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PEMBERIAN FORMULIR REKAM MEDIS DIBAGIAN PENDAFTARAN PADA KEGIATAN KHITANAN MASAL AL-KHITAN MADINAH BANJARMASIN Estiyana, Ermas; Yunita, Nirma
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.v3i1.1274

Rekam medis adalah berkas yang berisikan catatan dan dokumen tentang identitas pasien, pemeriksaan, pengobatan, tindakan, dan pelayanan yang telah diberikan kepada pasien. Sedangkan formulir rekam medis adalah formulir rekam medis sebagai alat pengumpulan data pasien yang di butuhkan harus di desain secara efektif dan efesien Khitan atau sirkumsisi (Inggris: circumcision) merupakan tind akan memotong atau menghilangkan sebagian atau seluruh kulit penutup depan dari penis. Frenulum dari penis dapat juga dipotong secara bersamaan dalam prosedur yang dinamakan frenektomi. Kata sirkumsisi berasal dari bahasa Latin circum (berarti "memutar") dan caedere (berarti "memotong"). Massal merupakan mengikutsertakan atau melibatkan orang banyak dalam suatu kegiatan seperti nikah, khitanan dan sebagainya. Pengabdian masyarakat ini bertujuan untuk menginformasikan pentingnya Informed Consent. Pengabdian masyarakat dilaksanakan di Al-Khitan Madinah Banjarmasin, dengan sasaran Petugas Kesehatan Al-Khitan Madinah Banjarmasin. Diskusi terarah selama 30 menit. Pemberian formulir rekam medis dibagian pendaftaran di Al-Khitan Madinah Banjarmasin sangat diperlukan karena dapat memberi / mengumpulkan segala informasi pasien terkait pelayanan yang diberikan sehingga dapat digunakan untuk berbagai kepentingan.

Desain Formulir Rekam Medis Di Bagian Pendaftaran Pada Kegiatan Khitanan Masal Al-Khitan Madinah Banjarmasin Estiyana, Ermas; Yunita, Nirma
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.v8i2.1256

In all health services it is mandatory to provide recording services medical records, as for the benefits of medical records, one of which is useful as written evidence of acts of service to a patient, too able to protect the legal interests of the patient concerned, hospitals and doctors and other health workers. Medical record is a file that contains notes and documents regarding patient identity, examination, treatment, actions, and services that have been given to patients. Al-Khitan Banjarmasin, which has been established since 2016, in every implementation of mass circumcision does not have a medical record form. The purpose of this study was to make a medical record form in the registration section of the Al-Khitan Medina Banjarmasin mass circumcision. This research method is a qualitative descriptive research. The subjects in this study consisted of the main informants who were registration officers of Al-Khitan Medina Banjarmasin, triangulation informants who were in charge of Al-Khitan Medina Banjarmasin, using observation and interview guide instruments. The data analysis technique is descriptive qualitative. The results of this study are the design of medical record forms that are made by taking into account the anatomical aspects, physical aspects and content aspects. The anatomical aspects of this design include the title of the form, the name of the circumcision house, Al-Khitan, Medina, Banjarmasin, the address of the circumcision house, no. medical record, introduction, basic information explaining the purpose of using the form in question, instructions containing clear instructions for fillers to write down patient data later. Physical aspects are made according to using black ink, white paper color, HVS paper material, A4 paper size, Aspects of the contents of the form are designed consisting of number, date of visit, history of illness, action, therapy/medicine, name and initials of the officer.

Keselamatan dan Kesehatan Kerja (K3) Petugas Rekam Medis Ruang Filling di Rumah Sakit Bhayangkara Tingkat III Banjarmasin Husin, Husin; Yunita, Nirma
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Vol. 9 No. 2 (2024): 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.v9i2.1673

