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Faktor Penyebab Ketidaklengkapan Pengisian Berkas Rekam Medis Pasien Rawat Inap Angga Kristiana Putri; Ida Nurmawati; Maya Weka Santi; Selvia Juwita Swari
Jurnal Penelitian Kesehatan SUARA FORIKES Vol 13, No 4 (2022): Oktober 2022
Publisher : FORIKES

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33846/sf.v13i4.2282

Abstract

Incomplete medical records have an impact on the low quality of medical records and health services. The purpose of this study is to analyze the factors that cause incomplete filling in medical record files for inpatients at the hospital based on the 5M elements of management (Man, Money, Methods, Machine, Material). This study was a literature review. The results of the analysis showed that incomplete medical record files were 34.3%. Many of the items that were not filled in completely from the medical record form included authentication from doctors and nurses, namely 7 articles. Factors causing incomplete filling of inpatient medical record files with the highest percentage were lack of knowledge of staff, lack of budget, lack of rewards and punishments, non-specific or incomplete checklists for assessing file completeness, and medical record files that were less systematic. Efforts that need to be made are increasing the knowledge of officers about the importance of completing medical record files, implementing a reward and punishment system to motivate officers, improving checklist sheets and medical record files according to standards.Keywords: incompleteness; filling; inpatient medical record ABSTRAK Ketidaklengkapan rekam medis berdampak pada rendahnya mutu kualitas rekam medis dan pelayanan kesehatan. Tujuan dari studi ini adalah untuk menganalisis faktor penyebab ketidaklengkapan pengisian berkas rekam medis pasien rawat inap di rumah sakit berdasarkan unsur manajemen 5M (Man, Money, Methods, Machine, Material). Studi ini merupakan literature review. Hasil analisis menunjukkan bahwa ketidaklengkapan berkas rekam medis adalah 34,3%. Item yang banyak tidak terisi secara lengkap dari formulir rekam medis di antaranya adalah autentifikasi dari dokter maupun perawat yaitu sebanyak 7 artikel. Faktor penyebab ketidaklengkapan pengisian berkas rekam medis rawat inap dengan persentase tertinggi adalah kurangnya pengetahuan petugas, kurangnya anggaran, belum adanya reward dan punishment, checklis penilaian kelengkapan berkas yang tidak spesifik atau tidak lengkap, dan berkas rekam medis yang kurang sistematis. Upaya yang perlu dilakukan adalah meningkatkan pengetahuan petugas tentang pentingnya kelengkapan berkas rekam medis, menerapkan sistem reward dan punishment untuk motivasi petugas, memperbaiki lembar checklist dan berkas rekam medis sesuai standar.  Kata kunci: ketidaklengkapan; pengisian; rekam medis rawat inap
Returning of Medical Record Documents Among Hospitalized Patients: Literature Review Ida Nurmawati; Sari Handayani
Jurnal Aisyah : Jurnal Ilmu Kesehatan Vol 6, No 3: September 2021
Publisher : Universitas Aisyah Pringsewu

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (664.422 KB) | DOI: 10.30604/jika.v6i3.516

