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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 Masyarakat (ABDIRA) Jurnal Pengabdian Ilmu Kesehatan Jurnal Ilmiah Pengabdian Kepada Masyarakat Journal of Public Health Science (JoPHS) Jurnal Kesehatan, Rekam Medis dan Farmasi (JUK-Medifa) COVID-19 : Journal of Health, Medical Records and Pharmacy Jurnal Pengabdian Ilmu Kesehatan
Sabela Hasibuan, Ali
Universitas Imelda Medan
Aerospace Engineering Chemistry Computer Science & IT Dentistry Economics, Econometrics & Finance Education Health Professions Immunology & microbiology Languange, Linguistic, Communication & Media Medicine & Pharmacology Nursing Public Health Social Sciences Veterinary Other

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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.
KLASIFIKASI PENGKODINGAN PENYAKIT DAN TINDAKAN DENGAN DIAGNOSA DIABETES MELITUS PADA TN. A DI UPT PUSKESMAS SERING TAHUN 2023 Sabela Hasibuan, Ali; Valentina, Valentina; Lubis, Siti Permata Sari; Simanjuntak, Esraida; Karo Karo, Siddik; Ritonga , Zuham Andi
Jurnal Ilmiah Pengabdian Kepada Masyarakat (Ji-SOMBA) Vol. 4 No. 1 (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.v4i1.1790

Abstract

Koding merupakan kegiatan menetapkan kode penyakit dan tindakan dengan tepat sesuai klasifikasi yang diberlakukan di Indonesia International Statistical Classification of Diseases, Tenth Revision (ICD-10) dan tentang Penyakit dan Tindakan Medis yaitu International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) dalam pelayanan dan manajemen kesehatan. Klasifikasi dan kodefikasi penyakit, masalah- masalah yang berkaitan dengan kesehatan dan tindakan medis merupakan kompetensi pertama Profesi Perekam Medis dan Informasi Kesehatan. Kegiatan pengabdian kepada masyarakat dilaksanakan di Puskemas Sering bertujuan memberikan penyuluhan tentang Pengkodingan penyakit dan tindakan DM. Metode yang digunakan dalam pengabdian kepada masyarakat ini adalah dengan memberikan penyuluhan secara langsung, demonstrasi dan pendampingan dalam pelaksanaan proses pengkodingan rekam medis untuk menurunkan ketidaktepatan penentuan kode penyakit dan tindakan DM di puskemas. Hasil dari kegiatan pengabdian kepada masyarakat ini adalah meningkatnya pengetahuan dan keterampilan dalam menentukan kode penyakit dan tindakan. Kegiatan ini berhasil dilaksanakan atas dukungan dan kerja sama yang baik dari semua pihak baik tim pelaksana, mahasiswa, petugas dan Kepala Puskesmas Sering serta Dinas Kesehatan Kota Medan.
ANALISIS PENERAPAN MANAJEMEN RESIKO PADA REKAM MEDIS ELEKTRONIK DI UPT PUSKESMAS KOTA MATSUM Simanjuntak, Esraida; Hasibuan, Ali Sabela; Lubis, Siti Permata Sari; Karo Karo, Siddik; Ritonga, ZuhamAndi; Hulu, Delisman
Jurnal Ilmiah Pengabdian Kepada Masyarakat (Ji-SOMBA) Vol. 4 No. 2 (2025): Jurnal Ilmiah Pengabdian Kepada Masyarakat (Ji-SOMBA)
Publisher : Universitas Imelda Medan

