Implementasi manajemen rekam medis dan informasi kesehatan pada layanan gigi dan mulut: A literature review
DOI: https://doi.org/10.33024/hjk.v20i6.3580
Dental Services Health Information Management Medical Record
Abstract
Background: Medical record and health information management is a crucial component in enhancing quality, patient safety, continuity of care, and fulfilling hospital accreditation standards. In dental and oral health services, medical record management possesses unique characteristics as it encompasses odontograms, treatment history, clinical interventions, informed consent, and patient data security.
Purpose: To analyze the implementation of medical record and health information management in the administration of dental practices.
Method: An article search was conducted using the PRISMA approach across Google Scholar, PubMed/PMC, ScienceDirect, Garuda, and other journal sources. A total of 94 articles were identified, and through a selection mechanism, 10 articles were retrieved to be used in the synthesis.
Results: The implementation of medical record and health information management in dental and oral health services encompasses six main focuses: the completeness and quality of dental medical record documentation, user compliance, digitalization and information efficiency, data security and confidentiality, accreditation standard-based quality audits, and oral-systemic data interoperability to support service quality, patient safety, and healthcare accountability.
Conclusion: The implementation of medical record and health information management in dental services should be supported by complete dental documentation, user compliance, data security, continuous audits, digitalization aligned with clinical workflows, and oral-systemic data integration to improve service quality, patient safety, accreditation readiness, and service accountability
Keywords: Medical Record; Health Information Management; Dental Services.
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