Pengenalan Rekam Medis Elektronik | Inovasi Kesehatan Modern

Jasa Medika Transmedic

25 Oct 202304:25

Summary

TLDRThis video explains the importance and functionality of electronic health records (EHR), which store patient information, including medical history, treatments, and services provided. EHRs replace traditional paper records, enhancing the efficiency and quality of healthcare services. Key features include initial assessments, vital signs, diagnoses, lab results, radiology reports, and prescriptions. EHRs improve workflow, reduce operational costs, and ensure patient data security. They play a crucial role in modern healthcare by enabling better coordination across departments and contributing to the broader digital transformation of healthcare systems.

Takeaways

💻 Electronic Health Records (EHR) are digital documents containing patient identification information, medical history, treatment, and services provided.
🏥 EHR systems replace traditional paper records, allowing healthcare providers to record and access patient information electronically.
📈 EHR enhances the efficiency and quality of healthcare services by streamlining information flow.
💰 EHR systems reduce operational costs and improve workflow optimization across hospital departments.
🔒 EHR ensures patient data integrity and security, providing secure access to patient information.
👨‍⚕️ EHR systems facilitate initial assessments, recording symptoms and other vital information during a patient's first visit.
💊 The system records all treatments and medications provided to patients, ensuring accurate tracking and monitoring of care.
🧪 EHR integrates lab results, such as blood or urine tests, making diagnostic data easily accessible for patient monitoring.
🩻 Radiology results like X-rays and MRIs are recorded and stored in the system for diagnosis and tracking purposes.
🌐 EHR plays a key role in the digital transformation of healthcare, linking various aspects of care and supporting the development of broader health information networks.

Q & A

What is an Electronic Health Record (EHR)?
-An Electronic Health Record (EHR) is a digital document containing information about a patient's identity, medical history, treatment, and services provided.
How does an EHR system benefit healthcare professionals?
-An EHR system allows healthcare professionals to record patient information electronically, replacing traditional paper records, and provides quick and consistent access to patient data.
What are the main advantages of using EHRs in healthcare?
-The main advantages include improved service efficiency and quality, reduced operational costs, easier data access, better integration between hospital units, optimized workflow, enhanced patient identification, and greater patient data integrity and security.
What happens when a patient arrives for medical care using an EHR system?
-When a patient arrives, healthcare providers can easily record examination details, treatments, and medical actions using the EHR system, with data stored electronically for quick access.
What is the role of the initial assessment in EHRs?
-The initial assessment records the patient's symptoms, complaints, and other important information when they first seek care. It helps doctors evaluate the patient’s condition and plan appropriate treatment.
How does the EHR system handle vital signs data?
-The EHR system records vital signs such as blood pressure, pulse, temperature, and respiration. This data helps monitor significant changes in a patient’s physical functions.
What is the purpose of ICD-10 and ICD-9 in EHRs?
-ICD-10 and ICD-9 are coding systems used to classify and record patient diagnoses. Accurate diagnoses help plan appropriate treatments and standardize the classification of medical conditions.
How does the EHR system handle medical procedures and actions?
-The EHR system records all medical procedures performed on the patient, such as physical examinations or other medical interventions, ensuring effective coordination of patient care.
What role does the laboratory section play in an EHR system?
-The laboratory section is used to order and record the results of tests like blood or urine analysis, which are crucial for diagnosing and monitoring patient conditions.
How does the EHR system contribute to digital health transformation?
-The EHR system connects various aspects of healthcare, supports the development of broader health information networks, and plays a key role in modernizing healthcare delivery through digital means.

Outlines

00:00

💻 Introduction to Electronic Health Records (EHR)

The introduction explains what Electronic Health Records (EHR) are. EHRs are digital documents containing patient identification information, medical history, treatment, and services provided. The EHR system is described as a crucial tool in modern healthcare, allowing medical professionals to document patient information electronically, replacing traditional paper records. The advantages include improved efficiency, easy access to patient data, and enhanced consistency in patient care.

📈 Benefits of Using EHR Systems

This section highlights the various benefits of using EHR systems. Key advantages include improved service quality and efficiency, operational cost reduction, ease of data access, hospital-wide integration across departments, optimized workflow, and enhanced patient identification for preventive care. Additionally, the system ensures patient information integrity and security, making it a reliable choice for healthcare providers.

🧑‍⚕️ Features of Electronic Health Records

The features of EHR systems are discussed in detail. One major feature is the initial assessment, where doctors record a patient's symptoms and complaints during their first visit. This helps in planning appropriate care. Other features include recording vital signs (blood pressure, pulse, temperature, and respiration), which helps in monitoring physical functions and detecting changes.

🧬 Patient Diagnosis and ICD Codes in EHR

This part focuses on the EHR system's ability to record patient diagnoses using standardized ICD-10 or ICD-9 codes. Accurate diagnosis helps plan appropriate care and categorize patient conditions. The system also tracks medical actions taken, such as physical exams and procedures, aiding in coordination and ensuring effective treatment.