Filling unit rekam medis mempunyai peran penting dalam pemeliharaan rekam medis terutama dalam hal penyimpanan dan perlindungan rekam medis. Penyimpanan rekam medis dapat berjalan dengan baik apabila fasilitas penunjang dalam kegiatan penyimpanan tersedia dan lingkungan kerja mendukung sehingga dapat memudahkan dalam pengambilan, penyediaan dan penyimpanan rekam medis. pengambilan dan penyimpanan dokumen rekam medis, petugas filling pernah tertimpa dokumen rekam medis, tergores dokumen rekam medis, rak rekam medis, petugas filling terjatuh saat mengambil dokumen rekam medis yang tinggi. Sehingga diteliti serta diketahui penerapan keselamatan dan kesehatan kerja (K3) berdasarkan faktor sumber daya manusia dan faktor lingkungan kerja di Rumah Sakit Bhayangkara Tingkat III Banjarmasin. Jenis penelitian dalam penelitian ini adalah kualitatif dengan pendekatan deskriptif. Subjek penelitian ini berjumlah 3 orang yaitu Kepala Unit Rekam Medis sebagai informan 1, Petugas filling rawat jalan sebagai informan 2 dan petugas filling rawat inap sebagai informan 3. Instrument penelitian ini menggunakan pedoman wawancara danobservasi. Hasil penelitian ini adalah Penerapan keselamatan dan kesehatan kerja (K3) di Rumah Sakit Bhayangkara Tingkat III Banjarmasin belum berjalan baik berdasarkan faktor sumber daya manusia dalam penggunaan alat pelindung diri (APD) sebagian besar menggunakan masker, berdasarkan faktor lingkungan kerja pada ruang filling rawat jalan pencahayaan dan jarak antar rak belum memenuhi standar, pada ruang filling rawat inap suhu, kelembaban, pencahayaan dan jarak antar rak belum memenuhi standar. Sehingga perlu sosialisasi penerapan penggunaan APD dan pengecekan sarana prasarana secara berkala terhadap sarana prasarana untuk pemenuhan standar ruang filling

STUDI DESKRIPTIF PELAKSANAAN SENSUS HARIAN RAWAT INAP RUMAH SAKIT BHAYANGKARA TINGKAT III HOEGENG IMAN SANTOSO BANJARMASIN Yunita, Nirma; Anhar, Aus Al; Ningsih, Eka Rahma
Jurnal Kajian Ilmiah Kesehatan dan Teknologi Vol 7 No 1 (2025)
Publisher : Politeknik Unggulan Kalimantan

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52674/jkikt.v7i1.240

Inaccurate filling of the daily inpatient census impacts the discrepancy in the hospital's performance (statistics). This study aims to examine the daily inpatient census at Bhayangkara Level III Hospital Hoegeng Iman Santoso Banjarmasin. This research uses a qualitative study with a descriptive approach, collecting data through observation and interviews. The subjects of this study are 7 individuals, including the Head of the Medical Records Unit, the Head of the Care Room, and IT staff. The results show that the implementation of the daily inpatient census involves one person responsible for each care room, while the daily census recap is performed by one person from the medical records department. The quality of census officers has been enhanced through training and socialization on how to manually fill out the inpatient daily census. The last education of the medical record staff responsible for the daily inpatient census recap is a DIII in medical records. The daily manual census recap is done using Microsoft Excel. The machine used for the daily inpatient census meets the needs of the staff. Additionally, there is a Standard Operating Procedure (SOP) for the manual daily census, but none for the SIMRS daily census. The implementation of the manual inpatient daily census does not fully comply with the hospital's SOP, as some staff inconsistently record the census for more than 24 hours. Materials used include Microsoft Excel with a daily census format created by the head of the medical records unit.

FAKTOR RISIKO KEJADIAN DIARE PADA BALITA DI PUSKESMAS P BANJARMASIN Solehin, Muhammad Mukhlis; Yunita, Nirma
Jurnal Kajian Ilmiah Kesehatan dan Teknologi Vol 7 No 1 (2025)
Publisher : Politeknik Unggulan Kalimantan

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52674/jkikt.v7i1.244

Diarrhea remains a leading cause of morbidity and mortality among toddlers, especially in developing countries like Indonesia. This study aimed to describe the incidence of diarrhea and its associated risk factors among toddlers in the working area of P Public Health Center, Banjarmasin. A descriptive study with a cross-sectional approach was used. A total of 265 toddlers were selected using total sampling. Data were collected through questionnaires and observation and analyzed descriptively. Results showed that the prevalence of diarrhea was 2.39%. Most toddlers were aged 1–12 months (30.57%). The most dominant risk factor was poor handwashing behavior (52%), followed by inadequate sanitation and unsafe water access (48%). Exclusive breastfeeding was not found to be a risk factor among diarrhea cases. These findings indicate that hygiene behavior and environmental sanitation play crucial roles in preventing diarrhea. Health workers should provide educational and promotive interventions to raise public awareness about personal and environmental hygiene.

