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All Journal Kesmas Indonesia: Jurnal Ilmiah Kesehatan Masyarakat Journal of Public Health Research and Community Health Development (JPH RECODE) Jurnal Aisyah : Jurnal Ilmu Kesehatan Jurnal Kesehatan Tambusai J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan BIOS : Jurnal Teknologi Informasi dan Rekayasa Komputer International Journal of Health and Information System (IJHIS) International Journal of Healthcare and Information Technology Jurnal ARSI : Administrasi Rumah Sakit Indonesia SEJAGAT : Jurnal Pengabdian Masyarakat Journal of Medical and Health Science
Nuraini, Novita
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Agriculture, Biological Sciences & Forestry Computer Science & IT Decision Sciences, Operations Research & Management Dentistry Engineering Health Professions Library & Information Science Medicine & Pharmacology Nursing Public Health Social Sciences Veterinary Other

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Improvement Strategy For Outpatient Medical Record Return Delay At Jambesari Public Health Center Bondowoso Nuraini, Novita; Kiromah, Siska Ainul; Wijayanti, Rossalina Adi
International Journal of Healthcare and Information Technology Vol. 3 No. 1 (2025): July
Publisher : P3M Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/ijhitech.v3i1.4951

Abstract

The delay in returning medical records significantly affects the quality of healthcare services. It was found that at Jambesari Health Center, there is a delay in returning outpatient medical records by 80 % due to the absence of Standard Operating Procedures (SOP), lack of tracer usage, and limited information media about service hours. Therefore, the purpose of this study is to develop an improvement strategy for outpatient medical record return delay using the PDCA approach. This type of research uses qualitative. The research informan were 8 informants consisting of 6 main subjects, namely 1 medical records officer, 1 counter clerk, 1 nurse, 1 general practitioner, 1 midwife, 1 dentist and 2 supporting subjects, namely 1 head of community health center and 1 head of administration. Data collection method use interviews, observation, documentation and brainstorming. The planning phase resulted in identifying 3 priority causes from the 7M process elements, namely the absence of specific SOP for returning outpatient medical records, lack of tracer usage and insufficient information for the community regarding operating hours with improvement actions including creating SOPs related to outpatient medical record return, acquiring tracers, and using banners as information media for service hours. The implementation phase lasted for 3 months from March to May 2023, guided by previously established TOR. The checking phase revealed a decrease of record return delay by 17% after improvements, followed by the action phase, which included brainstorming and socializing SOPs every month and optimizing tracer design and medical record training.
An Analysis of the Causes of Delays in the Return of Outpatient Medical Records at Jambesari Public Health Center, Bondowoso Kiromah, Siska Ainul; Nuraini, Novita; Deharja, Atma; Sabran, Sabran
International Journal of Healthcare and Information Technology Vol. 2 No. 1 (2024): July
Publisher : P3M Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/ijhitech.v2i1.6156

Abstract

Timely return of medical records is essential for evaluating the quality of services at Community Health Centers (Puskesmas). In the second quarter of 2022, Puskesmas Jambesari in Bondowoso experienced a significant delay in the return of outpatient medical records. Of the 1,822 expected files, 1,443 (approximately 80%) were returned late, resulting in frequent misfiling due to improper storage. The prolonged absence of these records was a major contributing factor to the issue. This study aims to analyze the underlying causes of delays in returning outpatient medical records at Puskesmas Jambesari by examining the seven elements of the 7M framework: manpower, money, materials, machines, methods, motivation, and media. Employing a qualitative research approach, data were collected through interviews, observations, documentation, and brainstorming sessions. The findings reveal several systemic issues: front desk staff lacked awareness of return deadlines; training for relevant personnel was insufficient; the use of tracers and phone communication was minimal; expedition books were not optimally utilized; no specific Standard Operating Procedure (SOP) existed for record return; motivational incentives were absent; the physical storage space for records was inadequate; and no budget proposal had been prepared to support improvements. Notably, the absence of a clear SOP further exacerbated the problem.
Analysis of Factors Causing Delays in Outpatient Medical Record Returns at Puskesmas Ajung Rahmadanti, Ainun Safira; Swari, Selvia Juwita; Nuraini, Novita; Vestine, Veronika
International Journal of Healthcare and Information Technology Vol. 2 No. 2 (2025): January
Publisher : P3M Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/ijhitech.v2i2.6162

