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Simanjuntak, Esraida
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PENYULUHAN PENGGUNAAN TRACER DI PUSKESMAS SERING KOTA MEDAN Simanjuntak, Esraida; Valentina
Jurnal Ilmiah Pengabdian Kepada Masyarakat (Ji-SOMBA) Vol. 1 No. 2 (2022): Jurnal Ilmiah Pengabdian Kepada Masyarakat (Ji-SOMBA)
Publisher : Universitas Imelda Medan

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (490.216 KB) | DOI: 10.52943/ji-somba.v1i2.786

Abstract

Puskesmas perlu meningkatkan mutu pelayanan kesehatan melalui pelayanan rekam medis. Kegiatan pengabdian kepada masyarakat ini dilaksanakan di Puskemas Sering yang bertujuan memberikan penyuluhan tentang penggunaan tracer untuk menanggulangi kejadian misfile dan duplikasi rekam medis kepada petugas penyimpanan di puskesmas. Metode yang digunakan dalam pengabdian kepada masyarakat ini adalah dengan memberikan penyuluhan secara langsung, demonstrasi dan pendampingan dalam pengimplemantasian tracer di bagian penyimpanan rekam medis. Hasil dari kegiatan pengabdian kepada masyarakat ini adalah bertambahnya pengetahuan dan keterampilan petugas penyimpanan dalam menggunakan tracer untuk meminimalisir kejadian kehilangan berkas rekam medis (misfile) dan duplikasi penomoran rekam medis. Kegiatan ini berhasil dilaksanakan dengan baik berkat kerja sama yang baik serta dukungan dari semua pihak baik tim pelaksana, mahasiswa, petugas dan Kepala Puskesmas Sering serta Dinas Kesehatan Kota Medan.
RANCANGAN KARTU INDEKS UTAMA PASIEN (KIUP) DI UPT PUSKESMAS SEI AGUL Simanjuntak, Esraida; Simanjuntak, Marta; Valentina, Valentina; Lubis, Siti Permata Sari
Jurnal Ilmiah Pengabdian Kepada Masyarakat (Ji-SOMBA) Vol. 2 No. 2 (2023): Jurnal Ilmiah Pengabdian Kepada Masyarakat (Ji-SOMBA)
Publisher : Universitas Imelda Medan

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (354.47 KB) | DOI: 10.52943/ji-somba.v2i2.1317

Abstract

KIUP bermanfaat untuk mencari nomor rekam medis apabila pasien tidak membawa KIB, memudahkan pencarian nomor rekam medis untuk keperluan retensi DRM, dan sebagai alat bantu penyusutan laporan kunjungan pasien. Kegiatan pengabdian kepada masyarakat ini dilaksanakan di Puskemas Sei Agul yang bertujuan memberikan penyuluhan tentang penggunaan KIUP untuk memudahkan petugas pendaftaran yang sulit untuk mencari rekam medis pasien jika pasien tidak membawa kartu berobat di puskesmas. Metode yang digunakan dalam kegiatan ini adalah dengan memberikan penyuluhan secara langsung, demonstrasi dan pendampingan dalam pengimplemantasian KIUP di bagian pendaftaran rekam medis. Hasil dari kegiatan pengabdian kepada masyarakat ini adalah bertambahnya pengetahuan dan keterampilan petugas penyimpanan dalam menggunakan KIUP untuk memudahkan pencarian rekam medis pada saat pasien datang berobat dan membantu keperluan penyusutan dan retensi. Kegiatan ini dilaksanakan dengan baik berkat dukungan dan kerja sama dari semua pihak baik tim pelaksana, mahasiswa, petugas dan Kepala Puskesmas Sei Agul serta Dinas Kesehatan Kota Medan.
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.
REDESAIN MAP REKAM MEDIS DI UPT PUSKESMAS PEKAN LABUHAN KOTA MEDAN Andi Ritonga, Zulham; Valentina, Valentina; Lubis, Siti Permata Sari; Simanjuntak, Esraida; Karo Karo, Siddik; Hasibuan, Ali Sabela
Jurnal Ilmiah Pengabdian Kepada Masyarakat (Ji-SOMBA) Vol. 3 No. 2 (2024): 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.v3i2.1677

