The Quality Assurance of Medical Record Service Unit in Kariadi Hospital Semarang During Covid-19 Outbreak

History Submitted (9th February 2022) Revised (29th March 2022) Diterima (25 May 2022) Policies regarding, the flow of the medical record service procedures are needed during the COVID-19 pandemic. This pandemic requires medical record unit to adapt quickly. Differences in established patients who were not confirmed by the 2019-nCoV virus. Evaluation of quality assurance medical record service procedures during the COVID-19 pandemic for established patients who are not confirmed by the 2019-nCoV that support person-centered health care is crucial for the officer's needs. This study aim was to know the quality assurance of the medical record service unit in Kariadi Hospital Semarang during COVID-19 outbreak. This research was conducted from 1 July to 15 August 2020. The research instrument used in-depth interviews sheet and direct with participants used COVID-19 health protocol. Interviews were transcribed verbatim and analyzed used Haase's adaptation of Colaizzi's phenomenological. The research was analyzed by data analysis used content analysis with software Nvivo 12 Plus. The results, Dr. Kariadi Hospital already has a Standard Operating Procedure (SOP) for the flow of medical record service procedures during the COVID-19 pandemic for new or old patients who are not confirmed by the 2019-nCoV virus. The conclusion that Dr. Kariadi Hospital used quality assurance of electronic medical record to processing medical record documents for patients who are not confirmed by the 2019-nCoV. Keywords


