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DESAIN SISTEM INFORMASI KELENGKAPAN REKAM MEDIS RAWAT JALAN UNTUK OPTIMALISASI DOKUMENTASI KLINIS Rina Marlina Nurjanah; Falaah Abdussalaam; Irda Sari
INFOKOM (Informatika & Komputer) Vol. 14 No. 1 (2026): JURNAL INFOKOM JUNI 2026
Publisher : POLITEKNIK PIKSI GANESHA

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.56689/infokom.v14i1.3006

Abstract

Outpatient medical record information management at the Catya Husada Pratama Clinic, Bravo 90 Detachment, Kopasgat is currently conducted manually using Microsoft Excel with copy-paste techniques. This condition leads to incomplete data, inaccuracies, and delayed completion of completeness reports due to inefficient workflows. This study aims to design and implement an information system to improve the completeness of outpatient medical record keeping to optimize clinical documentation. The research method applied is qualitative, utilizing data collection techniques through observation, interviews, and literature reviews. System development was carried out gradually and systematically using the Waterfall method. The results identified several key issues: suboptimal completeness of medical record keeping, inaccuracy and untimeliness of manual recording, and delays in returning medical record files. As a solution, a system was designed using flowmaps, context diagrams, DFDs, ERDs, and database specifications via Microsoft Access, consisting of 5 tables (officer, patient, doctor, polyclinic, and completeness). The system was implemented using Visual Basic.Net, which includes a Main Menu, Login Menu, Master Data Forms (Patient, Doctor, Polyclinic, Officer), a Completeness Analysis Form, and a Report Printing Form. System testing demonstrates that this application successfully presents analysis reports, completeness certificates, and visual graphs of analysis results. The author suggests the comprehensive implementation of this digital system to replace manual processes. The outcome of this research is an integrated system that accelerates report generation, minimizes data entry errors, and ensures the accuracy and integrity of clinical patient documentation.
DISAIN SISTEM INFORMASI ANALISIS KUANTITATIF RESUME MEDIS DALAM MENUNJANG REKAM KESEHATAN ELEKTRONIK DENGAN METODE V-MODEL Dyah Rizki Dwi Ariani; Yuda Syahidin; Irda Sari
Journal of Innovation Research and Knowledge Vol. 4 No. 12: Mei 2025
Publisher : Bajang Institute

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.53625/jirk.v4i12.10192

Abstract

Salah satu kegiatan rekam medis yang dilakukan yaitu menganalisa kelengkapan berkas rekam medis. Resume medis adalah ringkasan kegiatan pelayanan rekam medis yang diberikan oleh tenaga kesehatan khususnya dokter selama masa perawatan hingga pasien keluar baik dalam keadaan hidup maupun meninggal. Permasalahan yang sering terjadi adalah prosedur analisa kelengkapan resume medis rawat inap masih optima, kurangnya pemahaman tentang SOP pengisian resume medis rawat inap oleh petugas, seringnya terjadi ketidaklengkapan pengisian resume medis pasien dan keterlambatan dalam pengembalian rekam medis pasien dari ruang perawatan. Penelitian ini dilakukan untuk mendesain sistem informasi kelengkapan pengisian resume medis rawat inap. Metode penelitian kualitatif dengan pendekatan deskriptif digunakan pada penelitian ini, sedangkan V-Model digunakan pada pengembangan perangkat lunak. Hasil dari penelitian ini adalah membuat perancangan sistem informasi kelengkapan pengisian resume medis rawat inap agar lebih efektif dan adanya sosialisasi kepada petugas kesehatan tentang keharusan pengisian resume medis rawat inap, sehingga diharapkan dapat meningkatkan kualitas pelayanan rumah sakit.
ANALISIS KOMPETENSI SDM DALAM KESIAPAN IMPLEMENTASI SIMRS UNTUK MENDUKUNG OPTIMALISASI KLAIM IDRG Cyntia Suci Resma Wati; Irda Sari
An-Najat Vol. 4 No. 2 (2026): Mei : An-Najat: Jurnal Ilmu Farmasi dan Kesehatan
Publisher : STIKes Ibnu Sina Ajibarang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.59841/an-najat.v4i2.4002

