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All Journal LINK Jurnal Rekam Medis dan Informasi Kesehatan Ensiklopedia of Journal Jurnal Keperawatan Komprehensif (Comprehensive Nursing Journal) Oceana Biomedicina Journal 2-TRIK: TUNAS-TUNAS RISET KESEHATAN Abdi Dosen : Jurnal Pengabdian Pada Masyarakat Community Engagement and Emergence Journal (CEEJ) Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Jurnal Abdidas jurnal abdimas saintika International Journal of Engineering, Science and Information Technology Oceana Biomedicina Journal Indonesian Journal of Health Information Management Services (IJHIMS) Media Informasi JPIK - Jurnal Pengabdian Ilmu Kesehatan Jurnal Kesehatan Lentera Aisyiyah
Putra, Deni Maisa
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Journal : Indonesian Journal of Health Information Management Services (IJHIMS)

 1 
Dissemination of Tracer Usage Using Microsoft Access in the Medical Record Unit at Air Dingin Health Center, Padang City: Tracer Usage Using Microsoft Access in the Medical Record Deni Maisa Putra
Indonesian Journal of Health Information Management Services Vol. 2 No. 1 (2022): Indonesian Journal of Health Information Management Services (IJHIMS)
Publisher : APTIRMIKI

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (502.328 KB) | DOI: 10.33560/ijhims.v2i1.30

Abstract

The development of information technology today affects various aspects of life and profession, one of which is in the field of health services, especially in patient medical records. Health data and information contained in medical records are very useful for the management of health care institutions to assess whether their services are of high quality, efficient and effective. The speed in providing medical record files to the poly is one of the indicators of service quality in medical records, both in and out of medical records from Filing. The purpose of this community service activity is to socialize the use of Trecer using Microsoft Access in managing medical records Air Dingin Health Center, Padang City in 2019. Good medical record management is very helpful in carrying out activities so that they are not misplaced (missfile) and are not lost when the file is removed from the filing. The method used in this activity is training and socialization in the use of simple theoretical and practical applications. The result of this activity is that participants can use simple applications in managing medical records. Keywords: Medical records, public health center, tracer, microsoft access
Socialization of Filling in Completeness of Medical Record Resume and Accuracy of Diagnostic Code of Surgical Treatment Unit for BPJS Patients on Submission of Inpatient Service Claims Yulia Fitriani; Deni Maisa Putra; Dian Novita; Anisah Amartia
Indonesian Journal of Health Information Management Services Vol. 2 No. 2 (2022): Indonesian Journal of Health Information Management Services (IJHIMS)
Publisher : APTIRMIKI

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (255.709 KB) | DOI: 10.33560/ijhims.v2i2.48

Abstract

ABSTRACT. The completeness of the medical resume and the accuracy of the diagnosis code will affect the information generated due to the inaccuracy of the data presented so that it has an impact on the quality of information and the accuracy of the code in accordance with ICD-10. In RSI Ibnu Sina Padang, incomplete and inaccurate medical resumes are still found. This study aims to determine the review of the completeness of the medical resume and the accuracy of the diagnostic code of the surgical care unit for BPJS patients on filing BPJS claims for inpatient surgical care units. This type of research is descriptive, to see a description of the completeness of the medical resume and the accuracy of the diagnosis code of the surgical care unit for BPJS patients for submitting claims for inpatient services. The study was carried out in the case mix surgical treatment unit at Ibnu Sina Hospital. Data collection method using univariate analysis. The results showed that the completeness of the incomplete medical resume was (30.9%), the accuracy of the inaccurate diagnosis code was 14.8%, and there were no claims pending for BPJS claims. Based on the results of the study, it can be concluded that the incompleteness of the medical resume and inaccuracies are still not maximized, the researchers suggest paying attention to the medical record officer/coder starting from compliance with applicable regulations and policies, so that the completeness of the medical resume and the accuracy of the diagnosis code can be achieved as expected.
SOSIALISASI SISTEM PENYIMPANAN BERKAS REKAM MEDIS PUSKESMAS ULAK KARANG BERDASARKAN STANDAR AKREDITASI PUSKESMAS Deni Maisa Putra; Yulia Fitriani; Devid Leonard; Ade Wisandra; Alfauzain; Dian Novita; Washi Fadhila; Annisa Nada Shabrina; Muhammad Al Ashari
Indonesian Journal of Health Information Management Services Vol. 3 No. 2 (2023): Indonesian Journal of Health Information Management Services (IJHIMS)
Publisher : APTIRMIKI