INTRODUCTION
On December 31, 2019, the China Health Authority alerted the World Health Organization WHO declared the SARS-CoV-2 outbreak as a Public Health Emergency of International Concern (PHEIC) (4). Among patients admitted to hospitals, the mortality rate ranged between 11% and 15% (5,6). COVID-19 is moderately infectious with a relatively high mortality rate, but the information available in public reports and published literature is rapidly increasing (7).
Objects that are possible as modes of transmission of SARS-CoV-2 such as plastics, metals, woods, glass, food and papers (8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19). Currently, human-to-human spread of SARS-CoV-2 is the main source of transmission, so the spread has become more aggressive. Transmission of SARS-CoV-2 from symptomatic patients occurs via droplets released when coughing or sneezing (20). In addition, it has been studied that SARS-CoV-2 can be viable to aerosols (generated through a nebulizer) for at least 3 hours (21). WHO estimates the reproductive number (R0) of COVID-19 to be 1.4 to 2.5, however, other studies estimate the R0 of 3.28 (22). The stability of SARS-CoV-2 in inanimate objects is not much different from SARS-CoV. SARSCoV-2 is more stable on plastic and stainless steel (> 72 hours) than copper (4 hours) and cardboard (24 hours) (21). Another study in Singapore found extensive environmental pollution in the rooms and toilets of COVID-19 patients with mild symptoms. Viruses can be detected on door handles, toilet seats, light switches, windows, cabinets, and ventilation fans, but not in air samples (23).
Similar to other highly pathogenic coronaviruses (24), SARS-CoV-2 has been associated with outbreaks of healthcare associated infections in nursing homes (25) and hospitals (26). While the mode of transmission of SARS-CoV-2 from person to person remains unknown, it is expected that the primary route of transmission is by respiratory droplets and possibly small aerosols (21,27).
The Centers for Disease Control and Prevention (CDC) recommends that hospitalized persons be placed in a single person room with the door kept closed, and that an airborne infection isolation room (AIIR), also known as a negative pressure room, be used for such patients who may require an aerosol generating procedure in an effort to contain potentially infectious aerosols from patients known or suspected of an active infection due to SARS-CoV-2 (28). However, as was seen in Italy (29), the US (30) and in other countries (31), the first wave of the SARS-CoV-2 pandemic often quickly saturated the capacity of hospitals to provide an AIIR for all patients known to have or suspected of COVID-19 (15).
Beyond acute care hospitals, nursing facilities typically have little to no capacity to provide an AIIR for patients. Instead, nursing facilities tend to transfer patients suspected of an infectious disease transmitted by small particle aerosols to a hospital for care and isolation in an AIIR for the duration of the period the patient may be contagious. During the first wave of the SARS-CoV-2 pandemic, with both nursing facilities and hospitals often overwhelmed in regions that experienced the greatest prevalence of COVID, these hospital resources were not available (15). Neutral pressure rooms are not designed to contain potentially infectious aerosols, both because of these aerosols migrating outside of the room and since the conditioned air is recirculated rather than exhausted outside as is the case for air in an AIIR. To prevent droplet transmission of disease during these moments, plexiglass partitions were installed throughout the emergency department, analyzing information and data to identify and plan the need for medical services performed when a new patient is first served by health services. The follow-up of this initial assessment is used to determine the type of ODP or PDP patient that is used as a follow-up plan for patients with Covid-19 symptoms. The results of the initial assessment of the patient must be documented by medical personnel in a form prepared in such a way as to meet the data and information needs of quality with existing emergency conditions. This documentation is important to carry out as one of the functions of medical records that are used as a source of data that will later be used by health services for various purposes. In addition, this is in line with Permenkes 269 concerning medical records that in disaster conditions a special form is required to be used for documentation (34).
The hospital must have a medical record unit to manage patient medical record documents (35). The sub-unit of hospital medical records is a filing that has an archiving function including managing medical record documents. The paper base medical record documents that are still required because there is a need for approval or manual signature of medical personnel/patients required by patients for referral letters, inpatient approval letters, general approval, approval and operation reports (for surgical cases), birth identification reports, preoperative assessment, death report, discharge summary, death certificate, give birth report, external referral, and supporting examination results (36). Inherent to the operational management of a pandemic in the era of modern medicine is leveraging the capabilities of the electronic health record (EHR), which can be useful for developing tools to support standard management of patients and day-to-day operations, and, perhaps most importantly, offering telemedicine visits for patients (24,37,38). During the Ebola outbreak in 2014, attention was brought to the use of the EHR as a potential public health tool (39). Unfortunately, despite the recent Ebola epidemic, the infrastructure for outbreak management was not present in many US health systems and their EHR applications. The EHR is a useful tool to enable rapid deployment of standardized processes (40).
Additionally, indispensable during the pandemic, the personal protective equipment (PPE) used by hospital workers, composed of face masks, gloves, clothing, aprons, caps, covers, glasses/goggles, the vast majority of which are made of plastic. Exhausted air has to be filtered through high efficiency particulate air (HEPA) and medical personnel entering the room should wear PPE such as gloves, gown, disposable N95, and eye protection. Once the cases are recovered and discharged, the room should be decontaminated or disinfected and personnel entering the room need to wear PPE particularly facemask, gown, eye protection (7). Surgical gloves are made of natural rubber, which is also a type of polymer. The literature highlights the importance of using these PPEs (9,13). The role of PPE in avoiding SARS-CoV-2 transmission is suggested also by another nosocomial study carried out in Hong Kong (8). The COVID-19 is a fast expanding pandemic, which caught many countries off-guard. In many countries, the control of the infection is hindered by inadequate emergency settings, suboptimal logistics, and scarcity of personal PPE (19). Healthcare workers as part of the healthcare system that handles COVID-19 are prone to

Data collections
This study used source triangulation in testing the validity of the data to obtain more accurate and credible findings and interpretation of data by using sources other than the main data. Data collection techniques used are through in-depth interviews (depth interview). Sources of data in this study are primary data sources. The primary data source is in the form of interviews. The

Data processing and analysis
Following the procedures of the selected qualitative methods design, each type of data was analyzed independently. Responses to open-ended questions were coded by independent researchers following the data processing and procedures of content analysis with software Nvivo 12 Plus, namely: 1) data collection, using in-depth interview techniques that recorded using camera and voice recorder, then the results will be recapitulating to the transcript of the interview results for each informant, 2) data reduction, be carried out by identify the part founded in data that has meaning when it is associated with the focus of research problems followed by coding each data so that it can be traced where the data is sourced (coding) and grouped into sections that have In the MIRM Standards in SNARS, everything has been made, both for medical record service procedures in IRRAL, IRNAP, IGD. After that, URM will make SPO and standard service procedures in order to provide optimal service. (TI1).

