Prototyping of Medical Record Quantitative

Analysis Information System (Case Study: Patut

Patuh Patju Public Hospital, West Lombok)
Reni Chairunnisah
Noor Alamsyah Helmina Andriani
Medical Record and Health Information
Medical Record and Health Information Medical Record and Health Information
Management
Management Management
Politeknik Medica Farma Husada
Politeknik Medica Farma Husada Politeknik Medica Farma Husada
Mataram, Indonesia
Mataram, Indonesia Mataram, Indonesia
renicahirunnisah.fkm@gmail.com
alamsyahnoor90@gmail.com eena.andriani@gmail.com
Syamsuriansyah Rizal Pratama Adi Putra
Medical Record and Health Information Student of Health Administration’s
Management Master Degree Program
Politeknik Medica Farma Husada Universitas Qamarul Huda
Mataram, Indonesia Mataram, Indonesia
sam_bptk@yahoo.com adimfh10@gmail.com

Nowadays, the use of information and communication [6]. Medical record is a document that contains records and
technology becomes very emerging to increase effectiveness and documents about the patient's identity, examination,
efficiency of business processes in almost every companies treatment, actions and other services that have been
including hospital. This research conducted at Patut Patuh Patju provided to patients. Medical records must be written
Hospital in West Lombok. Based on observation in Patut Patuh
completely and clearly or electronically [5]. In order to
Patju Hospital, the existing implementation of medical record
analysis are by using retrospective approachment and digitalized obtain optimal quality medical records, it is necessary to
the data by using Microsoft Excel. However, there still are some audit and analyze medical records by examining medical
problems in using this software to digitalized the data. The first records produced by medical and paramedical staff as well
one is the security issue of data storage, because the data are only as the results examination of medical support units so that
saved in one local computer and not distributed into a specific the correct placement of diagnosis and completeness of the
server.The other issues are the data could not be accessed by medical recordis accountable [4]. Based on preliminary
another departments and data processing for final report is observations in November 2018 at Regional Public Hospital
conducted manually. The purpose of this research is to design a of Patut Patuh Patju in West Lombok, the analysis of
prototype model of information system of medical record
outgoing and ingoing patient’s medical records was carried
quantitative analysis. This prototype developed by using waterfall
model combines with data collection techniques such as out retrospectively or after the patient left. In order to obtain
observation and interviews. Result of this research is prototoype optimal quality medical records, it is necessary to audit and
model of information system for medical record quantitative analyze medical records by examining medical records
analysis for example the interfaces of form of patient produced by medical and paramedical staff as well as the
registration, examination data, automatic recapitulation and results examination of medical support units so that the
medical record analysis final reports. correct placement of diagnosis and completeness of the
Keywords—Hospital Information System, Medical Record,
medical records accountable [4]. Based on preliminary
Quantitative Analysis observations in November 2018 at Regional Public Hospital
of Patut Patuh Patju in West Lombok, the analysis of
outgoing and ingoing patient’s medical records was carried
I. INTRODUCTION
out retrospectively or after the patient left.
One of the methods implemented to improve the Regional Public Hospital of Patut Patuh Patju in
quality of service in a hospital so that becomes more West Lombok has used the Hospital Management
effective and efficient in this digitalization era is the Information System. However, in carrying out medical
application of systems and information technology [1]. record analysis,it applies Microsoft Excel. According to the
According to WHO in the book "Design and head of the medical record installation room at Regional
Implementation of Health Information System" An effective Public Hospital of Patut Patuh Patju, West Lombok, the
health information system can provide information support use of this software requires accuracy in inputting whether
for decision making processes at all levels of or not the medical record is complete. In addition, data
management. Information systems must also be used as an storage is also feared insecure because the computer may
effective tool for management and decision making [3]. experience errors that cause loss of data itself. This can
Hospital Management Information System is a cause the availability of insecure information and affected
communication information technology system that the decision making by the Director. From the problems as
processes and integrates the entire flow of hospital services mentioned above, it shows that the use of Microsoft Excel is
in the form of a network of coordination, reporting and not appropriate in processing medical record analysis. To
administrative procedures to obtain information precisely support the effective management of medical record
and accurately and is part of the health information system