Abstract

Pelayanan kesehatan di puskesmas tidak terlepas dari dukungan data-data pasien yang semuanya itu harus tercatat dengan baik dan benar di dalam rekam medis. Map rekam medis (folder) merupakan sampul yang berfungsi untuk menjaga semua formulir rekam medis pasien yang ada dalam satu file dan terlindungi dari kerusakan secara fisik serta menjaga kerahasiaan data pasien didalamnya. Tujuan dari pengabdian ini yaitu untuk mendesain ulang sampul rekam medis dilihat dari aspek anatomi, fisik dan isi, serta disesuaikan dengan kebutuhan data pasien yang ada di wilayah kerja UPT Puskesmas Pekan Labuhan Medan. Metode pengabdian yang digunakan adalah dengan melakukan kolaborasi dengan petugas penyimpanan rekam medis di puskesmas yang terdiri dari pemberian edukasi tentang desain rekam medis yang baik, konsultasi dan perancangan map rekam medis sesuai kebutuhan di puskesmas, serta melakukan demonstrasi dan pendampingan penerapan map rekam medis di puskesmas. Kegiatan pengabdian ini dilakukan pada bulan Februari 2024 dengan jumlah partisipan sebanyak 10 orang petugas kesehatan di UPT Puskesmas Pekan Labuhan. Kegiatan pengabdian ini dilakukan selama 3 bulan. Adapun hasil dari kegiatan pengabdian ini adalah meningkatnya pengetahuan dan keterampilan petugas dalam mendesain map rekam medis yang baik serta sebuah desain produk map (folder) rekam medis di UPT Puskesmas Pekan Labuhan Medan. Keberhasilan kegiatan pengabdian ini didukung oleh kerja sama yang baik dari tim pengabdian masyarakat, petugas dan kepala UPT Puskesmas Pekan Labuhan Medan serta Dinas Kesehatan Kota Medan.
Tinjauan Pelaksanaan Audit Koding Berkas Pengklaiman Pasien Peserta BPJS Kesehatan di Rumah Sakit Umum Imelda Pekerja Indonesia Tahun 2021 Sitorus, Mei Sryendang; Simanjuntak, Esraida; Gusla, Yeyi; Olviya , Cicha
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.v8i2.1296

Abstract

The coding audit is a review to ensure that the results of the diagnosis and treatment coding produced by the clinical coder are accurate, consistent and timely when compared to the information contained in the patient's medical record. The purpose of this study was to determine the implementation of the coding audit and to find out the efforts made to minimize the non-compliance of claims to the BPJS Health at Imelda Pekerja Indonesia Hospital in 2021. The type of research used was qualitative research with the number of informants as many as three coders who took Total Sampling. The research instrument used was an interview guide with qualitative descriptive data analysis techniques. Based on the results of the study, it was found that the level of knowledge of coding audit officers about coding audits is quite good but coding audits are still carried out post-claims and there are no instruments in implementing coding audits while the person in charge of coding audits at Imelda General Hospital is the Medical Committee, Verifier Internal, Quality Control and Cost Control Teamand Koder. Suggestions from researchers should Imelda Pekerja Indonesia Hospital socialize the coding audit SPO, then the coding audit is carried out pre-claim and in its implementation a coding audit instrument is made.
Penggunaan Aplikasi Excel Sebagai Aplikasi Pembantu SIMRS Gos Dalam Pencatatan Dan Pelaporan Di Rumah Sakit TNI AU Soewondo RSAU Dr. Abdul Malik Sitorus, Mei Sryendang; Simanjuntak, Esraida; Lubis, Siti Permata Sari; Hutasoit, Theresia; Sihite, Geovani Arta; Harefa, Calvin Natana Eli; Yani, Fitri
Jurnal ABDIMAS Budi Darma Vol 5, No 1 (2024): Agustus 2024
Publisher : Universitas Budi Darma