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jisomba.v4i2.1901

Abstract

Penerapan Rekam Medis Elektronik (RME) di fasilitas pelayanan kesehatan tingkat pertama, seperti Puskesmas, merupakan langkah strategis untuk meningkatkan mutu pelayanan kesehatan. Penelitian ini bertujuan untuk menganalisis penerapan manajemen risiko pada sistem RME di UPT Puskesmas Kota Matsum. Metode yang digunakan melibatkan observasi langsung dan analisis risiko terhadap berbagai permasalahan yang berpotensi mengganggu efektivitas sistem RME. Hasil menunjukkan bahwa risiko-risiko yang teridentifikasi, antara lain kelalaian input data, kebocoran informasi pasien, pemadaman listrik, gangguan server, dan infeksi virus komputer, termasuk dalam kategori risiko rendah. Kendati demikian, risiko tersebut tetap memerlukan pengendalian melalui pelatihan petugas, penguatan keamanan data, serta penyusunan SOP yang jelas. Kesimpulan dari penelitian ini menegaskan bahwa penerapan manajemen risiko yang baik pada sistem RME dapat meningkatkan efisiensi, akurasi, serta keamanan data medis, sehingga mendukung pencapaian pelayanan kesehatan yang optimal di Puskesmas
TERAPI ROM BERBASIS MORSE FALL SCALE PADA PASIEN PENYAKIT GINJAL KRONIK TAHUN 2025 Deddy Sepadha Putra Sagala; Ratna Dewi; Ali Sabela Hasibuan; Aureliya Hutagaol; Jhoon pieter Hulu
Journal of Public Health Science Vol. 2 No. 4 (2025): Desember
Publisher : Yayasan Nuraini Ibrahim Mandiri

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.70248/jophs.v2i4.3439

Abstract

Pasien dengan Penyakit Ginjal Kronik (PGK) memiliki risiko tinggi mengalami Pasien dengan Penyakit Ginjal Kronik (PGK) memiliki risiko tinggi mengalami penurunan mobilitas dan kejadian jatuh akibat kelemahan otot, gangguan keseimbangan, serta komplikasi akibat terapi hemodialisis yang dijalani. Risiko jatuh yang tidak ditangani dapat meningkatkan morbiditas, memperpanjang lama rawat inap, dan menurunkan kualitas hidup pasien. Morse Fall Scale (MFS) merupakan instrumen yang digunakan untuk menilai tingkat risiko jatuh secara sistematis, sedangkan terapi Range of Motion (ROM) berfungsi mempertahankan fleksibilitas sendi dan kekuatan otot untuk meningkatkan stabilitas postural. Penelitian ini bertujuan untuk mengetahui pengaruh terapi ROM berbasis MFS terhadap risiko jatuh pada pasien PGK di Rumah Sakit Umum Imelda Pekerja Indonesia Medan. Desain penelitian menggunakan quasi-eksperimen dengan pendekatan one-group pretest–posttest, melibatkan 32 responden yang memenuhi kriteria inklusi. Intervensi berupa latihan ROM aktif-pasif pada ekstremitas atas dan bawah dilakukan selama tujuh hari berturut-turut, masing-masing sesi 15–20 menit. Risiko jatuh diukur menggunakan Morse Fall Scale sebelum dan sesudah intervensi, kemudian dianalisis dengan uji Wilcoxon Signed Rank Test menggunakan taraf signifikansi p < 0,05. Hasil penelitian menunjukkan penurunan skor MFS yang signifikan (p = 0,000), di mana kategori risiko tinggi menurun dari 59,4% menjadi 18,8%, sedangkan risiko rendah meningkat menjadi 71,9%. Temuan ini menunjukkan bahwa terapi ROM efektif menurunkan risiko jatuh dan meningkatkan mobilitas pasien PGK. Oleh karena itu, latihan ROM berbasis MFS direkomendasikan sebagai bagian dari program rehabilitasi keperawatan rutin di unit hemodialisa untuk meningkatkan keselamatan dan kualitas hidup pasien. Kata kunci : Penyakit Ginjal Kronik, Range of Motion, Morse Fall Scale, Risiko Jatuh, Rehabilitasi.
Tahapan Audit Koding Rekam Medis dengan Menggunakan Analisa Kualitatif pada Pasien Rawat Inap di RS Khusus Mata SMEC Tahun 2025 Hutasoit, Theresia; Daeli, Cosmas Samuel; Sitorus, Mei Sryendang; Simanjuntak, Marta; Rotonga, Zulham Andi; Hasibuan, Ali Sabela; Liem, John Barker; Valentina, Valentina; Zulfahmi, Zulfahmi; Sitompul, Osayku Inesa
Jurnal Pengabdian Masyarakat (ABDIRA) Vol 6, No 1 (2026): Abdira, Januari
Publisher : Universitas Pahlawan Tuanku Tambusai

