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All Journal Jurnal Manajemen Informasi Kesehatan Indonesia (JMIKI) Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Jurnal Ilmiah Pengabdian Kepada Masyarakat Jurnal Siti Rufaidah Jurnal Kesehatan, Rekam Medis dan Farmasi (JUK-Medifa) COVID-19 : Journal of Health, Medical Records and Pharmacy
Ritonga, Zulham Andi
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Chemistry Computer Science & IT Economics, Econometrics & Finance Health Professions Immunology & microbiology Medicine & Pharmacology Nursing Public Health

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PENYULUHAN PENGISIAN INFORMASI KLINIS REKAM MEDIS BERDASARKAN AKREDITASI PUSKESMAS EDISI 2 VERSI 2019 SUB STANDAR 3.8.3 DI PUSKESMAS GLUGUR DARAT KOTA MEDAN Valentina, Valentina; Simanjuntak, Esraida; Lubis, Siti Permata Sari; Ritonga, Zulham Andi; Hasibuan, Ali Sabela
Jurnal Ilmiah Pengabdian Kepada Masyarakat (Ji-SOMBA) Vol. 3 No. 1 (2023): Jurnal Ilmiah Pengabdian Kepada Masyarakat (Ji-SOMBA)
Publisher : Universitas Imelda Medan

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/ji-somba.v3i1.1528

Abstract

Penilaian akreditasi menjadi hal yang sangat penting untuk pembinaan peningkatan mutu dan kinerja melalui perbaikan yang berkesinambungan di puskesmas. Kegiatan pengabdian kepada masyarakat dilaksanakan di Puskemas Glugur Darat bertujuan memberikan penyuluhan tentang pengisian informasi klinis rekam medis berdasarkan Akreditasi Puskesmas sub standar 3.8.3. Metode yang digunakan dalam pengabdian kepada masyarakat ini adalah dengan memberikan penyuluhan secara langsung, demonstrasi dan pendampingan dalam pelaksanaan proses pengisian informasi klinis rekam medis untuk menurunkan ketidaklengkapan pengisian rekam medis di puskemas. Hasil dari kegiatan pengabdian kepada masyarakat ini adalah meningkatnya pengetahuan, keterampilan dan komitmen bersama petugas untuk mengisi informasi klinis secara lengkap dan jelas di dalam rekam medis sesuai sub Standar 3.8.3 Akreditasi Puskesmas, ditetapkannya petugas analisa, serta penambahan ketentuan pengkoreksian dan penambahan data rekam medis pada SOP. Kegiatan ini berhasil dilaksanakan atas dukungan dan kerja sama yang baik dari semua pihak baik tim pelaksana, mahasiswa, petugas dan Kepala Puskesmas Glugur Darat serta Dinas Kesehatan Kota Medan.
Tinjauan Kelengkapan Pengisian Formulir Persetujuan Tindakan Kedokteran Pasien Bedah Rawat Inap Di Rumah Sakit Tere Margareth Tahun 2022 Sabela Hasibuan, Ali; Ritonga, Zulham Andi; Simanjuntak, Marta; Nababan, Edward Ramos
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Vol. 8 No. 2 (2023): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Agustus
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v8i2.1357

Abstract

Completeness of filling in the informed consent form is very important because it can affect the quality of medical records and the legal aspects contained in the medical records themselves. This type of research is descriptive with an observational approach, namely research that describes the current situation. The study population was the medical record document of the informed consent form of inpatients with the sample in this study being a portion of the total population. An overview of the completeness of filling out informed consent sheets in surgical cases at Tere Margareth General Hospital can be seen from the sample count with a total population of (235) divided by 1+235 (precision level/10%=0.1) which results in a sample of 70. Completeness of filling in the identification of providing information is 97% filled and 3% not filled. Completeness of filling in important report items is 92% filled and 8% not filled. Completeness of filling in medical action items is 98% filled and 2% not filled. Completeness of filling in authentication items is 87% filled and 3% not filled. The medical record unit is trying to be able to ask the nurse in charge to fill out the informed consent form so that it can fill it out completely.
Hubungan Mutu Pelayanan BPJS Kesehatan Dengan Kepuasan Pasien BPJS di Instalasi Rawat Inap Kelas III di RSU Imelda Pekerja Indonesia Medan Tahun 2023 Siregar, Miftahurrizky; Ritonga, Zulham Andi; Valentina
Jurnal Manajemen Informasi Kesehatan Indonesia (JMIKI) Vol 12 No 2 (2024)
Publisher : Asosiasi Perguruan Tinggi Rekam Medis dan Informasi Kesehatan Indonesia- APTIRMIKI

