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Analisa Terjadinya Duplikasi Nomor Rekam Medis Pada Pasien Rawat Inap Di RSU Madani Medan Tahun 2020 Yudica Rosalina; Peberiwati Br Kabar
Journal of Innovative and Creativity (Joecy) Vol. 5 No. 3 (2025)
Publisher : Fakultas Ilmu Pendidikan Universitas Pahlawan Tuanku Tambusai

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Duplication of medical record numbers is the existence of medical record numbers such as one medical record number owned by two patients and one patient has two medical record numbers. The impact of duplication of medical record numbers is that the contents of the medical record are not continuous, the medical record shelves will be full quickly, patients who have received new medical record numbers again if they are not known as duplicate numbers. The purpose of the study was to provide an overview of the implementation of medical record management and to find out about the occurrence of duplication of medical record numbers at RSU Madani Medan. This study is a descriptive study, namely describing data as a result of research. The method used in this study is the observation and interview method. Based on the results of the study on the double numbering of medical record files, it states that the medical record number is duplicated as many as 29 medical record numbers (29%) and the medical record number that is not duplicated is 71 medical record numbers (71%). The consequences of duplication of medical colleague numbering are: Services are hampered due to the length of time in searching for medical record files., Discontinuity of the contents of the patient's medical record. Information on the patient's medical history, examination results and treatment are not integrated, examinations and treatments are not maintained because they are not stored in one file. So it can be concluded that the numbering of medical record files will be achieved well if the officers really pay attention to their performance, are careful in working, and work professionally according to applicable procedures. The numbering used should use an online system, so as not to cause errors in the numbering of medical record files.

Analisa Kelengkapan Berkas Rekam Medis Pada Bagian Koding Penyakit Di Puskesmas Tuntungan Pancur Batu Yudica Rosalina; Eni Siswanti
Journal of Innovative and Creativity (Joecy) Vol. 5 No. 3 (2025)
Publisher : Fakultas Ilmu Pendidikan Universitas Pahlawan Tuanku Tambusai

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Medical records can support improving the quality of health services and providing fast and accurate information, one of these methods and efforts is by implementing disease codes in medical record documents. The assignment of disease codes to medical record documents is guided by the International Classification of Diseases (ICD This type of research is qualitative research with a case study approach. The population in this study were all health workers at the Tuntungan Pancur Batu Community Health Center. The sample is part of the number and characteristics of the population. The research sample took several officers in the medical records unit at the Pancur Batu Community Health Center as research samples. The technique used in taking samples is the Simple Random Sampling technique which is included in Probability Sampling. In random sampling techniques, the population has the same chance of being sampled. The research subjects were the results of coding in medical record files and primary care applications. Research tools and materials used: stationery, notebook, primary care application on computer, ICD 10/Electronic ICD book, smartphone for documentation. The primary data collection method is to use interview techniques, observation, while the secondary data is obtained from reports, notes and analysis of medical record documents. Data processing techniques using observation. Based on the results of the research, there is not much difference between the disease codes given by the officers giving disease codes at the Tuntungan Pancur Batu Community Health Center and the codes contained in ICD 10. However, according to the author, the method of assigning codes at the Community Health Center is very prone to errors because it is not in accordance with WHO.

Analisis Kebutuhan Sumber Daya Manusia Di Tempat Pendaftaran Pasien Rawat Jalan Rumah Sakit Universitas Sumatera Utara Yudica Rosalina; Eni Siswanti
Journal of Innovative and Creativity (Joecy) Vol. 5 No. 3 (2025)
Publisher : Fakultas Ilmu Pendidikan Universitas Pahlawan Tuanku Tambusai

