| Abstrak/Abstract |
Background: Today's rapid technological developments have covered almost all areas of human life, including the health sector. Along with technological developments, health facilities, including clinics, have an obligation to maintain medical records and implement a proper referral system. The service system at the Nima Medical and Rehabilitation Center clinic is still not effective and efficient. The clinic does not yet use an information system. Administrative services carried out are still using the manual method.
Methods: This research uses the type of research UCD (User Centered Design). UCD (User Centered Design)
is a method used for system development that focuses on the user interface.
Results: Clinical needs will document dynamic medical by designing medical records and patient registration. Image-based medical documentation is created to describe medical conditions in dynamic patients to provide up-to-date information. The digitization of electronic medical records provides potential access to a wealth of medical information. There are two significant advantages of combining photographs with imaging studies, including reduced medical errors and increased diagnostic capabilities. Use of standard data in medical documentation, especially for the terminology of medical disorders. Imaging is increasingly being used in dermatology for the documentation, diagnosis, and management of skin diseases. The lack of standards for dermatological imaging is an obstacle to clinical followup. Image-based documentation can be used as terminology for standardization of reports. Clinical data is always shaped by specific requirements such as communication between healthcare professionals, billing or quality management. Interpretation of clinical data relies heavily on implicit contexts, mostly unstructured, semi-structured or even standardized. Data interoperability is getting more attention than the high expectations for the value of large-scale predictive data analysis, this necessitates the need for standardized data to make data clinically interoperable and shareable in a virtuous cycle of continuous improvement.
Conclusions: In this clinical management information system can make it easier to write, add, change and make clinical reports. So that with this convenience it will reduce the risk of recording errors caused by lack of clarity or lack of clarity in the information obtained so that work is more effective and efficient.
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