Desain Formulir Rekam Medis Poli Gigi di Puskesmas : Literature Review

Yuliastin, Shafira (2022) Desain Formulir Rekam Medis Poli Gigi di Puskesmas : Literature Review. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

The dental medical record is the most important document in the medical service of dentistry, because it contains a record of the patient's medical condition and all the patient's medical actions. Currently, there is still a lack of uniformity in the writing procedures used to document the practice of dentistry. Some studies have shown that the forms used on dental polys use outpatient forms in general. The purpose of this research is to design a dental medical record form so that it can be used in health services so that the similarity of writing dental medical records can be achieved. This research method is literature review, with 27 articles that have been selected according to the inclusion criteria. In designing the dental medical record form, the researcher considers the needs of users contained in previous studies, then the form is designed based on aspects of the form design and the 2015 Dentistry Medical record guidelines. The result of this study is the design of the dental medical record form based on 3 aspects of the form design, namely the physical aspect, anatomical aspect, and content aspect. The physical aspect consists of Material (HVS paper 80 gsm), Size (F4 (33 cm x 21.5 cm)), Shape (rectangular orientation portrait), Color (White paper, with black ink). Anatomical aspects consist of components, headings with sub-components of form titles, form identification, date of issue and issue number, introduction, instruction, body, and close. Aspects of the content consist of the patient's identity, odontogram, treatment table, and supporting attachments. The suggestion from this study is that the design of the dental medical record form that has been made by the researcher can be considered for use as a dental poly medical record form to support the completeness of medical record information for dental poly patients at the health center.

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