Abstract

The implementation of Indonesian Diagnosis Related Groups (IDRG) in the healthcare financing system requires the readiness of Hospital Management Information Systems (SIMRS) and adequate human resource (HR) competencies in managing medical record data, coding, and claims. This study aimed to analyze HR competencies in the readiness to implement SIMRS to support the optimization of IDRG claims at Amanda Hospital, South Cikarang. A descriptive study with quantitative and qualitative approaches was conducted. Data were collected through questionnaires, interviews, observations, and documentation involving 20 informants selected using purposive sampling, comprising medical record officers, coding staff, casemix staff, SIMRS administrators, and information technology personnel. Quantitative data were analyzed descriptively based on the percentage of indicator achievement, while qualitative data were analyzed using the Miles and Huberman model. The results showed that HR competency in the knowledge domain was generally good, with 90% of informants understanding the basic concepts of IDRG, although they still required assistance in its implementation. In the skills domain, 80% of informants were able to operate SIMRS and perform coding according to established procedures. Regarding attitudes, 75% of informants demonstrated commitment and responsibility toward IDRG implementation, while 95% expressed readiness to support its implementation. Management support, training, and cross-unit coordination were reported by 90% of informants, although 25% identified unequal distribution of training as a challenge. HR competency and SIMRS implementation readiness increased from 45% to 90% during January–May 2026. These findings indicate that HR competency is an important component of SIMRS implementation readiness and IDRG claim optimization. Continuous training, technical assistance, and strengthened cross-unit coordination are needed to ensure HR readiness and improve the quality of claim data.
ANALISIS KEPATUHAN PENGISIAN REKAM MEDIS ELEKTRONIK PADA FORMULIR INFORMED CONSENT PASIEN OPERASI DI RUMAH SAKIT AZRA Sheftyzuani Minur; Irda Sari
An-Najat Vol. 4 No. 2 (2026): Mei : An-Najat: Jurnal Ilmu Farmasi dan Kesehatan
Publisher : STIKes Ibnu Sina Ajibarang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.59841/an-najat.v4i2.4004