Abstract

The rate of late returns of outpatient medical records at the Ajung Jember Health Center increased from 5.36% in July 2022–April 2023 to 20.07% in January–February 2024. Several factors are believed to contribute to these delays, including inadequate staff qualifications, the absence of rewards and punishments, suboptimal training, and ineffective implementation of standard operating procedures (SOPs). This study analyzes these delay factors using McCormick and Tiffin's performance theory, which considers both individual and situational factors. A qualitative research method was applied, with research subjects including the head of the puskesmas, registration officers, and other medical personnel. Data were collected through interviews, observations, and brainstorming sessions, and analyzed using data collection, data reduction, data presentation, and drawing conclusions. The results indicated that individual factors included the educational background of medical record officers and suboptimal application of punishment. Situational factors included a lack of training, inadequate SOP implementation, and ineffective expedition forms. It is expected that Puskesmas Ajung will conduct socialization with the officers involved in the return process, optimize the application of punishment, provide training related to medical record management (especially for staff involved in the return process), review the SOP, and add a borrowing date column as a monitoring tool.
Analysis of Factors Causing Noncompliance with Medical Record File Destruction Scheduling at Kalabahi Regional Hospital Olidela, Imanuel Nikson; Wijayanti, Rossalina Adi; Nuraini, Novita; Muflihatin, Indah
International Journal of Healthcare and Information Technology Vol. 2 No. 2 (2025): January
Publisher : P3M Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/ijhitech.v2i2.6163

Abstract

Destruction of medical records has not been carried out at Kalabahi Regional Hospital, resulting in the accumulation of medical record files that are not properly placed on storage shelves. This study aims to analyze the factors contributing to the mismatch in the scheduling of record destruction at Kalabahi Regional Hospital, based on the MOA (Motivation, Opportunity, Ability) performance theory. This research employed a qualitative approach, with problem-solving recommendations developed through brainstorming. The subjects in this study included the Head of the Medical Records Installation, the Head of the Medical Records Committee, and three filing officers. Data were collected through in-depth interviews, observation, documentation, and brainstorming sessions. Data validity was ensured using technique triangulation and source triangulation. The results of the study, based on the MOA performance theory, showed: Motivation factors included the absence of praise or reprimands from the head of the medical records installation to staff related to destruction activities. Opportunity factors included the lack of a designated room for destruction activities, insufficient filing shelves, the absence of an SOP for destruction, the absence of a dedicated destruction team, the lack of job descriptions for the destruction team, no budget planning for destruction activities, no preservation list, and no destruction tools. Ability factors included the officers' lack of practical skills and knowledge about destruction activities. Based on these findings, it is recommended to plan and implement training programs, provide praise and reprimands to filing staff regarding destruction activities, provide a designated room for destruction, increase the number of filing shelves, develop an SOP for destruction, establish a dedicated destruction team along with clear job descriptions, and allocate a budget for destruction activities.
Pendampingan Optimalisasi Manajemen Asuhan Gizi Pasien melalui Penerapan Electronic Mecial Record (EMR) dengan QR Code dan Whatsapp Bot di NCC Wijayanti, Rossalina Adi; Dewi, Riskha Dora Candra; Nuraini, Novita
SEJAGAT : Jurnal Pengabdian Masyarakat Vol. 2 No. 2 (2025): October (in Progress)
Publisher : P3M Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/sejagat.v2i2.6343

Abstract

The Nutrition Care Center (NCC) at Politeknik Negeri Jember (Polije) functions as a Teaching Factory (TEFA), providing comprehensive nutritional assessment, diagnostic services, nutritional counseling, and tailored dietary plans for clients. Health services, including nutrition, necessitate accurate medical records encompassing patient identification, examinations, treatments, interventions, and other pertinent information. However, NCC's manual paper-based medical records system faces challenges. It uses age-based instead of date of birth-based record numbering, lacks standardized nutrition assessment, and lacks disease code classification. This manual system is prone to damage, loss, and demands considerable time and storage space. Since its establishment in November 2021, NCC has seen a steady increase in both internal and external clients. Collaborations with educational institutions, offices, and senior citizen groups have further boosted visits. To enhance efficiency, NCC plans to implement Electronic Medical Records (EMR) with QR Codes and WhatsApp Bots. This approach aims to simplify access to clients' medical histories, allergies, and previous therapies, while also streamlining record retrieval. EMR integration is vital in managing the complexity of nutritional services and supports NCC's mission to provide high-quality care. This initiative aligns with the 2022 Health Department's Research Masterplan and the development of TEFA services. It also reflects the growing trend of using technology, including mobile apps and Artificial Intelligence, in healthcare services. In summary, the increasing number of clients and collaborative screenings with external institutions have led to complex medical records. NCC recognizes the need for a more efficient system and proposes implementation of EMR with QR Codes and WhatsApp Bots to optimize patient care. The project's outcomes will include publications, videos, and improved partner capabilities in EMR usage for patient nutrition care at NCC.
Faktor Risiko Leiomyoma Uterus di Rumah Sakit Umum Pusat Dr. Kariadi Semarang Prasetyo, Adi; Nuraini, Novita; Rachmawati, Ervina; Vestine, Veronika
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 6 No 4 (2025): September
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v6i4.6009

