434 - Pengisian Informasi Klinik #akreditasiklinik

Summary

In this video, Dr. Sufi explains the process of filling out clinical information in electronic medical records. He covers the importance of accurate documentation of patient care, including examinations, treatments, and services provided. The process must be clear, complete, and sequential, with the healthcare provider’s name, time, and signature included. Dr. Sufi emphasizes the need for integrated documentation across various healthcare providers and facilities, and mentions the role of family folders in primary healthcare settings while respecting patient privacy.

Takeaways

• 😀 The video discusses the process of filling out clinical information in electronic medical records.
• 😀 Health workers are responsible for entering clinical information after the patient receives medical services.
• 😀 Clinical information must be documented in a complete and clear manner, including the name, time, and signature of the healthcare provider.
• 😀 Documentation should be done sequentially in accordance with the timing of healthcare services provided.
• 😀 If there is an error in the documentation, healthcare providers can make corrections.
• 😀 When there are multiple types of healthcare providers in a healthcare facility, clinical information must be integrated across different providers.
• 😀 Integrated entry means that the electronic medical record contains all notes or health information from different healthcare providers in a single document.
• 😀 Health workers in primary healthcare facilities can enter clinical information in a family folder, considering the privacy of each family member.
• 😀 Accurate and proper documentation of healthcare services is crucial for effective patient management.
• 😀 The video emphasizes the importance of accurate documentation in electronic medical records for transparency and continuity of care.

Q & A

What is the primary focus of the video?

The video primarily focuses on the process of filling out clinical information in the context of electronic medical records (EMR), as well as the guidelines for recording health-related data.

Who is responsible for filling out the clinical information?

The healthcare workers, referred to as 'tenaga kesehatan' (health personnel), are responsible for filling out the clinical information.

What are the key activities involved in the EMR process?

The EMR process involves at least eight activities, one of which is the filling of clinical information, as mentioned in the video.

What does the clinical information filling process include?

It includes the documentation and recording of examination results, treatments, procedures, and other health services provided to the patient.

When should the clinical information be documented?

Clinical information must be documented after the patient receives healthcare services, ensuring that it includes the name, time, and signature of the healthcare provider.

What should be done in case of errors in the documentation?

If there is an error in the documentation, the healthcare provider is allowed to correct the information.

How should clinical information be recorded in a facility with multiple healthcare providers?

In facilities with more than one type of healthcare provider, clinical information must be recorded in an integrated manner, meaning all health records are captured in one document, including details from different healthcare providers.

What is the significance of integrated clinical information entry?

Integrated entry ensures that all relevant health information, such as examination, treatment, and healthcare services, is recorded in a unified document in a sequential manner.

Can healthcare workers in primary healthcare facilities record family health information?

Yes, healthcare workers in primary healthcare facilities can record information in a family folder, provided that they respect the privacy of each family member.

What is the next topic to be discussed in the following video?

The next video will discuss the processing of electronic medical record information.