Constraints in carrying out services according to the flow of procedures
"So far there have been no significant problems. Now there is indeed major transformation towards the digitalization of DRM. Although, now 100% are outpatient and inpatient care. The IGD is currently running for the transfer, but there are some things that cannot be

Differences in the Flow of Medical Record Service Procedures During the COVID-19
Pandemic "There are differences in the flow of the procedure. For this problem, there isdifference, namely Medical Services intervening here. All covid-19 patient files are their responsibility. Now, for this pandemic era, we at PPI have already overcome it, because before 2020 we have fully prepared, even though covid- 19 has not yet entered Indonesia. Then we actually want covid-19 or not, we are ready because before covid-19 came, we already had MERS, AI, SARS and many more. So we have set updated rules, namely SPO regarding the handling of emerging and re-emerging infectious diseases with the code of Director Decree No. HK.00.01/I.IV.I/17/2014 dated 17 November 2017 at the PPI Committee." (TI2)

Difference between new and old patients who were not confirmed with the N-Cov virus
"When there is patient, where it is new patient, it will be difficult to detect it clearly. When the screening officer finds patient who is indeed seeking treatment through outpatient poly or Emergency Departement and there is sign even though it is 1 sign, for example fever or several signs such as high fever, chills, influenza, coughs, it will be immediately declared the suspect. Then the screening officer did not suggest meeting or contacting the TPPRJ or TPPGD but directly handling the special officers and Medical Services was fully responsible. So that friends of medical records will not be touched or exposed to COVID-19." (TI2)

DRM COVID-19 isolation room, person in charge of DRM, handling and filling of DRM, and
Collengting and submitting to the Health Ministry "New and old patients must screen first. Then if there are new symptoms, rapid test and swab test are carried out. And it's free. So, to wait 1 week, we prepare an isolation room. If indeed the patient has comorbid, then medical isolation will be carried out in negative pressure isolation room (in the hospital) but if not, then isolate independently and with supervision from Medical Services. There is no DRM and it is certain that there is no transmission. Because those who fill the DRM and hold the DRM must take off and replace the PPE completely, and they cannot wear gloves or anything, and must wash their hands in running water and use handsrubs." (TI1)

Referral Patients Who Are Clearly Confirmed, and DRM For Confirmed Patients
"DRM in any room is indeed placed at the Nurse Station and that is the responsibility of the PJRM, now when all the medical teams who will write down the data there must be removed from PPE and put in special boxes or infectious items which will later become PPI and CSSD matters. To write or read or use DRM, clean, sterile conditions must first be used andnew surgical mask is worn. No gloves. Then the patient's data with covid data will be immediately submitted to Medical Services, after the DRM is declared complete (the patient has returned from the hospital), then the data will be sent to the Ministry of Health and claimed to be managed by the Covid RMIK team itself." (TI1)

DISCUSSION Policy Regarding the Flow of Medical Record Service Procedures during the COVID-19
Pandemic The use of telehealth improves the provision of health services. Therefore, telehealth should be an important tool in caring services while keeping patients and health providers safe during the covid-19 outbreak (42). Health protocol flow has already implemented using recommended standards (43). Based on interviews, the process of making SOPs to maintain the quality of service in medical records must be carried out together, because the Medical Records for Outpatient Registration, Emergency Registration, and PJRM Isolation Rooms know the conditions in the field.
After that, URM will make SPO and standard service procedures in order to provide optimal service.
Meanwhile, there is still nothing that needs to be changed. In the near future, this may change due to the RME-RJ (Outpatient Electronic Medical Records) system.
The workflow was essential to quickly identify, isolate to help containing the disease and prevent community spread (44). The flowchart design of the initial assessment electronic form system. During pandemic, to eliminate the spread of the virus with paper based services, it is necessary to develop electronic services. One of the efforts to achieve this by using electronic recording of the initial patient assessment.  (37). The current pandemic has caused digitization to flourish in the health care sector. e-Health, which iscombined use of electronic information and communication technology in the health sector, has high potential for optimizations and savings in the majority of health care systems worldwide. e-Health solutions can be supported care and treatment by exchanging treatment-relevant data among health care providers or between patients and health care providers in compliance with data protection regulations and by providing documents that are specially tailored to the needs of tele-intensive care of covid-19 patients (45).

Constraints in carrying out services according to the flow of procedures
Constraints are factors or circumstances that limit, hinder, or prevent the achievement of goals. Constraints also mean the forces cancellation of implementation.