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All Journal International Journal of Nursing and Health Services (IJNHS) Jurnal Keperawatan dan Fisioterapi (JKF) Jurnal Ilmiah Keperawatan Imelda Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Ability : Journal of Education and Social Analysis Jurnal Pengabdian Ilmu Kesehatan Jurnal Ilmiah Pengabdian Kepada Masyarakat Jurnal Kesehatan, Rekam Medis dan Farmasi (JUK-Medifa) COVID-19 : Journal of Health, Medical Records and Pharmacy
Sabela Hasibuan, Ali
Universitas Imelda Medan
Chemistry Computer Science & IT Dentistry Economics, Econometrics & Finance Education Health Professions Immunology & microbiology Medicine & Pharmacology Nursing Public Health Social Sciences Other

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Tinjauan Faktor Penyebab Ketidaklengkapan Dokumen Rekam Medis Rawat Inap Di Ruangan Anggrek Rumah Sakit Umum Imelda Pekerja Indonesia Medan Tahun 2021 Ali Sabela Hasibuan, Zulham Andi Ritonga, Rini Setiani Saragih
Ability: Journal of Education and Social Analysis Volume 2 No 2 April 2021
Publisher : Pusdikra Publishing

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

Abstract

Rekam medis merupakan bagian terpenting dalam pelayanan kesehatan di Rumah Sakit. Dalam peningkatan mutu rekam medis salah satu faktornya adalah bagaimana petugas rekam medis yang baik dan benar. Tujuan penelitian ini adalah untuk mengetahui faktor penyebab ketidaklengkapan rekam medis rawat inap. Jenis penelitian ini adalah deskriptif kualitatif. Waktu penelitian dilakukan pada bulan Juli sampai dengan Oktober 2021 di Rumah Sakit Umum Imelda Pekerja Indonesia Medan. Informan penelitian ini adalah kepala rekam medis sebanyak 1 orang, petugas review sebanyak 1 orang, petugas pelaporan sebanyak 1 orang, perawat 2 orang, dan dokter 1 orang. Hasil penelitian menunjukkan bahwa faktor yang mempengaruhi ketidaklengkapan rekam medis adalah Sumber Daya Manusia yaitu kedisiplinan, motivasi, beban kerja, komunikasi.
Analisis Kualitatif Pengisian Rekam Medis Rawat Inap Di Rumah Sakit Umum Daerah Kabupaten Aceh Tamiang Tahun 2022 Zulham Andi Ritonga; Ali Sabela Hasibuan; Tasya Adinda Putri
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Vol. 8 No. 1 (2023): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Februari
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v8i1.1228

Abstract

Completeness of filling out medical records in hospitals is a must for health workers and can be done using qualitative analysis. The purpose of this study was to determine the qualitative analysis of filling in inpatient medical records at the Aceh Tamiang District General Hospital. This research is a descriptive research with a quantitative approach. The research was conducted at the Aceh Tamiang District Hospital. The population in this study was 1,840 and the sample obtained was 95 inpatient medical records. The results showed that the review of the completeness and consistency of the diagnosis was 90 (95%) accurate and 5 (5%) inaccurate, namely in the inpatient doctor's notes. In the notes and nursing care and nursing diagnoses there were 87 (92%) complete and 8 (8%) incomplete. Review of the consistency of recording the diagnosis, there were 85 (89%) complete and 10 (11%) incomplete. There are 83 medical records (87%) accurate and 12 (13%) inaccurate. Incomplete and inaccurate filling of inpatient medical records is found in the consistency of development records and nursing care. There were 82 (86%) complete and 13 (14%) incomplete records of things that were carried out during treatment and treatment, namely on evidence of implementation of treatment plans, instructions and drug changes, and actions taken which were filled out by nurses. Review of informed consent from 16 inpatient medical records, there were 14 (87%) complete and 2 (13%) incomplete, namely the completeness of the contents of the informed consent filled out by nurses. Review of medical methods or practices, there are 84 (88%) complete and 11 (12%) incomplete, namely on the date and time, the signature / initials is easy to read filled in by the doctor
Sosialisasi Pengisian Kelengkapan Dokumen Rekam Medis Rawat Inap Pada Pasien Diabetes Mellitus Di Rsu Imelda Medan Ali Sabela Hasibuan; Ratna Dewi; Hamonangan Damanik; Esraida Simanjuntak; Mei Sryendang Sitorus
Jurnal Pengabdian Ilmu Kesehatan Vol. 3 No. 2 (2023): Juli : Jurnal Pengabdian Ilmu Kesehatan
Publisher : Pusat Riset dan Inovasi Nasional