Abstract

Uterine leiomyoma is a benign tumor originating from the smooth muscle and fibrous tissue of the uterus, with a global prevalence of 60–75% among women of reproductive age. In 2023, 978 cases of uterine leiomyoma were recorded at Dr. Kariadi General Hospital, Semarang. The incidence of uterine leiomyoma has shown a continuous increase in morbidity and mortality rates over the years. This study aims to analyze the association between risk factors—age, obesity, parity, hormonal contraceptive use, and family history—and the occurrence of uterine leiomyoma. A case-control design was employed using secondary data, involving 70 cases and 70 controls selected through simple random sampling. Data analysis was conducted using univariate and bivariate methods with the chi-square test. The results revealed significant associations between uterine leiomyoma and age (p=0.029; OR=6.048), obesity (p=0.001; OR=3.579), and parity (p=0.037; OR=0.448). In contrast, hormonal contraceptive use (p=0.426) and family history (p=1.000) showed no association. It can be concluded that women aged 20–50 years, those with obesity, and multiparous or grand multiparous women are at higher risk of developing uterine leiomyoma. Strengthening health education and early detection among at-risk groups is recommended through health promotion, healthy dietary practices, and regular physical activity.
ANALISIS KETIDAKLAKSANAAN PENGKODINGAN TINDAKAN MEDIS DI RSUD HAJI JAWA TIMUR Sabran, Sabran; Anelia, Zaifatul; Nuraini, Novita
Jurnal Kesehatan Tambusai Vol. 5 No. 1 (2024): MARET 2024
Publisher : Universitas Pahlawan Tuanku Tambusai

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31004/jkt.v5i1.25886

Abstract

Berdasarkan studi pendahuluan di RSUD Haji Provinsi Jawa Timur yang dilakukan pada tanggal 2 sampai 4 Oktober 2023 ditemukan data yang menunjukkan kejadian belum terlaksananya pengkodingan tindakan medis pasien RJ pada RME (aplikasi H3IS). Hal tersebut mengakibatkan data untuk pelaporan tindakan medis yang ada di menu Laporan Sentral hanya berisi daftar kode tindakan pasien RI saja. Selain itu, mutu RME menjadi kurang. Tujuan penelitian untuk menganalisis faktor penyebab belum terlaksananya pengkodingan tindakan medis pasien RJ pada RME di RSUD Haji Provinsi Jawa Timur. Penelitian kualitatif dengan analisis deskriptif. Subjek penelitiannya terdiri dari 10 informan. Objek penelitiannya berupa entry data tindakan medis pasien RJ pada RME. Teknik pengumpulan data menggunakan observasi, wawancara dan studi dokumentasi. Faktor penyebab belum terlaksananya pengkodingan tindakan medis pasien RJ pada RME berdasarkan predisposing factors yaitu kurangnya pengetahuan coder mengenai pengkodingan tindakan medis. Enabling factors yaitu belum adanya kolom tindakan pada fitur SOAP di aplikasi H3IS mengakibatkan coder merasa rancu dan bingung, belum tersedianya ICD-9CM versi terbaru, serta belum adanya pelatihan pengkodingan tindakan medis yang mengakibatkan pengetahuan coder menjadi kurang updated. Sedangkan untuk variabel reinforcing factors yaitu belum adanya reward dan bentuk punishment yang kurang tegas kepada coder serta belum adanya SPO pengkodingan diagnosis dan tindakan medis pasien RJ pada aplikasi H3IS mengakibatkan coder merasa tidak wajib melaksanakan pengkodingan tindakan medis. Dapat disimpulkan kurangnya pengetahuan, tidak tersedianya kolom tindakan medis, ICD-9CM versi terbaru, pelatihan koding, SPO serta kurang tegasnya bentuk punishment menjadi penyebab belum terlaksananya pengkodingan tindakan medis pada RME.
Co-Authors Adi Prasetyo Alfiansyah, Gamasiano Anelia, Zaifatul Atika Mima Amalin Damayani, Desnia Sindi Deharja, Atma Dewi, Riskha Dora Candra Farlida, Sustin Febriyanti, Bella Amalia Kiromah, Siska Ainul Maemunah Maemunah maya weka santi, maya weka Muflihatin, Indah Nurwijayanti Olidela, Imanuel Nikson Putri, Fitriana Rachmawati, Ervina Rahagiyanto, Angga Rahmadanti, Ainun Safira Sustin Farlinda, Sustin Swari, Selvia Juwita Vestine, Veronika Wijayanti, Rossalina Wijayanti, Rossalina Adi Wulandari, Savira Puteri Zatin, Widian Almas