic pathways. Cell membranes are composed of proteins and lipids with a very important function in maintaining the rhythm of circulation and cell transport. In addition, the cell membrane also plays a role in maintaining the integrity and relationship, and communication of cells.
细胞膜在细胞交通中起着重要的作用,因为它的功能是分泌各种分子。选择性转运系统允许分子进出细胞区室。通过控制物质从一个隔室到另一个隔室的运动,膜对代谢途径施加强烈的影响。细胞膜由蛋白质和脂质组成,在维持循环和细胞运输的节奏方面具有非常重要的功能。此外,细胞膜还起着维持细胞的完整性、相互关系和通讯的作用。
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引用次数: 0
Basic Concept of Cell: A Narrative Review 细胞的基本概念:叙述回顾
Pub Date : 2022-01-13 DOI: 10.37275/oaijmr.v1i6.167
R. Hidayat, Joko Marwoto, Lusia Hayati
All body functions depend on cell integrity. Therefore, understanding cell biology is intrinsically important for understanding disease. A vast amount of information reveals how the cell behaves like an organism with many social cells. At the heart of cell biology is cell communication—how messages originate and are transmitted, received, interpreted, and used by cells. This efficient communication between, and within the cell maintains the function of the cell and its specialization. Intercellular signals enable each cell to determine its position and specific role. Cells must demonstrate a "chemical preference" for other cells and the environment that surrounds them to maintain the integrity of the whole organism. When they no longer tolerate this preference, the conversation ends and the cell adapts (sometimes changes in function) or becomes vulnerable to isolation, injury, illness, or even death. This review explains the function of each component in the cell and its role in life.
所有的身体功能都依赖于细胞的完整性。因此,理解细胞生物学对于理解疾病本质上是重要的。大量的信息揭示了细胞是如何像一个有许多群居细胞的有机体一样活动的。细胞生物学的核心是细胞通讯——信息是如何产生、传递、接收、解释和被细胞使用的。这种细胞间和细胞内的有效交流维持了细胞的功能及其特化。细胞间信号使每个细胞确定自己的位置和特定的作用。细胞必须表现出对其他细胞及其周围环境的“化学偏好”,以维持整个生物体的完整性。当它们不再容忍这种偏好时,对话就结束了,细胞就会适应(有时会改变功能),或者变得容易受到隔离、伤害、疾病甚至死亡的影响。本文综述了细胞中各组成部分的功能及其在生命中的作用。
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引用次数: 0
Osteoarthritis Medication and Overview: A Narrative Review 骨关节炎药物治疗与综述:叙述性回顾
Pub Date : 2021-12-23 DOI: 10.37275/oaijmr.v2i1.153
R. U. Partan
Osteoarthritis, the most common form of joint disease, is primarily a disease of aging. Ninety percent of all people have radiographic features of osteoarthritis in weight-bearing joints by age 40. Symptomatic disease increases with age. Risk factors for this disorder include gender, genetics, obesity, and work history. Osteoarthritis develops in women more often than in men. This arthropathy is characterized by cartilage degeneration and bony hypertrophy at the articular margins. Inflammation is usually minimal. Hereditary and mechanical factors may be involved in the pathogenesis. This review provides an overview of counseling osteoarthritis and its treatment and management.
骨关节炎是最常见的关节疾病,主要是一种衰老疾病。到40岁时,90%的人在负重关节有骨关节炎的x线表现。症状性疾病随年龄增长而增加。这种疾病的危险因素包括性别、遗传、肥胖和工作经历。骨关节炎在女性中比在男性中更常见。这种关节病的特点是关节边缘的软骨变性和骨质肥大。炎症通常是轻微的。发病机制可能与遗传和机械因素有关。本文综述了咨询骨关节炎及其治疗和管理的概况。
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引用次数: 0
Diagnosis and Treatment of Gout Arthritis 痛风性关节炎的诊断与治疗
Pub Date : 2021-12-23 DOI: 10.37275/oaijmr.v2i1.152
M. Reagan
Gout is a heterogeneous, often familial, metabolic disease associated with abnormal deposits of uric acid in tissues and initially characterized by recurrent acute arthritis, usually monoarticular, and later by chronic deforming arthritis. Urate deposition occurs when serum uric acid is saturated (that is, at greater than 6.8 mg/dL [404.5 mcmol/L]). Hyperuricemia is caused by excess or underexcretion of uric acid, sometimes both. The disease is especially common in the Pacific islands, for example, the Philippines and Samoa. Acute gouty arthritis is sudden in onset and often occurs at night. It may develop without a clear precipitating cause or may follow a rapid increase or decrease in serum urate levels. Common precipitants are excess alcohol (especially beer), changes in medications that affect urate metabolism, and, in hospitalized patients, fasting before medical procedures. This literature review presents gout arthritis, symptoms and signs in general to the prognosis of this disease.