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.55606/jpikes.v3i2.2591

Abstract

This service aims to find out the number of incomplete medical records for inpatient diabetes mellitus patients at Imelda Hospital, Medan. This service uses a descriptive method, namely a research method carried out with the main aim of finding out the number of incomplete filling in inpatient medical records for Diabetes Mellitus patients. From the results of the service, it was found that the number of incomplete filling out of the integrated record form was found to be 17.40%, initial assessment was 15, 22% of medical resumes were 9.79% and informed consent was 17.40%, the doctor's name was 21.74% and the doctor's signature was 8.70%, while for patient identification, anesthesia records and the operation report is filled out completely. The suggestions from the author are: (1) the permanent procedure for analyzing incompleteness in filling out inpatient medical records needs to be revised so that all forms are analyzed, and continuous socialization needs to be carried out.
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 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.
Description Of Sleep Quality In Patients With Chronic Obstructive Pulmonary Disease At Imelda Pekerja Indonesia General Hospital Medan Hasibuan, Ali Sabela; Dewi, Ratna; Damanik, Hamonangan
Jurnal Kesehatan, Rekam Medis dan Farmasi (JUK-Medifa) Vol. 1 No. 02 (2023): JUK-Medifa (Jurnal Kesehatan, Rekam Medis dan Farmasi), Mey 2023
Publisher : SEAN Institute

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.58471/juk-medifa.v1i02.254

Abstract

Sleep quality is the sleep that a person gets which is useful for getting freshness and fitness when waking up from sleep and can be assessed by the number of hours of sleep. Chronic Obstructive Pulmonary Disease (COPD) is a chronic inflammation that leads to long-lasting narrowing of the airways caused by destruction of the alveolar walls. The aim of the research is to determine the description of the sleep quality of patients with chronic obstructive pulmonary disease (COPD) at the Imelda Pekerja IndonesiaGeneral Hospital, Medan in 2021. This research uses a descriptive method, a cross sectional approach with a sampling technique using nonprobability sampling with a sampling method, namely consecutive sampling involving 31 respondents. The instrument used was the Pittsburgh Sleep Quality Index (PSQI) sleep quality questionnaire. The results of this study were based on the sleep quality of 31 COPD patients in the orchid room at the Imelda Pekerja IndonesiaGeneral Hospital, Medan. The majority of respondents had poor sleep quality, 21 people (67.7%) and the minority had good quality, 10 people (32, 3%). It is hoped that it can be used for basic data and developed for subsequent research by adding respondents, conducting research on the description of patients with chronic obstructive pulmonary disease (COPD) in improving sleep quality, and before conducting interviews so that researchers can better understand the material. 7%) and minorities have good qualities as many as 10 people (32.3%). It is hoped that it can be used for basic data and developed for subsequent research by adding respondents, conducting research on the description of patients with chronic obstructive pulmonary disease (COPD) in improving sleep quality, and before conducting interviews so that researchers can better understand the material. 7%) and minorities have good qualities as many as 10 people (32.3%). It is hoped that it can be used for basic data and developed for subsequent research by adding respondents, conducting research on the description of patients with chronic obstructive pulmonary disease (COPD) in improving sleep quality, and before conducting interviews so that researchers can better understand the material.
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.
Effectiveness of Intradialytic Exercise on Muscle Strength and Fatigue Score in Chronic Kidney Failure (CKF) Patients in the Grandmed Hemodialysis Room Purba, Anita Gandaria; Sagala, Deddy Sepadha Putra; Ali Sabela Hasibuan; Yuni Suharnida Lubis
JURNAL KEPERAWATAN DAN FISIOTERAPI (JKF) Vol. 7 No. 1 (2024): Jurnal Keperawatan dan Fisioterapi (JKF)
Publisher : Fakultas Keperawatan dan Fisioterapi Institut Kesehatan Medistra Lubuk Pakam