Abstract

The delays in returning inpatient medical record documents in the hospital are still common. The purpose of this study was to analyze the delays in returning inpatient medical record document factors in the hospital. The study used the literature review method to 16 articles which were searched through Google Scholar, GARUDA, Rama Repository, and E-Library Politeknik Negeri Jember. The result of the research showed from 16 analyzed articles, the delays in returning inpatient medical record documents caused by the lack of doctor’s discipline in filing medical record documents completely, there is no reward and punishment for obedient officers, lack of the standard operating procedure socialization in returning inpatient medical record documentation for the nurses and doctors, the distance between inpatient and medical record unit is too far, there are no facilities for helping in returning of medical record document activity in medical record unit such as trolley. The suggestion that could be given is, they need to conduct socialization of the standard operational procedure in returning inpatient medical record documents at the hospital regularly. So that, the nurses and doctors are always paying attention to the specified time in returning inpatient medical record documents.Abstrak: Keterlambatan pengembalian DRM pasien rawat inap di rumah sakit masih sering terjadi. Tujuan dari penelitian ini adalah untuk menganalisis faktor penyebab keterlambatan pengembalian DRM pasien rawat inap di rumah sakit. Penelitian dilakukan dengan menggunakan metode studi literatur terhadap 16 artikel penelitian yang ditelusuri melalui Google Scholar, GARUDA, Rama Repository, dan E-Library Politeknik Negeri Jember. Hasil penelitian menunjukkan bahwa dari 16 artikel yang dianalisis, keterlambatan pengembalian DRM pasien rawat inap di rumah sakit disebabkan oleh kurangnya kedisiplinan DPJP dalam melakukan pengisian DRM secara lengkap, tidak terdapatnya reward dan punishment terhadap petugas, kurangnya sosialisasi SOP pengembalian DRM pasien rawat inap kepada perawat dan DPJP, jarak antara unit rawat inap dengan unit rekam medis yang terlalu jauh, dan belum terdapatnya sarana untuk menunjang kegiatan pengembalian DRM ke unit rekam medis seperti troli. Saran yang dapat diberikan adalah perlu diadakan kegiatan sosialisasi SOP pengembalian DRM pasien rawat inap di rumah sakit secara berkala agar perawat dan DPJP selalu memperhatikan standar waktu pengembalian DRM yang telah ditentukan.
Faktor Penyebab Ketidaklengkapan Pengisian Dokumen Rekam Medis Rawat Inap di Rumah Sakit Alfiansyah, Gamasiano; Pratiwi, Dita Melinda; Nuraini, Novita; Nurmawati, Ida
Jurnal Penelitian Kesehatan SUARA FORIKES 2022
Publisher : FORIKES

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33846/sf13nk355

Abstract

One of the characteristics of good medical record management is a complete medical record. This study aims to determine the factors causing the incomplete filling of inpatient medical record documents. The method used in this study was a literature review with 15 journal articles that had been selected according to the inclusion criteria. The results showed that there were several factors causing incomplete filling of inpatient medical record documents as seen from the "man" factor, namely lack of knowledge of officers, indiscipline of officers, lack of motivation of officers, high workload, and no training. The "machine" factor is the lack of communication between officers, the absence of monitoring and evaluation of medical records, and the absence of sanctions or rewards. The "method" factor, namely the implementation of filling out inpatient medical record documents is not in accordance with the SOP (Standard Operating Procedure). The "material" factor, namely medical record documents need to be simplified, there is no special room to fill in medical records, and there is no incomplete recapitulation data and the "money" factor, namely a limited budget. Hospitals need to pay attention to these factors so that they can maintain the quality of service and the quality of hospital medical records.Keywords: medical record documents; incompleteness; inpatient ABSTRAK Salah satu ciri penyelenggaraan rekam medis yang baik adalah rekam medis yang lengkap. Penelitian ini bertujuan untuk mengetahui faktor penyebab ketidaklengkapan pengisian dokumen rekam medis rawat inap. Metode yang digunakan dalam studi ini adalah literature review dengan 15 artikel jurnal yang telah dipilih sesuai dengan kriteria inklusi. Hasil penelitian menunjukkan bahwa ada beberapa faktor penyebab ketidaklengkapan pengisian dokumen rekam medis rawat inap yang dilihat dari faktor “man” yaitu kurangnya pengetahuan petugas, ketidakdisiplinan petugas, kurangnya motivasi petugas, beban kerja yang tinggi, dan tidak ada pelatihan. Faktor “machine” yaitu kurangnya komunikasi antar petugas, belum adanya monitoring dan evaluasi mengenai rekam medis, dan tidak adanya sanksi atau penghargaan. Faktor “method” yaitu pelaksanaan pengisian dokumen rekam medis rawat inap belum sesuai dengan SOP (Standard Operating Procedure). Faktor “material” yaitu dokumen rekam medis perlu disederhanakan, tidak adanya ruangan khusus untuk mengisi rekam medis, dan tidak ada data rekapitulasi ketidaklengkapan dan faktor “money” yaitu anggaran dana yang terbatas. Rumah sakit perlu memperhatikan faktor-faktor tersebut sehingga dapat menjaga mutu pelayanan serta mutu rekam medis rumah sakit.Kata kunci: dokumen rekam medis; ketidaklengkapan; rawat inap
Penyebab Keterlambatan Pengembalian Berkas Rekam Medis Rawat Inap di Rumah Sakit Nurmawati, Ida; Rohmah, Amaliya Nikmatul; Alfiansyah, Gamasiano
Jurnal Penelitian Kesehatan SUARA FORIKES 2022
Publisher : FORIKES

