Sahrul, Gunawan (2023) ANALISIS FORMULIR ELEKTRONIK ASSESMEN AWAL MEDIS GAWAT DARURAT DALAM PENERAPAN MIRM 13.1.1 DI RUMAH SAKIT DAERAH IDAMAN BANJARBARU. [Tugas Akhir]

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Abstract

The electronic initial medical assessment form is for each emergency patient containing the time of arrival, a summary of the patient's condition upon discharge from the emergency department and instructions for follow-up care. The aim of the study was to find out the regulations and to identify electronic forms of initial medical assessment at the Banjarbaru Ideal Hospital. Qualitative Descriptive Methods. The results of the study, namely the regulation of the electronic form of initial emergency medical assessment, patient arrival time, summary of the patient's condition at discharge and follow-up care have produced complete and partially incomplete report information. Regulations that apply regarding the electronic form of initial emergency medical assessment, the director's decree containing medical records number 487 of 2022. Technical instructions (juknis), Hospital guidelines/guidelines, complete standard operating procedures (SOP), electronic forms of related initial medical assessment 100% of the (120 medical record files) filled in completely, the electronic initial emergency medical assessment form for a summary of the patient's condition out of a total of 120 medical record files for the patient's introduction identity is filled in (70%) and not filled in (30%) and the electronic initial emergency medical assessment form related to the assessment of follow-up care instructions was completely filled in 100% of (120 medical record files). Keywords: Form, Assessment, Electronic Medical Record, MIRM.

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