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31004/abdira.v6i1.1278

Abstract

Medical records are crucial documents that document all healthcare services. Accurate coding forms the basis for claims billing, research, and clinical decision-making. However, incomplete and inaccurate recording often presents obstacles, necessitating a coding audit. This Community Service project aimed to identify the stages of a coding audit using qualitative analysis of inpatients. The audit was conducted on four cases. The analysis used six review components: consistency of diagnosis and treatment, clinical recording, treatment justification, informed consent, documentation practices, and potential for compensation. The results of the medical record coding audit indicated that most components were consistent and met standards, including diagnosis, treatment, clinical recording, and completion of informed consent. However, inconsistencies were still found in instructions for discontinuing or replacing medications. There were no incidents that could potentially result in compensation. However, improvements are still needed in the documentation of instructions for discontinuing or replacing medications. The results emphasize the importance of ongoing socialization and monitoring to optimize the quality of medical records.
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 : Lembaga Pengembangan Kinerja Dosen

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.
PENGALAMAN DUKUNGAN KELUARGA PADA PASIEN PENYAKIT GINJAL KRONIK YANG MENJALANI HEMODIALISA: STUDI FENOMENOLOGI DI RUMAH SAKIT IMELDA PEKERJA INDONESIA MEDAN Ali Sabela Hasibuan; Deddy Sepadha Putra Sagala; Ratna Dewi; Anita Sri Gandria Purba; Juni Mariati Simarmata; Areta Jasa Halawa
Jurnal Ilmiah Keperawatan IMELDA Vol. 12 No. 1 (2026): Jurnal Ilmiah Keperawatan IMELDA
Publisher : Program Studi S1/DIII-Keperawatan Universitas Imelda Medan

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jikeperawatan.v12i1.2091

Abstract

Hemodialysis is one of the treatments for chronic kidney disease. Because of this condition, it not only causes problems with declining physical health, but also has the potential to cause psychological, social and even spiritual problems, therefore family support from various aspects is one way to overcome this. Family is the closest person who can form interpersonal relationships in attitudes and actions. Therefore, family support has an important influence on chronic kidney disease patients to improve physical, psychological, social and even spiritual health. The purpose of this study was to determine family support for chronic kidney disease patients at the Imelda Buruh Indonesia Hospital, Medan. With qualitative descriptive research through a phenomenological approach. This study was conducted from December 2024 to April 2025. The sampling technique in this study used Purposive Sampling with a total of 8 participants. The research data were collected through interviews and analyzed thematically. The instrument in this study was the researcher himself with interview guideline tools, field notes and recording tools. The results of the study consisted of 4 themes, namely emotional support, information support, instrumental support and appreciation support. The conclusion of this study is that emotional support from the family to the patient is given in the form of the family's willingness to be a companion and provide encouragement and motivation, information support is given in the form of advice and reminders for the patient, instrumental support is given in the form of financing treatment, fulfilling transportation, accompanying and accompanying the patient, while appreciation support is given in theform of assessment and positive encouragement to the patient.
Sosialisasi Pemanfaatan Sistem Informasi Manajemen Rumah Sakit (SIMRS) terhadap Pengolahan Data pada Laporan Eksternal dan Internal di RSU Imelda Pekerja Indonesia Medan Tahun 2025 Sitorus, Mei Sryendang; Valentina, Valentina; Liem, John Barker; Ardanta, Yanda; Hutasoit, Theresia; Daeli, Cosmas Samuel; Hasibuan, Ali Sabela; Ritonga, Zulham Andi; Erlindai, Erlindai; Christy, Johanna
Jurnal Pengabdian Masyarakat (ABDIRA) Vol 6, No 2 (2026): Abdira
Publisher : Universitas Pahlawan Tuanku Tambusai