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33560/jmiki.v12i2.643

Abstract

Mutu pelayanan kesehatan merupakan kesempurnaan pelayanan yang sesuai dengan standar profesi dan standar pelayanan kesehatan, hal ini bertujuan untuk meningkatkan kepuasan pasien yang datang berobat. Tujuan penelitian ini adalah untuk mengetahui hubungan mutu pelayanan BPJS kesehatan dengan kepuasan pasien BPJS di Instalasi Rawat Inap kelas III di RSU Imelda Pekerja Indonesia Medan Tahun 2023. Metode penelitian ini menggunakan metode kuantitatif jenis analitik korelasi dengan pendekatan Cross sectional. Populasi dalam penelitian ini adalah pasien peserta BPJS Kesehatan rawat inap kelas III di RSU Imelda Pekerja Indonesia Medan sebanyak 4.325 orang. Berdasarkan hasil perhitungan sampel menggunakan rumus slovin, sampel yang akan diteliti sebanyak 98 responden. Teknik pengambilan sampel penelitian ini menggunakan teknik probability sampling dengan jenis simple random sampling. Instrumen penelitian menggunakan kuesioner yang dibuat oleh peneliti berdasarkan teori Tjiptono (2017). Data dianalisis dengan analisis univariat dan analisis bivariat menggunakan uji statistik chi-square. Hasil penelitian diperoleh kehandalan (p-value= 0,01), jaminan (p-value = 0,00), bukti fisik (p-value = 0,00), empati (p-value = 0,04), daya tanggap (p-value =0,02). Dapat disimpulkan bahwa ada hubungan mutu pelayanan BPJS Kesehatan dengan kepuasan pasien BPJS di Instalasi Rawat Inap Kelas III di RSU Imelda Pekerja Indonesia Medan Tahun 2023. Mutu pelayanan kesehatan merupakan kesempurnaan pelayanan yang sesuai dengan standar profesi dan standar pelayanan kesehatan, hal ini bertujuan untuk meningkatkan kepuasan pasien yang datang berobat. Tujuan penelitian ini adalah untuk mengetahui hubungan mutu pelayanan BPJS kesehatan dengan kepuasan pasien BPJS di Instalasi Rawat Inap kelas III di RSU Imelda Pekerja Indonesia Medan Tahun 2023. Metode penelitian ini menggunakan metode kuantitatif jenis analitik korelasi dengan pendekatan Cross sectional. Populasi dalam penelitian ini adalah pasien peserta BPJS Kesehatan rawat inap kelas III di RSU Imelda Pekerja Indonesia Medan sebanyak 4.325 orang. Berdasarkan hasil perhitungan sampel menggunakan rumus slovin, sampel yang akan diteliti sebanyak 98 responden. Teknik pengambilan sampel penelitian ini menggunakan teknik probability sampling dengan jenis simple random sampling. Instrumen penelitian menggunakan kuesioner yang dibuat oleh peneliti berdasarkan teori Tjiptono (2017). Data dianalisis dengan analisis univariat dan analisis bivariat menggunakan uji statistik chi-square. Hasil penelitian diperoleh kehandalan (p-value= 0,01), jaminan (p-value = 0,00), bukti fisik (p-value = 0,00), empati (p-value = 0,04), daya tanggap (p-value =0,02). Dapat disimpulkan bahwa ada hubungan mutu pelayanan BPJS Kesehatan dengan kepuasan pasien BPJS di Instalasi Rawat Inap Kelas III di RSU Imelda Pekerja Indonesia Medan Tahun 2023.
Quantitative Analysis Of Medical Records In Typhoid Patients At Madani General Hospital Medan Ritonga, Zulham Andi; Hasibuan, Ali Sabela; Siringoringo, Monika Belawanti
Jurnal Kesehatan, Rekam Medis dan Farmasi (JUK-Medifa) Vol. 2 No. 01 (2023): JUK-Medifa (Jurnal Kesehatan, Rekam Medis dan Farmasi), November 2023
Publisher : SEAN Institute

