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All Journal Jurnal Manajemen Informasi dan Administrasi Kesehatan Health Sciences and Pharmacy Journal Jurnal Bahana Kesehatan Masyarakat (Bahana of Journal Public Health) Bali Medika Jurnal Indonesian Journal of Global Health research Basic and Applied Nursing Research Journal JURNAL KESEHATAN SAMODRA ILMU Jurnal Akademika Baiturrahim Jambi
Adiputra, I Made Sudarma
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Computer Science & IT Dentistry Education Environmental Science Health Professions Languange, Linguistic, Communication & Media Medicine & Pharmacology Nursing Public Health

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Analisis Kelengkapan Pengisian Identitas Pasien Pada Formulir Lembar Masuk Dan Keluar Pasien Rawat Inap Rumah Sakit Wangaya Nuralim, Ristu Airul; Purwanti, Ika Setya; Adiputra, I Made Sudarma
Jurnal Bahana Kesehatan Masyarakat (Bahana of Journal Public Health) Vol 9 No 1 (2025): Jurnal Bahana Kesehatan Masyarakat (Bahana of Journal Public Health)
Publisher : Poltekkes Kemenkes Jambi

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.35910/jbkm.v9i1.804

Abstract

Background: Incompleteness in filling out medical record files will result in the records contained being out of sync and the patient's previous health information being difficult to identify. This study aims to determine the completeness of filling in the patient's identity on the inpatient admission and discharge form. Method: The research method used is quantitative descriptive. The sample used was 237 medical records of inpatients in October taken by simple random sampling. Results: The research results showed that 152 sheets of the entry and exit summary forms were complete (64.14%) and 85 sheets of the entry and exit summary forms were incomplete (35.86%). The reason for the incomplete filling in of the patient's identity on the admission and discharge summary form is because the implementation of standard operational procedures has not been optimal. What the hospital needs to do next is carry out outreach regarding filling in patient identity and immediately implement electronic medical records. Conclusion: There are still incompleteness in filling in the medical resume for the identity of inpatients at Wangaya Hospital.
Tingkat Kelengkapan Rekam Medis di Puskesmas I Denpasar Timur : Pendekatan Kuantitatif Indraswari, Made Ayu Savitri; Adiputra, I Made Sudarma; Faidah, Nurul
Jurnal Akademika Baiturrahim Jambi Vol. 14 No. 2 (2025): September
Publisher : Universitas Baiturrahim

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.36565/jab.v14i2.958

Abstract

Medical records are essential documents that serve as a means of communication among healthcare professionals and form the basis for service planning, evaluation, and legal evidence within the healthcare system. The completeness of medical record documentation is a key indicator in ensuring the quality of healthcare services. This study aims to analyze the completeness level of outpatient medical records at UPTD Puskesmas I, East Denpasar District Health Office. A quantitative descriptive approach was used with random sampling techniques applied to 372 medical record files out of a total population of 5,251. Data collection was conducted using a checklist that assessed four main aspects: patient identification, essential reports, authentication, and proper documentation. The data were analyzed using univariate analysis. The results showed that the average completeness for patient identification was 67.3%, essential reports 95.38%, authentication 50%, and documentation 100%. Overall, the completeness of medical records has not fully met the established standards, particularly in legal and administrative aspects. This incompleteness may lead to serious consequences, such as errors in medical service delivery, weak legal accountability, and reduced quality of healthcare services. Therefore, this study highlights the need to strengthen internal supervision, conduct regular training for healthcare workers on proper medical record documentation, and implement routine evaluations to improve service quality and regulatory compliance
The Role of the Family Companion Team (TPK) in Finding New Cases of Families at Risk of Stunting Oktaviani, Ni Putu Wiwik; Adiputra, I Made Sudarma; Trisnadewi, Ni Wayan
Indonesian Journal of Global Health Research Vol 5 No 4 (2023): Indonesian Journal of Global Health Research
Publisher : GLOBAL HEALTH SCIENCE GROUP