Abstract

Completion of surgical informed consent forms is an important component of the Electronic Medical Record (EMR) because it relates to administrative aspects, quality of care, and legal protection. However, incomplete entries in several components of the surgical informed consent form were still found at Azra Hospital. This study aimed to determine the compliance rate of surgical informed consent form completion in the EMR at Azra Hospital for the period January – March 2026 based on the completeness of each form component. A descriptive quantitative method with total sampling was used, including 131 surgical informed consent forms. Data were obtained from form recapitulation in Microsoft Excel and the Teramedik application. The results showed that the compliance rate for completing surgical informed consent forms was categorized as good. The component with the highest completeness rate was the patient’s signature at 97,71%, while the lowest completeness rate was found in the family witness name at 78,63%. The study concluded that compliance in completing surgical informed consent forms at Azra Hospital is generally good, but improvement is needed for certain components, particularly the name and signature of the family witness, so that all forms are fully completed according to regulations.
Co-Authors Aan Andarwati Abdul Qudus Abdussalaam, Falaah Ade Irma Suryani Adellia Permatasari Hartono Adinda Amalia Nurussyifa Adinda Febryllia Nanda Putri Bintari Aeni, Lafani Nur Agustin, Wulan Trie Ain Sodikin, Risma Nurul Akhmad Setiawan Al Fira Putriyanti Alfina Nur Aini Alifa Nur Azizah Althof, Dzaki Alvi Fahreza Amanda Putri Ghaisani Andara, Yudha Mulya Andini Kusdi Antini Anggriani, Mia Anisha, Selly Puji Annisa Syahwa Renjani Annisa Wijaya, Firgi Any Nurlatifah Ara Ariska Arfiandi ARIYANA ADY WIBAWA Aulia Fabia Aulya, Fajrina Avif Abdul Aziz Az-Zahra Rizky Aulia Azzaidi, Jihad Azzizah, Wulandari Gustina Bunga Efendi Candra Fatihah, Dian Candra Mecca Sufyana Chandra Saputra Cyntia Suci Resma Wati D.yani Dafiq Farhan Nurdias Dendi Setia Dewi Listiawati Astuti Dhiu, Yuliana Angelina Dhiva Sevia Dian Fitriani Diansyah Dilla Oktavitia Sjachrizal Dina Rismawati Divvy Dwi Ariani, Nurul Dwi Handoko Dyah Rizki Dwi Ariani Dzaki Althof Elicukia Elvira Handayani Elvira Handayani, Elvira Fabia, Aulia Fadhil Rifky Saefulloh Fadila, Tiwi Fahmi Ridwan Fahrudin, Hanif Fajrina Aulya Fauzan Mahar Dhika Rahmat Febrian Adiwijaya, Aditya Ferdiansyah, Muhammad Siraz Fika Nur Afifah Fika Nur Afifah Fikri Febriansyah Firgi Annisa Wijaya Franki Franki Ghina Farrah Fadhilah Gunawan, Erix Hafsah Ghina Ghaida Gunawan Hana Viranty Kahdini Hartono, Adellia Permatasari Hasna Latipah Sakinah Heni Kurnia Ningsih Herfiyanti, Leni Herlambang, Muhammad Bayu Hermawan, Putra Pangestu Hernawati, Euis Hidayat, M Taofik Ichsan, Revanza Maulana Ika Novita Sari Ika Rahman Indra Setia Budi Indri Ismawati Inka Rahmawati Iqbal Iskandar Zulkarnain Irfansah Irine Ramadhiane Iswaliyah, Rabialda Isya, Ghen Maulana Jeri Sukmawijaya Jeri Sukmawijaya Jihad Azzaidi Johni S Pasaribu Kesumawaty, Henny Khoirul Ihsan Khoirunnisa, Diana Kirana, Sri Ratu Dewi Kurniawan, Moh Bagus Laowo, Elisabeth Eunike Switenia Loren Dwi Okta Herbiana M Taofik Hidayat Maimun Maimun Maulana, Rifqi Maulidayanti, Rini Meilani, Silvi Milatun Khasanah Moh Rifky Moh. Rizky Adriansyah Muhamad Alfin Alamsyah Muhamad Rizki Muhammad Bayu Herlambang Muhammad Fajar Ramadhan Muhammad Rafiq Rafiuddin Muhammad Siraz Ferdiansyah Muhammad Yasin Mujahidah Kamil, Hanifah MUSYARROFAH, TAMI MUGHNIATUL Nabila Nur Raihanny Ali Nabilla Nur Hasna Nadia Rizki Pratami Najmuddin, Muhammad Naufal Nanda Novyadianti Narjati Soejoto, Nina Nasrulloh Imanudin Nela Noviyanti Neneng Yuniarty Nidaul khasanah Niken Dian Utami Nina Nursolihah Nisa Sri Penti Nisa, Zahira Novi Octaviani Novien Putri R Nunung Mardiah Nunung Mardiah Nur Wahidah, Zahrah Nur’ilmi, Wina Nursolihah, Nina Nurul Aulia Yulianti Nurul Dwi Ariyani Nurul Fadillah Nurul Janah, Suci Amalia Nurussyifa, Adinda Amalia Nur’ilmi, Wina Octaviana, Vina Oktaviana, Rizki Salma Pasaribu, Johni S Penti, Nisa Sri Poni Sapitri Pradysta, Linggar Adjie Pramudita, Cindy Surya Puseng Manik Qori Billqist Aina Yusuf Raden Rakasiwa Wijaya Rahayu, Fitri Mardiani Rahayu, Nisa Rahmat Rahmawati, Risa Luthfiani Raihanny Ali, Nabila Nur Raisa Salsabila Raisa Siti Khoirunnisa Ramadhan, Fadhlurrahman Dwi Ramadhan, Reno Ramdhani, Esa Maulana Ratih Purnama Sari Reno Ramadhan Reza Maulana, Lutfi Rian Rusmana Rima Rismawati Rina Hamidah Rina Kurniawati Rina Kurniawati Rina Marlina Nurjanah Rini Maulidayanti Rini Suwartika Kusumadiarti Rini Tisnawati Risma Nurul Ain Sodikin Rivan Tauvik Rizki Nurarif Faturrahman Rizky Tarenta Sari Rosdiana Lay Here Rukmini Minii Rustiawati, Senja Saefulloh, Fadhil Rifky Saepudin, Shofia Nurjannah Safira Nur Sabrina Safira Wulandari Sakinah Sania Fansilia Sapitri, Poni Saputra, Riska Oktaviani Septiana, Fanny Nur Setyawan, Adhita Arif Sheftyzuani Minur Shofia Nurjannah Saepudin Silvi Meilani Sintya Sisca Nurul Ratnaningrum Siti Insani Siti Silfia Sya'bani Siti Sofi Dzakia Alawiah Siti Wulandari Solihah, Yayu Siti Sri Dewi Wahyuni Sudrartono, Tiris Sukmawijaya, Jeri Supian Supriadi Supriadi, Redi Suyanti Suyanti Syahidin, Yada Syahputra, Ananta Khoirurrizal Syifa Ansori Tarenta Sari, Rizky TONI KURNIA SETIA BUDI Ulfah, Annisa Vahreza, Phahira Han Vina Octaviana Vitaloka, Rosida Wahid Sanjay Wahyu Permana Wina Nur’ilmi Wulan Anggela Yayu Siti Solihah Yuanita Alfa Oma Wele Yuda Syahidin Yudha Mulya Andara Yunengsih, Yuyun Zahra, Faridah Fathimatuz Zilvia, Leziza