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.58471/juk-medifa.v2i01.523

Abstract

Completeness of filling out medical records in hospitals is a requirement for quality medical records and can be done with quantitative analysis. The purpose of the study was to determine the quantitative analysis of medical records in Typhoid patients at Madani General Hospital. This study used descriptive research with a quantitative approach. The study was conducted at Madani General Hospital Medan. The study population was 1,237 and samples were obtained as many as 92 medical records. The results of the study reviewed item identification of patient names 88 medical records (96%) complete, medical record numbers 88 medical records (96%) complete, date of birth 85 medical records (92%) complete and gender 82 medical records (89%) complete. Review of important reporting on integrated initial review items 83 medical records (90%) complete, general consent 78 medical records (85%) complete, admission & exit summary 84 medical records (91%) complete, integrated patient progress records 86 medical records (93%) complete, medical resume 80 medical records (87%) complete and patient discharge plan 81 medical records (88%) complete. Review of auntetification on doctor name items 50 medical records (54%) complete, doctor's signature 55 medical records (60%) complete, nurse name 58 medical records (63%) complete, nurse signature 64 medical records (70%) complete, and professional degree 50 medical records (54%) complete. Review of correct documentation on items clearly reads 88 medical records (96%) complete, abbreviation use 89 medical records (97%) complete, error correction 64 medical records (70%) complete and blanks 85 medical records (92%) complete. It is recommended that the Madani Medan General Hospital re-socialize and provide training related to filling out medical records.
The Relationship Between BPJS Health Service Quality And BPJS Patient Satisfaction In Class III Inpatient Installations At Rsu Imelda Indonesian Workers Medan In 2023 Ritonga, Zulham Andi; Siregar, Miftahurrizky
COVID-19 : Journal of Health, Medical Records and Pharmacy Vol. 1 No. 02 (2024): COVID-19 : Journal of Health, Medical Records and Pharmacy
Publisher : CV. Devitara

Show Abstract | Download Original | Original Source | Check in Google Scholar

Abstract

Quality of health services is the perfection of services in accordance with professional standards and health service standards, this aims to increase the satisfaction of patients who come for treatment. The aim of this research is to determine the relationship between the quality of BPJS health services and the satisfaction of BPJS patients in class III inpatient installations at the RSU Imelda Pekerja Indonesia Medan in 2023. This research method uses a quantitative correlation analytical type method with a cross sectional approach. The population in this study was 4,325 class III BPJS Health inpatient participants at RSU Imelda Pekerja Indonesia Medan. Based on the results of sample calculations using the Slovin formula, the sample to be studied was 98 respondents. The sampling technique in this research uses a probability sampling technique with a simple random sampling type. The research instrument uses a questionnaire created by researchers based on Tjiptono's (2017) theory. Data were analyzed using univariate analysis and bivariate analysis using the chi-square statistical test. The results of this study show the quality of BPJS health services with the satisfaction of BPJS patients in class III inpatient installations at RSU Imelda Pekerja Indonesia. The results obtained are reliability (p-value= 0.01), guarantee (p-value = 0.00), evidence physical (p-value = 0.00), empathy (p-value = 0.04), responsiveness (p-value = 0.02). It can be concluded that there is a relationship between the quality of BPJS Health services and the satisfaction of BPJS patients in the Class III Inpatient Installation at the RSU Imelda Pekerja Indonesia Medan in 2023. It is hoped that the results of this research can be input for the Imelda Workers Indonesia RSU to improve the quality of service, especially in the Inpatient Installation. One of the class III stays is improving facilities at the RSU Imelda Pekerja Indonesia Medan.
Factors for Completeness of Filling Informed Consent Form for Inpatient at Mitra Sejati Medan General Hospital in 2023 Hasibuan, Ali Sabela; Ritonga, Zulham Andi; Pakpahan, Naziah
COVID-19 : Journal of Health, Medical Records and Pharmacy Vol. 1 No. 02 (2024): COVID-19 : Journal of Health, Medical Records and Pharmacy
Publisher : CV. Devitara