痛风是一种异质性的、通常是家族性的代谢疾病,与组织中尿酸的异常沉积有关,最初的特征是复发性急性关节炎,通常是单关节关节炎,后来是慢性变形关节炎。尿酸沉积发生在血清尿酸饱和时(即大于6.8 mg/dL [404.5 mcmol/L])。高尿酸血症是由尿酸排泄过多或不足引起的,有时两者都有。这种疾病在太平洋岛屿尤其常见,例如菲律宾和萨摩亚。急性痛风性关节炎发病突然,常发生在夜间。它可能在没有明确的沉淀原因的情况下发生,也可能随着血清尿酸水平的迅速升高或降低而发生。常见的沉淀因素是过量的酒精(尤其是啤酒),影响尿酸代谢的药物变化,以及住院患者在治疗前的禁食。这篇文献综述提出痛风关节炎,症状和体征在一般情况下,这种疾病的预后。
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引用次数: 0
The Effect of Flavonoid Consumption on Blood Pressure: A Systematic Review 类黄酮摄入对血压的影响:一项系统综述
Pub Date : 2021-12-23 DOI: 10.37275/oaijmr.v2i1.154
C. Wulandari
Hypertension is a common condition in which the long-term force of blood against artery walls is high enough to cause health problems, such as heart disease eventually. High blood pressure is known as the "silent killer". Most people with high blood pressure are unaware of the problem because it may not have any warning signs or symptoms. For this reason, it is essential to measure blood pressure regularly. A new study has shown that consuming foods rich in flavonoids can help patients with high blood pressure. This advantage of these compounds is due to their vasodilator properties. Flavonoids are a diverse group of biologically active polyphenol compounds found in plants and herbs. Regular consumption of flavonoids has cardioprotective effects and may reduce the onset or progression of many cardiovascular diseases, especially hypertension. The article search was done in PubMed, ScienceDirect, and Google Scholar databases. The current body of evidence supports the ingestion of flavonoids for their beneficial effect on blood pressure. However, more significant research should further investigate the vascular moderating effects and the safety and acceptability of almond consumption.
高血压是一种常见的情况,在这种情况下,血液对动脉壁的长期作用力足够高,从而导致健康问题,最终导致心脏病。高血压被称为“无声杀手”。大多数高血压患者都没有意识到这个问题,因为它可能没有任何警告信号或症状。因此,定期测量血压是很重要的。一项新的研究表明,食用富含类黄酮的食物可以帮助高血压患者。这些化合物的这种优势是由于它们的血管扩张特性。黄酮类化合物是一种多种多样的生物活性多酚化合物,存在于植物和草药中。经常食用黄酮类化合物具有保护心脏的作用,可以减少许多心血管疾病的发生或进展,特别是高血压。文章搜索是在PubMed, ScienceDirect和Google Scholar数据库中完成的。目前的大量证据支持摄入类黄酮对血压的有益作用。然而,更重要的研究应该进一步调查血管调节作用和杏仁消费的安全性和可接受性。
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引用次数: 1
The Outcomes of Patients with Mental Ilness Undergoing Surgical Procedures 精神疾病患者接受外科手术的结果
Pub Date : 2021-12-23 DOI: 10.37275/oaijmr.v2i1.151
Muh Firyal
Mental illness influences 3 % of the population and incorporates handicapping despondency and uneasiness, just as maniacal issues, such as bipolar and Schizophrenia. Patients with Schizophrenia were known to have a higher risk of complications during hospitalization. Quality of care has become the critical factor in reducing their potential mortality afterward. Patients with SMI were substantially less liable to have a significant medical procedure in the wake of controlling for age, other segment measures, and illness trouble. Patients of a similar age, sex, race, and comorbidity status having a previous genuine psychological instability passed on a significantly diminished probability of careful mediation. Clinical and careful hospitalizations for people with Schizophrenia had in some measure double the chances of a few kinds of unfriendly occasions than those for people without Schizophrenia. During the emergency clinic confirmation, these antagonistic occasions were related to poor clinical and financial results. Endeavors to decrease these unfriendly occasions should turn into an examination need.
精神疾病影响了3%的人口,包括残疾的沮丧和不安,就像狂躁的问题,如双相情感障碍和精神分裂症。精神分裂症患者在住院期间出现并发症的风险较高。护理质量已成为降低术后潜在死亡率的关键因素。在控制了年龄、其他部分测量和疾病问题之后,重度精神分裂症患者基本上不太可能接受重大的医疗程序。年龄、性别、种族和合并症相似的患者,既往有过真正的心理不稳定,通过谨慎调解的可能性显著降低。精神分裂症患者的临床和仔细的住院治疗在某种程度上比没有精神分裂症的人有两倍的机会出现一些不友好的情况。在急诊临床确认时,这些拮抗事件与临床和财务结果不佳有关。努力减少这些不友好的场合应该变成一种考试的需要。
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引用次数: 0
期刊
Open Access Indonesian Journal of Medical Reviews
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