Design of Inpatient Electronic Medical Records to Improve Patient

Health Services

Tominanto

, Eko Purwanto

and Novita Yuliani

Faculty of Health Sciences, Universitas Duta Bangsa Surakarta, Surakarta, Indonesia

Faculty of Computer Science, Universitas Duta Bangsa Surakarta, Surakarta, Indonesia

Keywords:

Electronic Medical Record, Inpatient, Patient, Health,Waterfall

Abstract:

Medical record is a ﬁle that contains records and documents about patient identity, examination, treatment, ac-

tions and other services that have been provided to patients in health care facilities. Most hospitals in Indonesia

have implemented a computer-based Hospital Management Information System, however for the majority of

patients’ medical record services are still manual. This manual medical record has the disadvantages of re-

quiring a large storage area, a long-time services, and a lot of human resources to access the data. Moreover,

documents are easily damaged and data security is not guaranteed. This can result in less optimal patient

health services. This research aims fasten the management of inpatient medical data recording, so it can run

quickly, precisely and efﬁciently. This system development method uses waterfall. This information system

is based on WEB using the PHP programming language supported by the MySQL database. The results of

this designed system show that the system is able to store and present inpatient treatment history information

faster and more accurate. This designed system will be able to improve the inpatient medical record service to

be more optimal. This designed system can be one of the solutions to the problems of inpatient medical record

services that have been done manually.

1 INTRODUCTION

Generally, every hospital in Indonesia will improve

its services to patients as well as possible. There-

fore, support from various related health service fac-

torsare needed. One of them is the implementation

of applicable standardsfor medical record. Medical

records are ﬁles that contain records and documents

about patient identity, history, examination, treatment,

actions, and other services to patients at patient care

facilities (Permenkes, 2008). Medical record is conﬁ-

dential, secure, and contains information that can be

accounted for. Medical Record is also a compilation

of facts about a patient’s health condition and illness

which includes documented data about the present

and past illness, also treatment that has been and will

be carried out by medic in writing (Puspitasari et al.,

2013).

Electronic Medical Record (EMR) is a medical

record technology that uses information technology

devices to collect, store, process and access data

stored in patient medical records with a database man-

agement system that collects various sources of med-

ical data (Handiwidjojo, 2015). The use of EMR can

provide information on the history of examinations,

treatment and development of patient health quickly

and accurately to improve higher quality advanced

health services. In addition to improving administra-

tive services, the use of electronic medical records can

facilitate retrieval of patient health service informa-

tion that has been provided (Schnipper et al., 2008).

Most hospitals in Indonesia have implemented

a computer-based Hospital Management Information

System. However most of the patient’s medical record

services are still done manually. This manual med-

ical record has the disadvantage of requiring a large

storage area, a long-time service, a lot of human re-

sources to access, more over the documents are eas-

ily damaged and data security that is not guaranteed.

This can result in less optimal patient’s health ser-

vices(Tominanto et al., 2018).

Research on the development of information sys-

tems or applications of electronic medical records has

been widely carried out including (Chuan, 2014),(Pan

et al., 2014), (Kho et al., 2012), (Purnama, 2020),

(Khasanah and Rosyidah, 2011). These studies de-

velop various electronic medical record models to

solve the problem of managing medical records by us-

Tominanto, ., Purwanto, E. and Yuliani, N.

Design of Inpatient Electronic Medical Records to Improve Patient Health Services.

DOI: 10.5220/0009908502410245

In Proceedings of the International Conferences on Information System and Technology (CONRIST 2019), pages 241-245

ISBN: 978-989-758-453-4

241

ing various methods, software and speciﬁc databases.

However, most of them produce conclusions that elec-

tronic medical records can improve patient health ser-

vices. This study focuses on the development of an

electronic medical record model for inpatient medical

record services, namely the design of inpatient elec-

tronic medical records using the waterfall software

development method (Sasmito, 2017), PHP program-

ming language and MySQL database.

2 METHODS

The method of developing electronic medical record

software using waterfall has 5 stages : communica-

tion, planning, modeling, contruction, and deploy-

ment as in Figure 1 :

Figure 1: Waterfall method

The stages of the waterfall system development in

Figure 1 are as follows :

1. Communication is a comparison of the current

system with the information system proposed us-

ing the PIECES aspect

2. Planning is the retrieval of information related to

the needs of system users

3. Modeling is the representation of system require-

ments into a design as a standard for designing an

application

4. Construction is a waterfall system design imple-

mentation into an application through coding and

testing processes

5. Deployment is the implementation of applications

that have been created by testing the system that

has been run.

The stages of developing the waterfall system in

Figure 1 are carried out sequentially from the com-

munication, planning, modeling, contruction, and de-

ployment. However, when a stage ﬁnds a problem, it

can be repeated back to the previous stage or to an ear-

lier stage, then proceed to the next stage in sequence

until the inpatient electronic medical record software

is successful in the system testing phase.

3 RESULTS AND DISSCUSION

3.1 Designed System

The results of this study began with the design of

an inpatient electronic medical record architecture as

shown in ﬁgure 2 :

Figure 2: Inpatient electronic medical record architecture

In the system architecture, the ﬁgure 2 shows that

the patient who conducts the examination or treatment

in the inpatient unit will get an electronic medical

record information service from the inpatient EMR.