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37287/ijghr.v5i4.2483

Abstract

Increasing human resources is one of Indonesia's efforts to build a golden Indonesia in 2045. Stunting is the current nutritional issue that Indonesia is dealing with. The Indonesian government has created a national strategy to accelerate stunting reduction through families involving health workers known as the Family Companion Team (TPK). According to the results of the evaluation of stunting prevention programs, most local governments have been unable to implement activities to accelerate stunting reduction. This research aims to determine the role of the family companion team in finding new cases of families at risk of stunting. Data collection in this study was carried out using multiple random sampling techniques, distributing questionnaires to 62 TPK in the working area of Puskesmas II Blahbatuh, the inclusion criteria for this study were TPK who had been listed in the Regent's Decree (SK), domiciled in the working area of the puskesmas II Blahbatuh and willing to be a respondent. This research hypothesis test uses Chi square. The results of this study show that there is no significant relationship between the role of TPK in finding new cases of families at risk of stunting and a p value > 0.05. The family approach is a good strategic innovation in providing assistance to families at risk of stunting, but it is not optimal in identifying new findings.
TINJAUAN ANALISIS KUANTITATIF KELENGKAPAN REKAM MEDIS KASUS SECTIO CAESAREA Sanjaya, I Made Manu; Devhy, Ni Luh Putu; Adiputra, I Made Sudarma
Jurnal Manajemen Informasi dan Administrasi Kesehatan Vol. 6 No. 1 (2023): JMIAK
Publisher : Program Studi D3 Rekam Medis dan Informasi Kesehatan

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.32585/jmiak.v6i1.3705

Abstract

Kelengkapan rekam medis memiliki peranan penting di rumah sakit, jika rekam medis tidak lengkap maka informasi yang dihasilkan tidak lengkap juga, sehingga akan mengakibatkan terhambatnya proses klaim asuransi yang diajukan dan terhambatnya proses tertib administrasi. Penelitian ini bertujuan untuk mengetahui kelengkapan pengisian rekam medis pasien rawat inap kasus sectio caesarea di Rumah Sakit Umum Daerah (RSUD) Wangaya Kota Denpasar berdasarkan analisis kuantiatif rekam medis. Metode penelitian yang digunakan yaitu deskriptif dengan jumlah sampel 35 rekam medis menggunakan Simple Random Sampling. Hasil dari penelitian menunjukkan kelengkapan pengisian rekam medis pasien rawat inap kasus sectio caesarea di Rumah Sakit Umum Daerah Wangaya Kota yaitu pada identifikasi diperoleh hasil kelengkapan terendah pada item tanggal lahir/umur sebesar 34 (99,1%). Pada item review pelaporan penting diperoleh persentase kelengkapan terendah terdapat pada item general consent 24 (68,6%) rekam mdis. Pada item autentifikasi diperoleh persentase kelengkapan n terendah pada item tanda tangan dokter 23 (65,7%) rekam medis. Pada item pendokumentasian yang benar diperoleh jumlah terendah kelengkapan pada item pencatatan yang jelas sebesar 25 (71,4%). Dapat disimpulkan bahwa kelengkapan pengisian rekam medis di RSUD Wangaya Kota Denpasar belum mencapai 100%, disarankan untuk melakukan Concurrent Analysis secara berkala untuk menggambarkan kelengkapan rekam medis berdasarkan komponen analisis kuantitatif rekam medis.
Co-Authors Arianta, I Made Dwi Damayanti, Putu Sri Gristiari, Ni Made Piar I Gusti Agung Ngurah Putra Pradnyantara Indraswari, Made Ayu Savitri Komalasari, Ni Luh Putu Ratih Made Wahyu Aditya Arta Mitayanti, Ni Kadek Ni Luh Putu Devhy, Ni Luh Putu Ni Wayan Trisnadewi, Ni Wayan Nuralim, Ristu Airul Nurul Faidah Oktaviani, Ni Putu Wiwik Oktviani, Ni Putu Wiwik Parlin, Gusti Ayu Ketut Utari Pinatih, G. N. Indraguna Pramesti, Theresia Anita Sanjaya, I Made Manu Urmilasari, Ni Putu Yessi Wahyudi, Hendro Widiastuti, Dewa Ayu Putri