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analysis, an information system is needed to help the implementation of the system unit, and improving
medical record officer perform his work optimally. system services as new requirements.
Based on the existing problems, the researcher wants
to design a web-based medical record analysis information
C. PIECES
system at Regional Public Hospital of Patut Patuh Patju,
West Lombok. To identify problems, an analysis of performance,
II. LITERATURE STUDY information, economy, securityof application, efficiency
and customer service must be carried out. This guide is
A. Medical Record Analysis known as PIECES analysis
(Performance, Information, Economy, Control, Efficienc
Quantitative analysis activities are intended to assess the
y, and Service) [2].
completeness and accuracy of the inpatient and outpatient
health records owned by health service facilities. Processing  Performance
of incomplete medical record data can be done by Performance analysis is the ability to complete
incomplete statistical means by processing incomplete business tasks quickly so that goals are reached
medical record data and presenting incomplete figures, so immediately. This developed system will provide a
that it can be used as a warning to improve the recording of sufficient amount of production and response time for
complete medical records. Incomplete statistics can be management needs.
calculated by incomplete medical records and delinguent  Information
medical records [4]. Information is the focus of a limit or
policy. While information analysis
 Incomplete Medical Record (IMR) examines system output, data analysis examines data
Incomplete medical record is a medical record with specific stored in a system.
deficiencies that can still be completed by the health care  Economy
provider. Economic analysis is a system assessment of the
reduction and benefits that will be obtained from the
 Delinguent Medical Record (DMR) system developed. This system will provide operational
Delinguent medical record is a medical record that is savings and increase company profits.
incomplete according to the time limit.  Control
The control system used must be able to secure
B. Waterfall Methods data from damage, for example by backing up data. In
Waterfall is a systematic and sequential information addition, the security system must also be able to secure
system development model. The stages of development data from unauthorized access, usually by giving
include [7]. a password to the application form and database.
 Efficiency
 Requirements analysis and definition Efficiency involves how to produce as
System services, constraints, and goals are much output as possible with the smallest
determined by the results of consultations with users possible input.
who are then defined in detail and function as system  Service
specifications. The growth of an organization depends largely
 System and software design upon the quality of services.
System design stages allocate system
requirements both hardware and software by forming III. RESEARCH METHODOLOGY
the overall system architecture. Software design This research use the Waterfall Method which includes:
involves identifying and describing the software
system's basic abstraction and its relationships. A. Requirements analysis and definition
 Implementation and unit testing
At this stage, the analysis conducted by
At this stage, software design is realized as a
researchers is:
series of programs or program units. The testing
 Analysis of old system weaknesses
involves verifying that each unit fills its specifications.
In the analysis of the weaknesses of the old system the
 Integration and system testing
researcher uses analysis with the PIECES framework.
The individual units of the program or program
 Requirement analysis
are combined and tested as a complete system to
The researcher analyzes the system requirements obtained
ascertain whether it matches the software requirements
from the analysis of system weaknesses.
or not. After the esting, the software can be sent to
the customer. B. System and software design
 Operation and maintenance At this stage the researcher will implement the
Usually (although not always), this stage is the requirements in the form of blueprints. To assist in
longest stage. The system is installed and used making the design of the design, the researcher
significantly. Maintenance involves correcting errors uses Microsoft Visio 2016. The design stages include:
that are not found in the previous stages, increasing the
  Flowchart system.  Service
 UML design (Use case diagram and Sequence Human errors in inputting quantitative analysis of
diagram). medical records.
 Entity Relationship Diagram (ER Diagram).
 Interface Design. Requirements analysis
 Performance
The next stages are Implementation and unit It takes the design of a medical record analysis
testing, Integration and system testing, and Operation and information system that can help officers work on
maintenance. At this stage the researcher does not do it medical record analysis on time.
because it is not included in the scope of the study.  Information
Required information system design that can
C. Data Collection Techniques produce information related to medical record
 Observation analysis.
The researcher observes Hospital Information System  Economy
(SIMRS) and manages the medical record analysis at Because Regional Public Hospital of Patut Patuh
Regional Public Hospital of Patut Patuh Patjuin West Patju in West Lombok in the future plans to
Lombok with the aim of producing an effective provide computers in each poly/ward, the
information system design for medical records officers. information system that will be designed is very
 Interview likely to help the hospital in terms of health
In this research the interviews are conducted with the information management.
head of the medical record room at Regional Public  Control
Hospital of Patut Patuh Patju, West Lombok. The aim is A medical record analysis information system is
to obtain more detailed system requirements. needed that has a backup system and access rights
for officers.
IV. RESULTS  Efficiency
The development of a medical record analysis
A. Requirements analysis and definition
information system is also needed so that it can
assist officers in completing their work related to
Here is the procedure for carrying out medical record medical record analysis.
analysis.  Service
 Review the complete patient social data An information system is needed in analyzing
(demographics) including information about the medical records that can reduce the errors of
patient's identity: name, medical record number, officers in inputting complete or incomplete
address, age, gender, patient responsibility, medical records.
signature of consent.
 Examining existing record evidence. B. System and Software Design
 Reviewing evidence of the validity of records from  Flowchart System
health workers and other personnel involved in
service to patients so that information can be
legally accounted for.
 Examine the procedure for recording
(administrative) which includes the date, time
information, writing in a fixed line and applying
the correct way of correction.