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.30865/pengabdian.v5i1.8329

Abstract

The Hospital Management Information System (SIMRS) is a vital component in hospital operations to ensure the efficiency of recording and reporting medical and administrative data. This research aims to analyze the use of the Microsoft Excel application as an auxiliary application in supporting SIMRS Gos at the Soewondo TNI AU Hospital RSAU Dr. Abdul Malik. The use of Excel aims to increase the speed and accuracy of recording and reporting hospital data which has not been fully accommodated by SIMRS Gos. The research method used is a qualitative descriptive approach with interviews and direct observation of hospital officers involved in the recording and reporting process. The research results show that the Excel application provides flexibility in processing data, but requires increased integration with SIMRS to minimize data input errors and duplication of work. The recommendation from this research is further development of SIMRS so that it can accommodate the functions currently carried out by Excel, in order to increase work efficiency and data accuracy in hospitals
Faktor - Faktor Yang Mempengaruhi Ketepatan Koding Congestive Heart Failure (CHF) Pasien Rawat Inap di RSU Imelda Pekerja Indonesia Medan Tahun 2023 Hutasoit, Theresia; Sitorus, Mei Sryendang; Simanjuntak, Esraida; Valentina, Valentina
Jurnal Media Informatika Vol. 5 No. 2 (2024): Jurnal Media Informatika
Publisher : Jurnal Media Informatika

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Abstract

Code accuracy is very necessary so that the information generated from diagnoses and medical actions is correct. The accuracy in providing diagnostic codes and medical actions is influenced by coding officers who determine the code based on data in medical records. Coding officers need to attend training related to procedures for determining the right and accurate code. The initial survey at RSU Imelda Pekerja Indonesia Medan found that from 62 medical records of CHF patients in January – March 2023, as many as 29 files (40.3%) did not have the correct diagnosis code. The purpose of this study was to determine the factors that affect the accuracy of coding Congestive Heart Failure (CHF) inpatients at RSU Imelda Pekerja Indonesia Medan. The research method used is descriptive research with a quantitative approach. Data collection by observation method by directly observing what factors affect the accuracy of coding Congestive Heart Failure (CHF) hospitalized patients. The results of the Chi-Square test analysis found that the officer's characteristics affect the accuracy of coding with a P-Value value of 0.011<0.05 for the officer's level of knowledge, a P-Value value of 0.009<0.05 for coding training that has been attended and a P-Value value of 0.000<0.05 for the length of service of the officer. The completeness of the assessment does not affect the accuracy of coding with a P-Value value of >0.05 but the completeness of diagnostic examinations and medical resumes affects the accuracy of coding with a value P-Value 0.002<0.05 and P-Value 0.015<0.05
Analysis Of the Health Services of Tuberculosis Patients Regarding Compliance with Drinking Drugs In Puskesmas Of Medan Nasution, Yulia Afrina; Lubis, Siti Permata Sari; Simanjuntak, Esraida
Benih : Journal of Midwifery Vol. 4 No. 01 (2025): Benih : Journal of Midwifery
Publisher : Cattleya Darmaya Fortuna

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.54209/benih.v4i01.359

Abstract

Tuberculosis is the second most deadly infectious disease. Indonesia is in the top three countries after India and China. The number of patients in North Sumatra in 2019 was recorded at 37,865 people while in 2020 there were 33,779 cases. Medan has the highest number of cases, which were 12,105 cases in 2020. This research aims to analyze health services such as pharmacy services and nursing services for tuberculosis patients in relation to medication compliance in Puskesmas of Medan. This research uses an observational method with a cross-sectional design. The number of samples is 100 people with purposive sampling technique. The analysis used is univariate, bivariate and multivariate. The pharmaceutical service shows that there is an effect of pharmaceutical service with medication compliance (p= 0.004; 95% CI 1.550-9.309). The OR value is 3.798 meaning that people who experience less effective pharmaceutical service have a risk of 3.798 time to not comply with medication compared to people who experience effective pharmaceutical services. The nursing service shows that there is an effect of nursing service with medication compliance (p= 0.002; 95% CI 1.671-10.602) with an OR value of 4.209, meaning that people who experience ineffective nursing services have a risk of 4.209 times to not comply with medication compared to people who experience effective nursing care. There is an influence of pharmacy services and nursing services with medication compliance in tuberculosis patients in Puskesmas of Medan.
Factors for Duplication of Medical Record Numbers at UPT Puskesmas Pasar Merah Simanjuntak, Marta; Lubis, Siti Permata Sari; Simanjuntak, Esraida; Hutasoit, Theresia
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