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.35451/jkf.v7i1.2338

Abstract

Chronic kidney failure is a progressive and irreversible kidney dysfunction in which the body's ability to maintain metabolism, fluid and electrolyte balance is disrupted, resulting in uremia or azotemia. Hemodialysis is a form of treatment for patients with chronic kidney failure, in which the patient's blood is diverted out of the body through a dialyzer, which occurs through diffusion and ultrafiltration, after which the blood is returned to the patient's body. Several methods to maintain muscle strength and reduce fatigue scores, namely intradialytic exercise is an exercise program developed that can increase muscle strength, muscle endurance and physical activity. The general objective of this study was to determine the effectiveness of intradialytic exercise involvement interventions on muscle strength and fatigue scores in hemodialysis patients at GrandMed Lubuk Pakam Hospital. This research method is a quantitative study, using a quasy experiment with a one group pre-test post-test design. The population in this study were all patients with Chronic Kidney Failure who were recorded at the Medical Records Hospital Grandmed Lubuk Pakam from October 2021 to December 2022. With inclusion criteria: respondents experienced movement disorders, muscle cramps, and weakness. The number of samples was 22 respondents. The sampling technique used in this research is non-probability sampling, namely purposive sampling. The statistical test used is the Wilcoxon test. The Wilcoxon test results obtained significant results from the intradialytic exercise technique on muscle strength and fatigue scores with a p value of 0.00 each. So that it can be concluded that there is an effect of giving good intradialytic exercise interventions on muscle strength & fatigue scores in chronic kidney failure patients undergoing hemodialysis
Overview of the Implementation of Incomplete Control of Medical Record Documents at Sentosa Baru Health Center in 2023 Hasibuan, Ali Sabela; Lubis, Siti Permata Sari; Gulo, Leli Nurmeida
COVID-19 : Journal of Health, Medical Records and Pharmacy Vol. 1 No. 01 (2023): COVID-19 : Journal of Health, Medical Records and Pharmacy
Publisher : CV. Devitara

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

Abstract

One of the implementations of controlling medical record documents is by completing medical record documents properly in accordance with SOPs. This study was shown to determine the implementation of medical record document control at Sentosa Baru Health Center. This research is a Quantitative descriptive research. The method used in this study is by Observation. The research was conducted at Sentosa Baru Health Center. The study was conducted from June to August 2023. The population at Sentosa Baru Health Center is 780 medical record documents The sample size in this study was calculated based on the slovin formula so that 80 medical record documents were obtained as research subjects. For the completeness of medical record documents, in the section of writing patient identity, name, time, doctor's signature, there are 80 medical record documents completely (100%). The column of date, month, year, justification for writing medical records there are 40 complete medical record documents (50%) and in the writing section of Assessment, Planning, Screening-vital sign there are 60 complete medical record documents (75%). Thus, the author suggests to the medical record officer at Sentosa Baru Health Center, to re-socialize related to the SOP by filling out medical record documents and then evaluating the suitability between the SOP and the performance of the medical record officer.
Co-Authors Andi Ritonga, Zulham Cindi Permadani Damanik, Hamonangan Deddy Sepadha Putra Sagala Esraida Simanjuntak Giovani Malau Gulo, Leli Nurmeida Hulu, Delisman Kartika Pulungan, Nidiya Lubis, Siti Permata Sari Lubis, Yuni Suharnida Malau, Giovani Mei Sryendang Sitorus Melita W Siburian Nababan, Edward Ramos Nidiya Kartika Pulungan Pakpahan, Naziah Purba, Anita Gandaria Purba, Anita Sri Gandaia Purba, Jenny Marlindawani Ratna Dewi Ratna Dewi Ritonga , Zuham Andi Ritonga, ZuhamAndi Ritonga, Zulham Andi Sarida Surya Manurung Sasmita Dewi Hasibuan, Yawi Siddik Karo-Karo Simanjuntak, Esraida Simanjuntak, Marta Siringoringo, Monika Belawanti Syara, Arfah May Tasya Adinda Putri Valentina Valentina, Valentina W Siburian, Melita Yawi Sasmita Dewi Hasibuan Yuni Suharnida Lubis Ziliwu, Yokhebed Agatha Eka Rista Zulham Andi Ritonga