Manajemen Kesiapan Rekam Medis Elektronik Di Rumah Sakit TK III DR. R. Soeharsono Banjarmasin Noor, Fatmawati Bakri; Yunita, Nirma; Ningsih, Eka Rahma
Jurnal Kajian Ilmiah Kesehatan dan Teknologi Vol 6 No 1 (2024)
Publisher : Politeknik Unggulan Kalimantan

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52674/jkikt.v6i1.130

Health facilities are currently required to implement electronic medical records. Minister of Health Regulation Number 24 of 2022 concerning medical records. Every health service facility is required to implement electronic medical records. Therefore, readiness is needed to see the success of implementing RME in hospitals, which is currently still in the process of including forms available at the hospital into SIMRS to be applied. This study aims to determine the readiness of electronic medical records at the TK III Dr.R.Soeharsono Banjarmasin Hospital. This research method uses qualitative research with a descriptive research design. This research instrument uses interview and observation guidelines. The research subjects were the head of medical records, IT officer, inpatient registration officer and outpatient registration officer. The results of this research are that readiness in terms of quantity is adequate and in terms of quality is not yet adequate, readiness in terms of methods, there are no standard operating procedures, readiness in materials, there are no facilities, hardware is not ready and software is not ready, readiness of materials in manual medical records is currently it is still in use and will be transferred in stages, while the electricity or generator and computer network are not yet ready because there are still frequent problems with power outages and network disruptions. Based on the research results, it can be concluded that the readiness to implement electronic medical records at TK III Dr Hospital. R. Soeharsono Banjarmasin is not yet fully ready.

Kesiapan Petugas Berdasarkan Pengetahuan Dalam Penerapan Rekam Medis Elektronik Di Puskesmas SMB Yunita, Nirma; Rusdiansyah, Rusdiansyah
Jurnal Kajian Ilmiah Kesehatan dan Teknologi Vol 6 No 2 (2024)
Publisher : Politeknik Unggulan Kalimantan

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52674/jkikt.v6i2.170

Many obstacles occur in the implementation of electronic medical records in health facilities due to the unpreparedness of officers. The implementation of Electronic Medical Records at the SMB Health Center is in the transition stage using the E-Puskesmas application. The use of the E-Puskesmas application has not been fully implemented because officers are constrained in understanding how to fill out the form on the E-Puskesmas application and their skills in using computers are still lacking. The purpose of this study was to determine the readiness of officers based on their knowledge in the implementation of electronic medical records at the SMB Health Center. The type of quantitative research is a descriptive approach, the sampling technique uses total sampling and the research instrument is a questionnaire. Most of the knowledge is good as many as 6 people (93.2%) and knowledge is lacking as many as 2 people (6.8%) about electronic medical records in general and has legal value at the SMB Health Center. Officers need to attend training and seminars on electronic medical records to improve their knowledge in supporting their work.

PEMBERIAN INFORMED CONSENT KHITANAN MASAL AL KHITAN MADINAH BANJARMASIN Yunita, Nirma; Estiyana, Ermas
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.v4i1.1684