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Abstract

Duplication of medical record numbers is a problem that often occurs in the Integrated Service Unit (UPT) of the Pasar Merah Health Center. This study aims to identify the factors that cause duplication of medical record numbers at UPT Puskesmas Pasar Merah. This research method uses a qualitative approach with in-depth interviews with medical administration officers, patient registration officers, and medical personnel directly involved in managing medical record numbers. In addition, observations were also made to understand the process of managing medical record numbers at UPT Puskesmas Pasar Merah.The results showed that the factors of duplication of medical record numbers involved several aspects, including lack of training of medical administrative officers in database management, recording systems that were not effectively integrated between service units, and the unavailability of medical record number validation when registering new patients. In addition, human error factors such as writing and recording errors are also the cause of duplication of medical record numbers. The recommendations of this study include improving training for medical administrative officers in database management, developing an integrated recording system, implementing direct validation of medical record numbers during patient registration, and strengthening supervision mechanisms to prevent human error in managing medical record numbers. This research is expected to contribute to the improvement of the medical record management system at UPT Puskesmas Pasar Merah, so as to reduce the incidence of duplication of medical record numbers and increase efficiency and accuracy in managing patient data.
Factors Inhibiting the Accuracy of Outpatient Morbidity Reporting Data in SIMRS at Imelda General Hospital Lubis, Siti Permata Sari; Simanjuntak, Esraida; Bancin, Sri Wahyuni
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

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Abstract

The implementation of reporting is very important for hospitals because it can be used as a comparison of visits of old patients or new patients who previously and now reporting in hospitals is divided into 2, namely Internal reporting and External reporting, reporting systems in hospitals will usually be reported monthly, quarterly, and annually. This report aims to produce relevant, accurate and timely information. To be able to produce good and correct, accurate and complete computer output data and can be accounted for is greatly influenced by the discipline of the unit towards patients. Time and place of research May 2023-August 2023 at RSU Imelda, The purpose of this study is to determine the implementation of the management of outpatient morbidity data reporting at SIMRS based on human factors (Man), Method (Method) and Facility (Machine). This type of research is descriptive qualitative. The methods used for data collection are Observation and Interview. The informants in this study amounted to 2 people consisting of 1 SIMRS officer and 1 reporting officer. The result of this study is human resources (Man) where officers still often get errors in writing early diangnosa in patient files, incompleteness of Medical Record files, lack of hospital management preparation, procedure updates and technical instructions in reporting. Facilities (Machine) where the network is often problematic makes officers late in sending reporting data, SOP (Method) where there is no specific SOP in outpatient morbidity reporting but the reporting process still runs well. The suggestion that can be given is to create a special SOP for reporting outpatient morbidity data and improve the network contained in the ruagan so that the processing in reporting can be carried out more optimally.
Co-Authors Agatha Wismona, Sara Andi Ritonga, Zulham Angelia S, Clara Bancin, Sri Wahyuni Dasopang, Mustamil Alwi Fajar Insani Fitri Yani Gusla, Yeyi Harefa, Calvin Natana Eli Hulu, Delisman Lubis , Siti Permata Sari Lubis, Siti Permata Sari Napitupulu, Bintang NASUTION, YULIA AFRINA Nurhaliza, Nurhaliza Olviya , Cicha Ritonga , Zuham Andi Ritonga, ZuhamAndi Ritonga, Zulham Andi Sabela Hasibuan, Ali Shella, Rizka Mei Siddik Karo-Karo Sihite, Geovani Arta Simanjuntak, Marta Sitorus, Mei Sryendang Theresia Hutasoit Valentina Valentina Valentina, Valentina Wati Oktavin Sirait, Lisna