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33560/ijhims.v3i2.70

Abstract

 Sistem penyimpanan rekam medis menjadi salah satu penilaian dalam standar akreditasi puskesmas. Sistem penyimpanan rekam medis sangat peting untuk dilakukan dalam penilaian intitusi pelayanan kesehatan. Karena sistem penyimpanan dapat memudahkan berkas rekam medis yang akan disimpan di rak penyimpanan, mudah pengembaliannya, dan melindungi berkas rekam medis dari pencurian. Tujuan kegiatan ini untuk sosialisasi Sistem Penyimpanan Berkas Rekam Medis Puskesmas Ulak Karang berdasarkan Standar Akreditasi Puskesmas. Metode yang digunakan adalah pendekatan fenomenologi dengan teknik wawancara, pemaparan materi Standar Akrediatsi Puskesmas, Simulasi dan sosialisasi kepada kepala Puskesmas, petugas Rekam Medis, dan 1 taff Puskesmas. Hasil dalam pelaksanaan sosialisasi sistem penyimpanan berkas rekam medis masih ditemukan permasalahan seperti masih adanya missfile dalam penyimpanan, masa retensi yang tidak ada hal ini tidak sesuai dengan standar akreditasi kriteria 8.4.3 yaitu adanya kebijakan dan prosedur tentang masa retensi. Serta kurangnya sarana dan prasarana ruang penyimpanan rekam medis. Berdasarkan pembahasan dan sosialiasi pada sistem penyimpanan berkas rekam medis masih ada terjadi missfile dan belum dilakukan pemusnahan karena untuk masa retensi puskesmas menurut permenkes nomor 269 tahun 2008 pasal 9 ayat (1) rekam medis pada sarana pelayanan kesehatanan non rumah sakit wajib disimpan sekurang-kurangnya 2 tahun teritung saat pasien terakhir berobat. Dan disarankan untuk petugas melakukan pembinaan untuk menambah ketelitian petugas rekam medis serta membuat kebijakan tentang masa retensi.
SOSIALISASI APLIKASI PEMINJAMAN DAN PENGEMBALIAN REKAM MEDIS SEBAGAI MEDIA PEMBELAJARAN MAHASISWA/I REKAM MEDIS STIKES DHARMA LANDBOUW PADANG Fitriani, Yulia; Maisa Putra, Deni; Novita, Dian; Handam Dewi, Siti; Alfauzain
Indonesian Journal of Health Information Management Services Vol. 4 No. 1 (2024): Indonesian Journal of Health Information Management Services (IJHIMS)
Publisher : APTIRMIKI

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33560/ijhims.v4i1.88

Abstract

Electronic Medical Record Storage is an activity of storing data on digital-based media in health service facilities. Based on the results of interviews with level 2 students, it was found that there is no application for borrowing and returning medical record files for learning on campus. The aim of this research is to design a system. borrowing and returning medical records as a learning medium for students of STIKES Dharma Landbow Padang. This type of research uses the Research and Development development method. This research was carried out at STIKES Dharma Landbouw Padang in December 2022 - July 2023. The population in this research is RMIK level 2 students with a sample size of 50 people taken by Simple Random Sampling. This research was carried out using interviews and observations, the data was processed using computerization. The research results showed that the flow of borrowing and returning medical record files at the STIKES Dharma Landbouw Padang campus had been done manually in expedition books and treacers, but now it has developed with the design of an application for borrowing and returning medical record files which produces output and uses a black box. which means the application is running well according to student needs. Based on the research results, it can be concluded that there is a need for learning, practice and development of the application system for borrowing and returning medical record files by the STIKES Dharma Landbouw Padang campus in order to make it easier and shorten the time for students to store and return medical record files in order to train students before going out into the field for street vendors or work later.
SOSIALISASI PENYEDIAAN REKAM MEDIS RAWAT JALAN SESUAI STANDAR PELAYANAN MINIMAL DI RUMAH SAKIT X Maisa Putra, Deni; Fitriani, Yulia; Novita, Dian; Fadhila, Washi; Fatullah, Naufal
Indonesian Journal of Health Information Management Services Vol. 4 No. 2 (2024): Indonesian Journal of Health Information Management Services (IJHIMS)
Publisher : APTIRMIKI