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31004/abdira.v6i2.1951

Abstract

Hospital Management Information System (HMIS) at Imelda Pekerja Indonesia General Hospital has been in place since 2015; however, the system has not yet been utilized as the primary source for data processing.Reporting staff sometimes still process data manually collected from each service unit.External reports are mandatory reports submitted by every hospital to the Health Office. Internal reports are used for the hospital’s internal purposes.The implementation method of this community service activity consisted of socialization on the utilization of SIRS for data processing, reviewing the Standard Operating Procedure (SOP) for Reporting and creating a checklist of data requirements for reports.The socialization was provided to all 16 medical record officers in the Medical Records Unit using discussion, lecture, and question-and-answer methods. The results of this activity are expected to improve the staff’s knowledge regarding the utilization of HMIS for data processing in reports at hospital.This activity was successfully carried out due to the cooperation and support of all implementing team members and hospital team.However, the common obstacles faced by staff include network and application disruptions, which hinder the data processing for hospital reporting. Therefore, improving network stability within the system is necessary to ensure that the reporting process can run more effectively and efficiently.
EFEKTIVITAS TERAPI REMINISCENCE DALAM MENGURANGI DEPRESI PADA PASIEN GAGAL GINJAL KRONIK YANG MENJALANI HEMODIALISA DI RUMAH SAKIT UMUM IMELDA PEKERJA INDONESIA MEDAN TAHUN 2024 Deddy Sepadha Putra Sagala; Ali Sabela Hasibuan; Anita Sri Gandaia Purba; Yuni Suharnida Lubis; Arfah May Syara; Yokhebed Agatha Eka Rista Ziliwu; Sarida Surya Manurung
Jurnal Ilmiah Keperawatan IMELDA Vol. 11 No. 1 (2025): Jurnal Ilmiah Keperawatan IMELDA
Publisher : Program Studi S1/DIII-Keperawatan Universitas Imelda Medan

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jikeperawatan.v11i2.1794

Abstract

Chronic kidney failure is a non-communicable disease caused by a decrease in the ability of the kidneys to carry out their functions. Hemodialysis therapy is a therapy given to sufferers of chronic kidney failure which functions to replace the work of the kidneys using a dialysis machine. Hemodialysis procedures performed on kidney failure patients are likely to cause depression because sufferers undergoing hemodialysis may experience feelings of discomfort or depression due to weakness in their physical condition and dependence on dialysis machines throughout their lives. The aim of this study was to determine the effectiveness of reminiscence therapy in reducing depression in chronic kidney failure patients undergoing hemodialysis at Imelda Pekerja Indonesia Hospital. This type of research is quantitative research, with the Quasy Experiment method, and with a pre-test and post-test group research design. This research was conducted in April – July 2024 in the Hemodialysis Room at Imelda Pekerja Indonesia Hospital, Medan. This research uses a non-probability sampling technique using a purposive sampling method, namely using inclusion criteria in determining the sample, so that the total research sample is 20 respondents. The instrument used in this research is a questionnaire that refers to the Beck Depression Inventory (BDI-II) to determine depression status. Data analysis used univariate and bivariate analysis with the Wilcoxon test in the SPSS application. The results of the Wilcoxon statistical test showed a significant (p) value of 0.000 (p < 0.05), meaning that there was an effect of giving reminiscence therapy on depression status or in other words reminiscence therapy was effective in reducing depression in chronic kidney failure patients undergoing hemodialysis at Imelda Pekerja Indonesia Hospital, Medan.
Co-Authors Andi Ritonga, Zulham Anita Sri Gandaia Purba Anita Sri Gandria Purba Ardanta, Yanda Areta Jasa Halawa Arfah May Syara Christy, Johanna Cindi Permadani Cosmas Samuel Daeli Damanik, Hamonangan Deddy Sepadha Putra Sagala Deddy Sepadha Putra Sagala Erlindai, Erlindai Esraida Simanjuntak Esraida Simanjuntak Giovani Malau Gulo, Leli Nurmeida Hulu, Delisman Hutagaol, Aureliya Jhoon pieter Hulu Juni Mariati Simarmata Kartika Pulungan, Nidiya Liem, John Barker Lubis, Siti Permata Sari Malau, Giovani Mei Sryendang Sitorus Mei Sryendang Sitorus Melita W Siburian Nababan, Edward Ramos Nidiya Kartika Pulungan Pakpahan, Naziah Purba, Anita Gandaria Purba, Jenny Marlindawani Ratna Dewi Ratna Dewi Ratna Dewi Ritonga , Zuham Andi Ritonga, ZuhamAndi Ritonga, Zulham Andi Rotonga, Zulham Andi Sarida Surya Manurung Sasmita Dewi Hasibuan, Yawi Siddik Karo-Karo Simanjuntak, Esraida Simanjuntak, Marta Siringoringo, Monika Belawanti Sitompul, Osayku Inesa Sitorus, Mei Sryendang Tasya Adinda Putri Theresia Hutasoit Valentina Valentina, Valentina W Siburian, Melita Yawi Sasmita Dewi Hasibuan Yokhebed Agatha Eka Rista Ziliwu Yuni Suharnida Lubis Yuni Suharnida Lubis Zulfahmi Zulfahmi Zulham Andi Ritonga