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Workload analysis is an effort to calculate the workload on a work unit by adding up all workloads and then dividing it by the individual work capacity per unit of time. The type of research used in this study is descriptive with a qualitative approach, the descriptive research method is a research method that aims to provide an objective picture of a situation. In this study, the researcher conducted a descriptive study of the process in the outpatient registration section of the University of North Sumatra Hospital. Qualitative research methods are research methods used to research natural object conditions where the researcher is the key instrument, data collection techniques are carried out triangulation (combination), data analysis is inductive, and the results of the study emphasize meaning rather than generalization. Qualitative research obtains data based on field conditions experienced by participants/data sources. The research design used in this study is phenomenology. With a phenomenological design, researchers try to find out the meaning of an event for people who experience or are in that situation. The subject of the study is an object, thing, or person who has information to be used as a research variable. Based on the results above, it can be seen that the obstacle from the method factor is that the existing SOP still does not cover all the service procedures for the method factor in registration. The number of outpatient registration officers available at the University of North Sumatra Hospital is 4 core outpatient registration officers. Based on the results of the registration officer estimates above, the appropriate number of registration officers is 6 people, so an additional 2 more people are needed

Perancangan Sistem Informasi Rekam Medis Di Rumah Sakit Pita Insani Siantar Yudica Rosalina; Kesawa Sundarsih
Journal of Innovative and Creativity (Joecy) Vol. 6 No. 2 (2026)
Publisher : Fakultas Ilmu Pendidikan Universitas Pahlawan Tuanku Tambusai

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The patient medical record information system at Vita Isani Siantar Hospital is a system that aims to manage patient data that registers for treatment until the patient leaves the hospital within a certain period of time. In this case, the information system is very important to be designed to prevent errors in the implementation of registration procedures and data processing so that it can be used optimally. The design of the patient medical record information system aims to create a patient medical record information system at Vita Insani Siantar Hospital using computer programs, namely PHP and MySQL in order to facilitate the registration process and create a recapitulation of patient visit reports. In designing the patient medical record information system at Vita Insani Siantar Hospital, the System Development Life Cycle method is used, which consists of system planning, system analysis, conceptual system design, system selection evaluation, functional system design, and system implementation. The design of this system produces a patient recording application until the patient leaves the hospital consisting of three forms, namely a recapitulation report of inpatient and outpatient visits every month and a recapitulation report of the highest annual patient visits. The design of a patient medical record information system at Vita Insani Siantar Hospital is expected to facilitate the process of recording patients and making reports at the hospital so that the hospital can produce accurate data.

Prosedur Pelaksanaan Pengisian Dan Pengolahan Data Sensus Harian Rawat Inap Hingga Menjadi Sumber Data Di RSUD dr. R.M. Djoelham Binjai Yudica Rosalina; Gatot Santosa
Journal of Innovative and Creativity (Joecy) Vol. 5 No. 3 (2025)
Publisher : Fakultas Ilmu Pendidikan Universitas Pahlawan Tuanku Tambusai

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Health service facilities according to the Regulation of the Minister of Health of the Republic of Indonesia Number 269 / MENKES / PER / II1 / 2008 are places for organizing health service efforts that can be used for medical or dental practice. Hospitals are one example of health service facilities. Descriptive research is research that is intended to investigate conditions, conditions or things that have been mentioned, the results of which are presented in the form of research reports. The research design used in this study is a cohort survey study. The location of the research will be carried out at Dr. R.M DJOELHAM BINJAI Regional Hospital located on Jl. Sultan Hasanuddin No. 9, This research began in June - July 2019. Population is a group of subjects who are the objects or targets of research, who have certain characteristics and are determined by researchers to be able to draw conclusions. Based on the definition above, the population of this study is the inpatient nurses who carry out the implementation of the daily inpatient census filling and the process of processing the daily inpatient census in medical records. The sample in this study is the population or total population recorded in the implementation of filling and processing the daily inpatient census data. The subjects used in this study were 1 medical records officer and 7 nurses. The data collection technique that will be used in this study using qualitative research, the primary data source is interviewing medical records officers and inpatient nurses and the secondary data source in this study is the daily inpatient census form from each inpatient room. The data collection technique also uses more interview lists, observations and documentation studies

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