Tutorial Software Rumah Sakit, SIMRS KhanzaHMS Bagian 6 Registrasi & Rekam Medis

Summary

This tutorial demonstrates the process of medical record registration in a healthcare system. It covers key steps such as adding both new and existing patients, entering personal details, selecting the appropriate medical unit, and printing patient identity cards. The script also details the various features within the system, such as handling referrals, diagnoses, and generating reports for patient visits. Additionally, it explains the functionality of the registration module, which integrates with hospital departments like billing and room assignments, streamlining workflows for medical staff.

Takeaways

• 😀 Patients can be registered either by searching for their existing medical record number or by adding new patients through the registration menu.
• 😀 For existing patients, their medical record number is entered to retrieve their information; for new patients, their details are manually entered.
• 😀 The system allows users to search for patients by various parameters such as name, address, or other identifiers, facilitating quick data entry.
• 😀 The medical registration system includes an option to select the assigned doctor and department, such as obstetrics and gynecology.
• 😀 New patient registration involves inputting personal details like name, gender, parent’s name, and contact information.
• 😀 After entering patient information, users can print various medical documents, such as patient identification cards, using compatible printers (e.g., Zebra or PVC card printers).
• 😀 The system can generate a patient index card, a medical identity card, and a medical record resume to help track patient care history.
• 😀 A patient's medical history, including previous treatments and therapies, can be displayed and printed for record-keeping purposes.
• 😀 Patient data can be compiled into various reports, such as demographic statistics, medical records, or visit summaries, with options for graphical presentation.
• 😀 The system allows for detailed patient care documentation, including the diagnosis, referral information, and medical actions performed, ensuring comprehensive patient tracking.

Q & A

What is the first step in the patient registration process in this tutorial?

The first step is to click on the 'Registrasi' menu, either from the main menu or directly from the top bar of the interface.

How do you handle the registration of an existing patient?

For an existing patient, you simply enter the medical record number and press 'Enter'. If the patient is not found, you can manually add the details by clicking the up arrow on the keyboard to open the patient search menu.

What method is used to search for an existing patient in the system?

You can search for an existing patient by typing their name, address, or other identifiable information in the search field, then select the correct patient using the keyboard's spacebar.

What details are required when registering a new patient?

For a new patient, you need to input their name, gender, mother’s name, responsible person, and address. Additionally, information like the patient's guardian or the referring doctor can be added if applicable.

How is a new patient's data saved after entering the necessary details?

Once all the necessary details are filled in, you save the new patient’s data by clicking 'Simpan' (Save).

What is the function of the 'Kartu Berobat' feature in the system?

The 'Kartu Berobat' (Treatment Card) feature allows the printing of patient treatment cards, which can be used for patient identification and tracking during visits. This can be printed on PVC cards similar to ATM cards.

What types of patient reports can be printed from the system?

The system can print various reports such as treatment cards (front and back), patient identity sheets, patient index cards, and medical records summaries like the patient's treatment history or hospitalization report.

How can a hospital staff member handle the diagnosis input process?

The staff member can input the patient's diagnosis by selecting it from a predefined list or typing the diagnosis directly. The main diagnosis is marked as the primary diagnosis, and then the record is saved.

How are referrals handled in the registration process?

If a patient is referred from another facility or health center, the referral information can be entered directly during registration. If this is missed, the referral can be added later by accessing the 'Rujukan' (Referral) option.

What is the purpose of the demographic and medical statistics reports in the system?

These reports provide insights into the distribution of patients by gender, occupation, and other demographics. It helps generate graphical reports such as bar charts or pie charts that summarize the medical data.