Show Abstract | Download Original | Original Source | Check in Google Scholar

Abstract

The completeness of filling out the informed consent form is very important because it can affect the quality of medical records and legal aspects in the medical records themselves. This study aims to determine the factors that affect the completeness of the inpatient surgical patient's informed consent form at Mitra Sejati Medan General Hospital in 2023. The research method used is descriptive quantitative, which is to describe a situation objectively. The population of this study was an informed consent form for inpatient surgical cases (235) divided by 1+235 (precision rate/10%=0.1) resulting in a sample of 70. The sample of subjects in this study was 13 officers and for the object in this study 70 documents informed consent hospitalization. The type of data in this study is primary data obtained by distributing questionnaires and using checklist sheet observations. The results of the study were 71% complete, and 29% incomplete. The influencing factors are the officer's knowledge in the completeness of filling out the inpatient informed consent form illustrates that there are 7 people who show good knowledge, and there are 6 people who show poor knowledge.
Overview Of the Completeness of Filling Out Important Reports On The Internal Transfer Form Based On Accreditation Standards At Imelda Pekerja Indonesia General Hospital Ritonga, Zulham Andi; Ziliwu, Martha Riang Cahyani
COVID-19 : Journal of Health, Medical Records and Pharmacy Vol. 2 No. 01 (2024): COVID-19 : Journal of Health, Medical Records and Pharmacy
Publisher : CV. Devitara

Show Abstract | Download Original | Original Source | Check in Google Scholar

Abstract

Internal Transfer Form aims to source important information data when transferring patients from a service unit or room to another room. Incomplete information input can cause communication errors between health workers in providing services to patients. This study used a quantitative method where researchers looked at the completeness of filling out the internal transfer form at the Imelda Pekerja Indonesia Medan General Hospital and how it conformed to Hospital Accreditation Standard No.1128, Year 2022 with a sample of 99 forms. This study starts from April to September 2023. The sampling technique used is probabiity sampling by means of simple random sampling using a check-list sheet instrument. The lowest percentage of form filling incompleteness was found in the "Procedures Performed" component, as many as 7 forms with a percentage (7.1%) of 99 forms, followed by the component "Reasons for Admission and Other Care Patients Have Received", as many as 5 forms (5.1%), the "Significant Findings" component as many as 2 forms (2%), and the "Medicines" component as many as 1 form (1%). The completeness of filling out forms with the highest percentage was found in the component "Diagnosis and Condition of Patients at Transfer", as many as 99 forms with a percentage (100%). Of the 99 samples of internal transfer forms at Imelda Medan Hospital, 18 forms were found to be incomplete with a percentage (18.2%) and 81 forms that were filled out completely (81.8%).
The Implementation of Hospital Service Data Reporting (RL 3.1) in SIRS Online is Reviewed from Facilities and Infrastructure at RSIA Artha Mahinrus Medan in 2024 Nainggolan, Ade Sherevina; Valentina, Valentina; Ritonga, Zulham Andi
COVID-19 : Journal of Health, Medical Records and Pharmacy Vol. 2 No. 01 (2024): COVID-19 : Journal of Health, Medical Records and Pharmacy
Publisher : CV. Devitara