🧪 Laboratory and Radiology Integration in EHR

EHRs are shown to be important for ordering and recording laboratory tests, such as blood and urine tests. These results assist in diagnosing medical conditions and monitoring patient progress. The radiology feature also allows for the ordering and recording of imaging tests like X-rays, MRIs, and CT scans, which help in diagnosing and monitoring diseases.

💊 Medication and Prescription Tracking in EHR

The final section covers the prescription feature of the EHR system, which records all medications administered to patients, including dosage. It ensures that patients receive the correct medication and helps monitor for side effects or drug interactions. EHRs contribute to healthcare digital transformation, connecting various healthcare aspects and supporting the development of broader health information networks.

Mindmap

Keywords

💡Electronic Health Record (EHR)

An Electronic Health Record (EHR) is a digital version of a patient's medical history, including information like personal identity, examination history, treatments, and services provided. The video emphasizes the role of EHRs in modern healthcare by replacing traditional paper records and ensuring quick, consistent access to patient data.

💡Efficiency

Efficiency in the context of EHR refers to the system's ability to enhance healthcare service delivery by speeding up data access, reducing manual tasks, and improving the coordination of patient care. The video explains how EHR systems increase efficiency by streamlining operations like documentation and treatment planning.

💡Data Access

Data access refers to the ability of healthcare providers to quickly and easily retrieve patient information through EHR systems. The video points out that EHRs provide consistent and fast access to patient records, allowing for more informed and timely decision-making in medical treatments.

💡Integration

Integration in EHR systems refers to how different units and departments within a hospital or clinic are connected, enabling seamless information sharing. The video mentions that integration between departments leads to smoother workflows and better communication, which ultimately benefits patient care.

💡Security

Security in the context of EHR ensures that patient information is protected from unauthorized access, ensuring the confidentiality and integrity of sensitive medical data. The video highlights that EHR systems offer robust security measures to safeguard patient information, an essential aspect of modern healthcare.

💡Initial Assessment

Initial assessment is a key feature in EHR systems where a patient's first symptoms, complaints, and other important information are recorded during their initial visit. This step helps doctors evaluate the patient's condition and plan the appropriate treatment, as explained in the video.

💡Vital Signs

Vital signs, such as blood pressure, pulse, temperature, and respiration, are critical indicators of a patient's physical health. The video explains that the EHR system records these vital signs, aiding in monitoring the patient’s condition and detecting significant changes.

💡Diagnosis (ICD-10/ICD-9)

The International Classification of Diseases (ICD) codes, such as ICD-10 and ICD-9, are used to classify and code diagnoses in healthcare. In the video, the EHR system is shown to store these standardized codes, which help in creating uniformity in diagnosis and treatment across medical institutions.

💡Laboratory Results

Laboratory results, including tests like blood or urine analysis, are essential for diagnosing and monitoring a patient’s health condition. The video highlights how the EHR system is used to order and store these results, providing essential diagnostic tools for healthcare providers.

💡Digital Transformation

Digital transformation in healthcare refers to the shift from traditional methods to digital systems, like EHRs, that connect various aspects of patient care. The video emphasizes the importance of EHRs in advancing this transformation, linking healthcare networks, and improving overall patient outcomes.

Highlights

Electronic Health Record (EHR) is a document containing patient identification information, medical history, treatments, and services provided.

EHR applications are beneficial in modern healthcare, allowing medical professionals to record patient information electronically, replacing traditional paper records.

Doctors and medical staff can easily record examination details, treatments, and medical actions using EHR applications.

EHR data is stored electronically, allowing quick and consistent access to patient information.

EHR improves efficiency and quality of service, operational cost efficiency, data access, integration between hospital units and departments, optimized workflow, and ensures patient identification for preventive care.

Initial assessment records the results of the patient's first assessment, including symptoms, complaints, and other important information.

Vital signs section records patient vital signs such as blood pressure, pulse rate, temperature, and respiration, helping in monitoring significant changes.

Diagnosis data section records patient diagnosis based on ICD-10 or ICD-9 codes, helping in planning appropriate care and classifying patient conditions.

Medical actions section records all medical actions performed on the patient, including physical examinations, medical procedures, and other actions.

Laboratory section is used to order and record lab test results such as blood tests, urine tests, and other tests.

Radiology section is used to order and record radiology results such as X-ray, MRI, CT scan, and other imaging results.

Prescriptions section records all medications given to the patient along with the doses, ensuring the patient receives the correct medication and allows monitoring of side effects or drug interactions.

EHR applications play a significant role in digital health transformation, connecting various aspects of healthcare and supporting the development of a broader health information network.

EHR systems facilitate patient record keeping, availability of patient information, and enable digital transformation in healthcare.

EHR applications help ensure the integrity and security of patient information.