Analysis of old system weaknesses

 Performance
The medical records officers are unable to
complete a quantitative analysis of the medical
record.
 Information
In SIMRS there is no information regarding
quantitative analysis of medical records. Figure 1. Flowchart System
 Economy
Officers are not given overtime fees. This flowchart system consists of 4 actors, starting from the
 Control TPP/Counter officers inputting patient registration, patients
Officers do not back-up of data in Microsoft excel. who have been served by health care providers, then the
 Efficiency examination data in the medical record will be inputted by
The medical record analysis is not optimal because the input officer (Input officer is the officer who will input
the officers are charged with other work. the patient examination data in each poly/emergency
room/ward), then the analysis officer will verify the
completeness of the patient examination data. After that it  Entity Relationship Diagram
will be recapitulated and made an analysis report.

 Use Case Diagram

Figure 4. Entity Relationship Diagram

The diagram shows the relationship between entities of

Outpatient Registration Place and Outpatient Examination
Data, Outpatient Examination Data with Outpatient
Recapitulation, Outpatient Registration Place with Inpatient
Examination Data and so on.

 Interface Design
Figure 2. Use Case Diagram
The figure above explains the role of users that involves on
the system.

 Sequence Diagram

Figure 5. Login Interface

Figure 3. Sequence Diagram Figure 6. Registration Form Interface

Sequence diagrams are interactions between the Analysis This work is carried out by the Patient Registration Place /
Officer and the System. On the dashboard the officer Counter staff. The registration officer can choose register
chooses the analysis form, and then the system will display button to continue registration, print button to print the
the form in the form of verification of the completeness of treatment card and cancel button to cancel the patient
the patient examination data. After that the officer will recap registration.
the results of the analysis which will later produce a medical
record analysis report.

Figure 7. Examination Resume Interface

In order to input the examination data to each patient, the
officer can search the patients by using search menu. The Based on Figure 10 and 11, the analysis officer can see the
officer will input the information from the patient's medical details of the completeness and incompleteness of the IMR
record on the column provided. In each column there is save or DMR analysis for outpatients and inpatients. After that,
button which aims to save the inspection data when the the officer can see the final report by clicking the report
officer has finished inputting and cancel button to cancel the view button.
action taken previously.

Figure 11. Final Report of Outpatient Medical Records

Figure 8. Verification of Outpatient Medical Records Completeness Interface
Completeness Interface

Figure 12. Final Report of Intpatient Medical Records

Figure 9. Verification of Inpatient Medical Records Completeness Interface
Completeness Interface
Figure 11 and 12 are the final report of IMR and DMR
Based on Figure 8 and 9, it is seen that all of patient medical record analysis.
examination data can be seen from this menu. The analysis
officer will input the completeness based on patient's
medical record in the completeness column before the
verification process is done.

Figure 13. Logout Interface

V. CONCLUSION

Figure 10. Recapitulation of Inpatient Medical Records The development process of prototype model of the
Completeness Interface medical record analysis information system adopt
waterfall method. The actors in this medical record analysis
information system are TPP/counter officers, data
input officers, analysis officers and management. This
information system has user access rights
becauseeach actor has their own username and password. A
interface design stage, this research produces the design of
login dashboard interface, patient registration form
interface, patient examination data interface, medical record
analysis and reporting interfaces, and also logout dashboard
Figure 11. Recapitulation of Outpatient Medical Records interface.
Completeness Interface
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