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Abstract

Hospital reporting is an organizational tool that aims to produce fast, precise, and accurate reports. This study aims to identify the factors that hinder the reporting of hospital service data (RL 3.1) at RSIA Artha Mahinrus Medan, as well as evaluate the impact of the condition of facilities and infrastructure on the effectiveness of the reporting process using the online SIRS application, by considering three indicators of infrastructure: completeness, condition, and use. The approach used is qualitative descriptive, with data collection through interviews and observations of research subjects including the head of medical records, registration officers, poly officers/nurses, and IT officers. The instruments used are interview guidelines and observation sheets. The results of the study show that the reporting of hospital service data (RL 3.1) in the online SIRS at RSIA Artha Mahinrus Medan experienced obstacles, such as the lack of number of computers in the medical record unit, computer system failures, and limited internet connections, which caused slow networking. Based on the results of the study, delays in making reports can be caused by problems with existing facilities and infrastructure. Therefore, the researcher suggests that the reporting of hospital service data (RL 3.1) be carried out outside of the collection time to prevent additional delays.
The Description of Work Stress Among Medical Record Officers in the Coding Section at Haji General Hospital Medan in 2024 Faadyah, Siti; Ritonga, Zulham Andi; Karo Karo, Siddik; Hulu, Delisman
COVID-19 : Journal of Health, Medical Records and Pharmacy Vol. 2 No. 02 (2025): COVID-19 : Journal of Health, Medical Records and Pharmacy
Publisher : CV. Devitara

Show Abstract | Download Original | Original Source | Check in Google Scholar

Abstract

Stress is the result of an imbalance between demands and the resources an individual possesses—the greater the gap, the higher the level of stress experienced, which can pose a threat to well-being. The aim of this study was to describe the work stress experienced by medical record officers in the coding section at Haji General Hospital Medan in 2024. This study employed a qualitative research method. The informants included four individuals: one outpatient coding officer, two inpatient coding officers, and one head of the medical record installation. The findings revealed that the causes of work stress among coding officers included workload, work-related conflicts, inadequate work equipment, and poor working environment. It is recommended that the hospital provide adequate workspace and facilities that ensure comfort for the officers. Additionally, coding officers should pay more attention to task distribution and provide education to other healthcare workers to ensure timely delivery of medical record files for coding. Officers must also maintain effective communication with other healthcare personnel to prevent conflicts and misunderstandings.
Pengisian Identitas Profesional Pemberi Asuhan pada Berkas Rekam Medis Berdasarkan Standar Akreditasi di Rumah Sakit Umum Haji Medan Tia Mufida Muthmainnah Siregar; Ritonga, Zulham Andi; Karo, Siddik Karo
Jurnal Siti Rufaidah Vol. 3 No. 4 (2025): :Jurnal Siti Rufaidah
Publisher : PPNI UNIMMAN

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.57214/jasira.v3i4.255

Abstract

Accreditation is the recognition of the quality of hospital services after an assessment has been conducted to determine whether the hospital has met accreditation standards approved by the government. Every note in the medical record must clearly identify the professional care provider (PPA), including the full name and signature, as well as the date and time of writing. The purpose of this study was to determine how the PPA's identity is filled in in medical records based on accreditation standards at Haji General Hospital, Medan. The research method used was qualitative research, with data collection techniques using in-depth interviews and observation. Six informants participated, including doctors, nurses, and medical records officers. The results showed that despite the existence of Standard Operating Procedures (SOPs) for filling in the PPA's identity, incomplete medical records were still found, such as only including a signature without a clear name and an omitted date and time. Incomplete files were returned to the relevant unit for correction. The main obstacle faced was the PPA's limited working time to complete the medical record files. In conclusion, the PPA's identity is not fully compliant with existing SOPs. Therefore, regular monitoring and evaluation, along with training for all PPAs, are needed to ensure optimal completeness of medical record documentation.
Co-Authors Faadyah, Siti Hulu, Delisman Karo, Siddik Karo Lubis, Siti Permata Sari Nababan, Edward Ramos Nainggolan, Ade Sherevina Pakpahan, Naziah Sabela Hasibuan, Ali Siddik Karo-Karo Simanjuntak, Esraida Simanjuntak, Marta Siregar, Miftahurrizky Siringoringo, Monika Belawanti Tia Mufida Muthmainnah Siregar Valentina Valentina Valentina, Valentina Ziliwu, Martha Riang Cahyani