Inpatient EMR accesses data from databases that have

been connected with various health services including

registration, supporting examinations, medical mea-

sures, supporting examinations and medicines.

The ﬂowchart overview of the process of inpatient

electronic medical records such as Figure 3 below:

Figure 3: Inpatient electronic medical record ﬂowchart

The of inpatient electronic medical record

ﬂowchart in Figure 3 ﬂows as follows:

1. When patients come for treatment is determined

as a new visit or an existing patient

2. If a new visit then inputted registration as a new

patient, whereas if an existing patient then the data

is sought in the registration system and then reg-

istered as existing patient

3. The next stage is the doctor’s examination process

and nurses in the inpatient room, at this stage the

CONRIST 2019 - International Conferences on Information System and Technology

242

doctor or nurse can read or access the patient’s

medical record before giving medical treatment

4. Doctors, nurses and other medic can provide

medical treatment, supporting examinations and

medicines during the patient being treated and

record the entire medical treatmentand services at

the Inpatient EMR.

5. All medical record data during treatment will be

stored in a database and can be used for further

treatment services and for the purposes of hospital

management reports.

The next design is the Use Case Diagram of an in-

patient electronic medical record as as shown in ﬁgure

4 :

Figure 4: Use Case diagram of an inpatient electronic med-

ical record

Use Case Diagram of an inpatient electronic med-

ical record in ﬁgure 4 shows that in this inpatient

electronic medical record system there are at least

6 actors namely: Patients, Medical Record Ofﬁcers,

Nurses, Doctors, Laboratory Assistants, and Pharma-

cists. The ﬁrst stage begins with patients who register

to be served by medical records ofﬁcers. The sec-

ond stage the patient gets an examination and med-

ical action from doctors and nurses, in this process

there will be carried out supporting tests of laboratory

tests conducted by the laboratory assistantif needed.

The third stage is the process of prescribing medicines

by the doctor and continued with the service of tak-

ing medicines by the Pharmacist. The processes in

the Use Case Diagram are developed electronically

and are interconnected in a database of inpatient elec-

tronic medical records.

3.2 System Implementation

The inpatient electronic medical records design is im-

plemented with the PHP programming language and

MySQL database. The results of the implementation

are as follows:

1. Inpatient data input form

The inpatient data input form is used to input new

inpatients. Display form is like the following ﬁg-

ure 5:

Figure 5: Input form for inpatients

Data entered on this form is patient’s identity. Pa-

tient identity that has been entered is stored in an

inpatient electronic medical record database. Be-

sides input data, there is also a data update menu

on this form.

2. Inpatient registration data input form

The registration data input form is used to enter

new and existing patients who will register for

hospitalization. Display the form as shown in ﬁg-

ure 6 :

Figure 6: Inpatient registration form

In this form, inpatient registration data is consistof

patient identity data, responsible data, method of

payment, guarantee number, treatment room, and

the doctor.

3. Initial Medical Assesment input form

The initial medical assessment form is used to

input the patient’s initial examination data when

hospitalized. This initial examination data is

needed to take further treatment. Display this

form as shown in ﬁgure 7:

Figure 7: Initial medical assessment form

4. Input Form of Integrated Patient Development

Records for Doctors and Nurses

Integrated Patient Development Record Form is a

Design of Inpatient Electronic Medical Records to Improve Patient Health Services

243

form used by doctors and nurses in inputting the

examination and treatment of patients while being

treated at the Hospital. Display the form shown in

ﬁgure 8 below:

Figure 8: Integrated Patient Development Record Forms for

Doctors and Nurses

5. Input form doctor’s instructions

This doctor’s instruction form completes the ex-

amination and treatment process carried out by the

doctor. It looks like the following ﬁgure 9:

Figure 9: Doctor’s instruction form

In the doctor’s instruction form there is input

for the disease course and medication or medical

treatment needed.

6. Operation record form

The surgery entry form is used if there are patients

with surgical medical procedures. Display form is

as shown in ﬁgure 10:

Figure 10: Operation record form

7. Medicines administration form

This Medicines administration form is used by

doctors to input the medicines prescriptiongivento

patients. Display this form as shown in ﬁgure 11:

Figure 11: Medicines administration form

The prescription data entered will be forwarded

by the system to the Pharmacists to prepare the

medicines needed by the patient.

3.3 System Testing

The inpatient electronic medical record system test-

ing uses the Black Box Testing method. Testing the

system with this method emphasizes testing the func-

tional program and checking input and output data

(Larrea, 2017) (MZ, 2016).

Testing is done by testing data input 30 times with

10 times printing output in each process. The ﬁnal

results of the trial show that the inpatient electronic

medical record system is running well and without an

error. The inputted data is stored valid to each table

and can be accessed which produces valid output.

4 CONCLUSIONS

The conclusion of this research is the design of in-

patient electronic medical record software developed

by the waterfall method, using the PHP programming

language and MySQL database. The test results show

that this software can store and present inpatient treat-

ment history information properly and without errors.

This will improve inpatient medical record services to

be more optimal.

ACKNOWLEDGEMENTS

This paper is one of theresearch publications in

the Higher Education Applied Research (PTUPT)

scheme. This research was funded by the Directorate

of Research and Community Service at the Ministry

of Research, Technology and Higher Education in

2019.

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244

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