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All Journal Jurnal Kesehatan Pengabdian Masyarakat Jurnal Health Information Management and Medical Record
Syarah Mazaya Fitriana
Poltekkes Kemenkes Yogyakarta
Dentistry Education Health Professions Library & Information Science Medicine & Pharmacology Neuroscience Nursing Public Health

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Tinjauan Faktor Penyebab Ketidaklengkapan Pengisian Rekam Medis Rawat Jalan dengan Metode Fishbone dan USG di RSUD X Zanu Nury Latifah; Anton Kristijono; Syarah Mazaya Fitriana; Abdul Hadi Kadarusno
Journal of Health Information Management and Medical Record Vol. 2 No. 1 (2026): Volume 2 No 1 ( Juni ) 2026
Publisher : Poltekkes Kemenkes Yogyakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.29238/himmr.v2i1.3260

Abstract

Kelengkapan rekam medis merupakan bagian penting dalam proses pencatatan pelayanan, pengobatan pasien, dan pengajuan klaim asuransi, sehingga perlu dilakukan evaluasi terhadap ketidaklengkapan pengisiannya, terutama pada pelayanan rawat jalan dengan jumlah kunjungan pasien yang tinggi. Kelengkapan pengisian Rekam Medis Elektronik rawat jalan di Rumah Sakit X belum memenuhi standar sesuai ketentuan yaitu 100%. Tujuan mengetahui tingkat kelengkapan rekam medis rawat jalan periode bulan Oktober–Desember 2025 dan mengetahui faktor penyebab ketidaklengkapan menggunakan metode Fishbone dan USG. Penelitian deskriptif dengan metode campuran dilakukan pada Januari–April 2026. Pengumpulan data melalui Google Form, wawancara, dan kuesioner kepada tiga responden. Hasil penelitian menunjukkan rata-rata kelengkapan pengisian rekam medis rawat jalan 88,72%. Berdasarkan Analisis Fishbone ditemukan faktor penyebab ketidaklengkapan rekam medis yaitu tingginya beban kerja, sosialisasi pengisian RME, anggaran, tidak ada penghargaan atau punishment, belum ada SOP Pengisian RME, perangkat masih terbatas, dan format, tampilan, serta fitur RME yang belum tersedia. Berdasarkan analisis USG prioritas utama penyebab ketidaklengkapan rekam medis yang harus segera ditindaklanjuti adalah belum optimalnya penerapan sistem RME. Oleh karena itu, diperlukan evaluasi, pengembangan sistem RME secara berkelanjutan untuk meningkatkan kelengkapan rekam medis, dan mendukung pelayanan kesehatan.
Optimalisasi Mutu Pelayanan Rekam Medis melalui Edukasi, Pelatihan, Pendampingan, dan Implementasi Sistem Informasi Manajemen Klinik bagi Petugas PMB Jurusan Kebidanan Poltekkes Kemenkes Yogyakarta : Optimizing Medical Record Service Quality through Education, Training, Mentoring, and Implementation of a Clinic Management Information System for Staff at the Independent Midwifery Practice (PMB), Department of Midwifery, Poltekkes Kemenkes Yogyakarta Arif Nugroho Triutomo; Nita Budiyanti; Hari Wibowo; Syarah Mazaya Fitriana
Jurnal Kesehatan Pengabdian Masyarakat (JKPM) Vol. 6 No. 2 (2025): 2
Publisher : Poltekkes Kemenkes Yogyakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.29238/jkpm.v6i2.3444

Abstract

Quality medical record services are an important component in supporting the efficiency and quality of healthcare delivery. A preliminary assessment at the Independent Midwifery Practice (PMB), Department of Midwifery, Poltekkes Kemenkes Yogyakarta, identified several problems, including the continued use of manual medical record documentation, suboptimal utilization of computers, relatively long registration service times, and limited storage capacity for medical record documents. This community service program aimed to improve staff knowledge and competency regarding Electronic Medical Records (EMR) through education, training, mentoring, and implementation of a Clinic Management Information System (SiKlik), while improving the quality of registration services. The program was conducted from March to October 2024 using a blended approach and involved 12 staff members at the Independent Midwifery Practice (PMB), Department of Midwifery, Poltekkes Kemenkes Yogyakarta. The activities included EMR education, demonstration and hands-on practice in using SiKlik, mentoring during system implementation in the registration process, and evaluation using pretest and posttest assessments. Service quality was evaluated through a satisfaction survey involving 30 patients who had received services before and after EMR implementation. The results showed that the mean staff knowledge score increased by 24 points, from 65 at pretest to 89 at posttest. All participants (100%) were able to operate the basic functions of SiKlik, and system utilization in daily services reached 100%. The implementation of SiKlik also improved registration service efficiency, with the mean service time decreasing from 35 minutes to 15 minutes. All patients (100%) reported that the service was faster, and overall patient satisfaction reached 100%. The education, training, mentoring, and implementation of SiKlik demonstrated positive outcomes in improving staff competency, service efficiency, and patient satisfaction. The implementation of a Clinic Management Information System can support the transition from manual to electronic medical records and contribute to improving the quality of services at the Independent Midwifery Practice (PMB), Department of Midwifery, Poltekkes Kemenkes Yogyakarta.
Co-Authors Abdul Hadi Kadarusno Anton Kristijono Arif Nugroho Triutomo Hari Wibowo Nita Budiyanti Zanu Nury Latifah