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33846/sf13nk313

Abstract

Accuracy in returning medical record files is necessary in order to realize good medical record management, because it influences policy making, management decisions, and the delivery of information to each patient. So a study is needed that aims to study the causes of delays in returning inpatient medical record files at the hospital. This study is a literature review involving 19 articles from Google Scholar and the Garuda Portal. The results of the study stated that the causes of delays in returning medical record files were: 1) man: lack of knowledge regarding the deadline for returning medical record files, training had not been carried out, staff attitude was not good, education level was not appropriate, staff had less years of service; 2) money: budget is not yet available; 3) method: there is no SOP, the SOP has not been socialized, the officers do not work according to the SOP, monitoring has not been carried out; 4) material: incomplete filling of the patient's medical record file; 5) machine: lack of other supporting facilities.Keywords: hospital; late returns; medical records ABSTRAK Ketepatan pengembalian berkas rekam medis diperlukan guna mewujudkan manajemen rekam medis yang baik, karena berpengaruh terhadap pengambilan kebijakan, keputusan manajemen, serta penyampaian informasi kepada setiap pasien. Maka diperlukan studi yang bertujuan untuk mempelajari penyebab keterlambatan pengembalian berkas rekam medis rawat inap di rumah sakit. Studi ini merupakan literature review yang melibatkan 19 artikel dari Google Scholar dan Portal Garuda. Hasil studi menyatakan bahwa penyebab keterlambatan pengembalian berkas rekam medis adalah: 1) man: kurangnya pengetahuan terkait batas waktu pengembalian berkas rekam medis, belum dilakukan pelatihan, kurang baiknya sikap petugas, tingkat pendidikan tidak sesuai, masa kerja petugas kurang; 2) money: belum tersedianya anggaran; 3) method: belum ada SOP, belum disosialisasikannya SOP, petugas tidak bekerja sesuai SOP, belum dilaksanakannya monitoring; 4) material: ketidaklengkapan pengisian berkas rekam medis pasien; 5) machine: kurangnya sarana penunjang lain.Kata kunci: rumah sakit; keterlambatan pengembalian; rekam medis
Level of Knowledge of Menstruation in Supporting Elementary Students Preparation For Menarche Ida Nurmawati; Feby Erawantini
Jurnal Kesehatan Masyarakat Andalas Vol 12 No 1 (2017): Jurnal Kesehatan Masyarakat Andalas
Publisher : Faculty of Public Health, Andalas University

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.24893/jkma.v12i1.270

Abstract

Nowadays, the first menstrual period in adolescent occurs faster with a lack of their preparation for menarche. This condition make them respond negatively to the menarche by experiencing mixed emotions; fears, shocked, sad, disappointed, embarrassed, worried, and confused. The result of SDKI in 2012 suggested that adolescents need to be provided with sufficient information before their first menstruation. Thus, this research purposes to determine the relationship of knowledge level of elementary school adolescent girls about menstruation and their preparation for menarche. It is an observational study using cross sectional approach. The population of this research is 37 female students of the six graders in SDN Tegalgede 01 Jember Regency who also as the research sample taken by saturated sampling technique. The data is analyzed using Rank Spearman test. The bivariate analysis is done by applying crosstabulation that students with good preparation are found more on students with good knowledge (82,4%) than students with less knowledge (30%). There is a relationship between the students’ level of knowledge about menstruation and their preparation for menarche (p value = 0,026). Based on r = 0,367, there is a passive relationship between the level of knowledge with menarche.
The Determinant of HIV Testing on Housewives in The Pesisir Jember Area Ida Nurmawati; Ervina Rachmawati; Faiqatul Hikmah
Jurnal Aisyah : Jurnal Ilmu Kesehatan Vol 6, No 1: March 2021
Publisher : Universitas Aisyah Pringsewu