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33560/ijhims.v4i2.107

Abstract

Standar Pelayanan Minimal Rumah Sakit Penyediaan rekam medis mengacu pada penyediaan rekam medis mulai dari saat pendaftaran pasien sampai saat rekam medis diberikan atau ditemukan. Waktu standar klinik rawat jalan untuk menyediakan rekam medis adalah ≤ 10 menit. Di Rumah Sakit X masih banyak di dijumpainya keterlambatan dalam penyediaan berkas rekam medis. Tujuan pengabdian ini adalah untuk mengetahui tinjauan waktu penyediaan rekam medis rawat jalan sesuai standar pelayanan minimal di Rumah Sakit X. Metode yang digunakan deskriptif dengan pendekatan kuantitatif menggunakan mengunakan angket untuk menilai dalam kecepatan penyediaan rekam medis, dengan analisis data sesaca univariat. Hasil dalam pelaksanaan sosialisasi sistem penyedian berkas rekam medis sesuai standar pelayanan minimal rumah sakit masih dalam kategori masih ada keterlambatan dan masih belum sesuai dengan standar pelayanan minimal. Berdasarkan pembahasan dan sosialiasi terhadap penyediaan berkas rekam medis perlunya upaya setiap pengambil kebijakan untuk bisa memberikan arahan dan pelatihan bagai mana cara dalam penediaany berkas rekam medis yang berlaku di rumah sakit. Maka dari itu disarankan perlu adanya evaluasi, sosialisasi, pelatihan lebih lanjut terhadap permasalah yang dapat mempengaruhi keterlambatan penyediaan rekam medis rawat.
Co-Authors Ade Wisandra Ade Wisandra Adella Esa Septika Sari Afridon Afridon Agni Fahira Alfauzain Alfauzain, Alfauzain Anadya Afriyanti Anisah Amartia Annisa Nada Shabrina Ashari, Muhammad Al Athiyah Holindra Aulia, Mirza Berly Nisa Srimayarti Chairunnisa Mufli Hunna Devid Leonard Devid Leonard Dian Novita Dian Novita Dian Novita Dian Novita Dian Sari Dicho Zhuhriano Yasli Dicho Zhurhriano Yasli Dinda Putri Anisa Fadhila, Washi Fatullah, Naufal Gusdiansyah, Edo Hakki, Nur Habibah Handam Dewi, Siti HandamDewi, Siti Hendra Nusa Putra Hendra Nusa Putra Hiddati Aulia Indah Oktavia Irvan Zafrant Pratama Juniarti, Neti Kalasta Ayunda Putri Leonard, Devid Mardiawati, Dewi Mellatul Husni Mirza Aulia Muhammad Al Ashari Nesri Helmi Niki Febriandari Nur Habibah Hakki Oktamianiza Oktamianiza Oktamianiza Oktamianiza Oktamianiza Oktamianiza Oktamianiza Oktamianiza Oktavia, Sri Jingga Putri, Kalasta Ayunda Rafika Aini Rahmadhani Rahmadhani Rahmadhani Rahmadhani Rahmadhani Rahmadhani, Rahmadhani Ramadhani Swara Sarah Nur Azizi Shabrina, Annisa Nada Sheizi Prista Sari Sopiana, Nela Srimayarti, Berly Nisa Syarli, Setiadi Tasya Nurul Huda Tri Wijayanto Washi Fadhila Washi Fadhila Washi Fadhila Wisandra, Ade Yasli, Dicho Zhuhriano Yudhanto, Satrio Bagas Yulfa Yulia Yulfa Yulia Yulia Fitriani Yulia Fitriani Yulia Fitriani Yulia Fitriani, Yulia Yulia, Yulfa Yuniar, Mega Zani Safitri