Informed Consent adalah suatu proses yang menunjukkan komunikasi yang efektif antara dokter dengan pasien, dan bertemunya pemikiran tentang apa yang akan dilakukan dan apa yang tidak akan dilakukan terhadap pasien. Rekam medis adalah berkas yang berisikan catatan dan dokumen tentang identitas pasien, pemeriksaan, pengobatan, tindakan, dan pelayanan yang telah diberikan kepada pasien. Khitan atau sirkumsisi (Inggris: circumcision) merupakan tindakan memotong atau menghilangkan sebagian atau seluruh kulit penutup depan dari penis. Frenulum dari penis dapat juga dipotong secara bersamaan dalam prosedur yang dinamakan frenektomi. Kata sirkumsisi berasal dari bahasa Latin circum (berarti "memutar") dan caedere (berarti "memotong"). Massal merupakan mengikutsertakan atau melibatkan orang banyak dalam suatu kegiatan sepertinikah, khitanan dan sebagainya. Pengabdian masyarakat ini bertujuan untuk menginformasikan pentingnya Informed Consent. Pengabdian masyarakat dilaksanakan di Al-Khitan Madinah Banjarmasin, dengan sasaran Petugas Kesehatan Al-Khitan Madinah Banjarmasin. Diskusi terarah selama 30 menit. Pemberian Informed Consent di Al-Khitan Madinah Banjarmasin sangat diperlukan karena dapat memberi perlindungan pasien terhadap tindakan petugas kesehatan Al- Khitan Madinah Banjarmasin yang tidak sebenarnya tidak diperlukan dan memberi perlindungan hukum kepada petugas kesehatan Al- Khitan Madinah Banjarmasin terhadap suatu kegagalan.

Efektifitas Aplikasi Pendaftaran Rawat Jalan Si Palui Terhadap Produktivitas Petugas Registrasi UPT Puskesmas Martapura 1 Kabupaten Banjar Nisa, Khairun; Yunita, Nirma
Jurnal Kesehatan Indonesia Vol 14 No 2 (2024): Maret 2024
Publisher : HB PRESS

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33657/jurkessia.v14i2.912

The quality of service based on the outpatient registration application has been implemented by the Martapura 1 Health Center since 2019 and this is a technological innovation developed to simplify health services at the health center. So the operation of the Palui outpatient registration application should be carried out as closely as possible by the registration officer. However, in fact, the officers who act as admins controlling the operation of the application are deemed not to have the qualifications, one of which is that all non-medical recording officers, their responsiveness and concern for the operation of the Si Palui outpatient registration application are considered to be less than optimal. The aim of this research is to find out more deeply about the effectiveness of the Si Palui outpatient registration application on the productivity of UPT registration officers at Martapura 1 Health Center, Banjar Regency. This research is descriptive research with a qualitative approach. The number of samples was 4 people consisting of the Head of Medical Records and Outpatient Registration Staff. The results of the research are that the effectiveness of the outpatient registration application at Palui UPT Puskesmas Martapura 1 in terms of the aspects of achieving goals, integration and adaptation is included in the fulfilled category because it makes it easier for people to register for outpatient care. The productivity of registration officers on average falls into the High Productivity category of UPT Puskesmas Martapura 1. In conclusion, there is a link between the effectiveness of the Si Palui outpatient registration application and the productivity of UPT registration officers at Puskesmas Martapura 1.

Uji Validasi Rancangan Aplikasi Kelengkapan Resume Medis di Klinik Almeta Medika Yunita, Nirma; Persadha, Galih; Husin, Husin
Jurnal Kesehatan Indonesia Vol 14 No 1 (2023): November 2023
Publisher : HB PRESS

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33657/jurkessia.v14i1.914

The quality of medical records becomes more valuable if the information written is complete, especially on the medical resume. Complete medical resume writing at Almeta Medika Clinic Banjarmasin has not been carried out, this causes patient information to be incomplete. So a complete medical resume application was designed. This research aims to validate the complete medical resume application at the Almeta Medika Clinic, Banjarmasin. This research method is descriptive qualitative, collecting data using questionnaires and checklists. The subjects in this research were medical records officers, Almeta Medika Banjarmasin clinic managers, IT expert respondents and materials experts. The results of this research were that by testing it was found that the design of the ERD, DFD and application for complete medical resumes at the Almeta Medika Banjarmasin Clinic contained a login, dashboard, 4 components of quantitative analysis and the results of quantitative analysis reports/summaries. ERD and DFD were created using Microsoft Visio and the medical resume application was created using Microsoft Access after identifying user needs and identifying data requirements. The complete medical resume application at Almeta Medika Clinic Banjarmasin has been designed according to the clinic's needs. Validation with medical records officers, Almeta Medika Banjarmasin clinic manager, IT expert respondents and material experts found the appropriate category. Validation testing of the medical resume completeness application at Almeta Medika Clinic Banjarmasin is designed according to the clinic's needs and is feasible to implement.

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