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (217.224 KB) | DOI: 10.30604/jika.v6i1.423

Abstract

The development of HIV / AIDS cases in Jember Regency from year to year also tends to increase, but people who take HIV tests have decreased. Most cases of HIV / AIDS are in the "Golden Triangle" Subdistrict, namely Puger, Kencong, and Gumukmas which are the coastal areas of Jember. Objective: to determine the predisposing factors, enabling, reinforcing housewives in the implementation of HIV testing. Methods: This research was an analytical survey with a cross-sectional approach to proving the research hypothesis in the form of a correlation and influence together with the predisposing, enabling, and reinforcing factors of housewives on the implementation of HIV testing. The population was all housewives in Kencong sub-district and the study sample was 96 households. The sample collection technique used quota sampling and data collection were carried out by giving questionnaires to housewives who visited to Public Health Center of  Kencong. Data analysis using chi-square test and logistic regression test. Results: The results showed that there was correlation between age (p = 0.042), education (p = 0.0001), knowledge (p = 0.025), access to HIV testing services (p = 0.025), husband's support (p = 0.019), support from friends. (p = 0.002), health care support (p = 0.001) and there is a co-effect of age (p = 0.046; ExpB = 2.531), education (p = 0.001; ExpB = 4.620), access to HIV testing services (p = 0.041; ExpB = 3,928) on the implementation of HIV testing at Public Health Center of Kencong. Conclusion: There is a co-effect of the housewife's age, housewife education, and access to HIV testing services on the implementation of HIV testing at the Public Health Center of  Kencong. Empowerment of productive age housewives as peer cadres for HIV / AIDS promotion and HIV testing. Abstrak: Perkembangan kasus HIV/AIDS Kabupaten Jember dari tahun ke tahun juga cenderung meningkat, namun orang yang melakukan tes HIV mengalami penurunan. Kasus HIV/AIDS terbanyak berada pada Kecamatan “Segi Tiga Emas” yaitu Puger, Kencong, dan Gumukmas yang meruapakn daerah pesisir Jember. Tujuan: mengetahui faktor predisposing, enabling, reinforcing ibu rumah tangga dalam pelaksanaan tes HIV. Metode: Penelitian ini merupakan survei analitik dengan pendekatan waktu crossectional untuk membuktikan hipotesis penelitian berupa ada hubungan dan pengaruh secara Bersama-sama factor predisposisi, pemungkin, dan penguat ibu rumah tangga terhadap pelaksanaan tes HIV. Populasi adalah seluruh ibu rumah tangga di kecamatan Kencong dan sampel penelitian sebesar 96 IRT. Teknik pengumpulan sampel menggunakan quota sampling dan pengumpulan data dilakukan dengan pemberian angket kepada ibu rumah tangga yang berkunjung ke Puskesmas Kencong. Analisis data menggunakan uji chi square, dan uji regresi logistic. Hasil: Hasil penelitian diketahui ada hubungan usia (p=0,042), pendidikan (p=0,0001), pengetahuan (p=0,025), akses layanan tes HIV (p=0,025), dukungan suami (p=0,019), dukungan teman (p=0,002), dukungan nakes (p=0,001) serta ada pengaruh secara bersama-sama usia (p=0,046; ExpB=2,531), pendidikan (p=0,001; ExpB=4,620), akses layanan tes HIV (p=0,041; ExpB=3,928) terhadap pelaksanaan tes HIV di Puskesmas Kencong. Kesimpulan: Ada pengaruh secara bersama-sama usia IRT, Pendidikan IRT, dan akses layanan tes HIV terhadap pelaksanaan tes HIV di Puskesmas Kencong. Pemberdayaan IRT usia produktif sebagai kader teman sebaya untuk promosi HIV/AIDS dan tes HIV.