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All Journal Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Jurnal Pengabdian Masyarakat (ABDIRA) COVID-19 : Journal of Health, Medical Records and Pharmacy
Liem, John Barker
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Aerospace Engineering Chemistry Computer Science & IT Health Professions Immunology & microbiology Languange, Linguistic, Communication & Media Medicine & Pharmacology Nursing Public Health Social Sciences Other

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Review of the Completeness of the Medical Resume Form Based on the Assessment Elements of Mirm 15 National Hospital Accreditation Standards (SNARS) at Imelda Pekerja Indonesia Hospital Medan 2021 Liem, John Barker; Rifhan, Zanurul; Simanjuntak, Marta; Sitorus, Mei Sryendang; Alna, Jihan
COVID-19 : Journal of Health, Medical Records and Pharmacy Vol. 2 No. 01 (2024): COVID-19 : Journal of Health, Medical Records and Pharmacy
Publisher : CV. Devitara

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Abstract

Incompleteness in filling out a medical resume will greatly affect the hospital's accreditation assessment listed in the MIRM 15 SNARS standard sub-group Issue 1.1. This study aims to determine the completeness of filling out the resume form based on the assessment elements of MIRM 15 SNARS Edition 1.1 at Imelda Pekerja Indonesia Hospital in Medan. This study uses quantitative and qualitative methods, with a population of 1,355 medical resume forms at Imelda Pekerja Indonesia Hospital Medan in November-December 2021 and a sample of 93 medical resumes which are completed into 100 medical resume forms. Based on the results of the study, it was found that 76 medical resume forms were filled (70%) and 30 medical resume forms were incomplete (30%). score Based on the assessment of SNARS Edition 1.1, the number of complete medical resume forms was 76% with a score of 5 (partially fulfilled) because the achievement range was 29%-79%. The highest completeness on the medical resume form at Imelda Pekerja Indonesia Hospital is found in the patient history component, diagnostic examination, therapeutic procedures and actions, drugs given and drugs when the patient leaves the hospital, the patient's health condition (current status) and follow-up instructions (100% ) Medical resume forms and the lowest completeness were found on physical examination (15%) indication of patients being treated (6%), comorbidities (12) and patient/family signatures (24%) of medical resume forms. Researchers suggest that there is a need for socialization that continuously increases knowledge to medical officers about filling out the complete medical resume form according to SNARS at Imelda Pekerja Indonesia Hospital in Medan.
Evaluation of Clinical Pathway Implementation for Acute Appendicitis at Mitra Medika General Hospital, Medan Tanjung Mulia, 2022 Liem, John Barker; Siregar, Rabia Ulfa
COVID-19 : Journal of Health, Medical Records and Pharmacy Vol. 2 No. 02 (2025): COVID-19 : Journal of Health, Medical Records and Pharmacy
Publisher : CV. Devitara

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This study evaluated the implementation of the Clinical Pathway for acute appendicitis at Mitra Medika General Hospital, Medan Tanjung Mulia, in 2022. The objective was to assess the compliance level of healthcare professionals with the established clinical pathway and to identify factors influencing its application in patient management. A descriptive retrospective design was employed, using medical records of acute appendicitis patients treated during the specified period. Data analysis focused on adherence to diagnostic, therapeutic, and postoperative care standards outlined in the clinical pathway. The results showed that overall compliance was high, particularly in preoperative and operative phases, while postoperative follow-up displayed moderate adherence due to variations in discharge planning and documentation. Factors affecting implementation included staff workload, availability of medical resources, and differences in clinical judgment. It was concluded that the clinical pathway was effectively implemented, although improvements are required to enhance consistency in postoperative care. Strengthening monitoring systems and conducting regular training are recommended to improve adherence and optimize patient outcomes.
Determinan Pelayanan Pendaftaran Terhadap Kepuasan Pasien BPJS Dan Pasien Umum Di RSU Sari Mutiara Lubuk Pakam Tahun 2022 Liem, John Barker; Haruman, Sakinah Tasya; Karo-Karo, Siddik
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Vol. 10 No. 1 (2025): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Februari
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v10i1.1799

Abstract

The level of patient statisfication is considered as one of the most important dimensions of quality and is one of the main indicators of the standard of a health facility which is the result of the influence of health services on the hospital. This study aims to determine the Determinats of Registration Services for BPJS Outpatients and General Patients at Sari Mutiara Lubuk Pakam Hospital in 2022. This study uses a quantitative method, with apopulation is unknown and the sample of 96 people is then rounded up to 100 people. The data were analyzed using Chi-Square test statistics to determine differences in the level of statistification of BPJS and General patients with the registration service of Sari Mutiara Hospital. Lubuk Pakam 2022. Based on the results of the study, it was found that the statisfication of BPJS patients who chose very satisfied 25 people 64.1% satisfied 22 people 50.0% quite satisfied 2 people 14.3% dissatisfied 1 person 33.3% and in General petients who chose very satisfied 14 people 35.9% satisfied 22 people 50.0% quite satisfied 12 people 85.7% dissatisfied 2 people 66.7%. Based on the results of statistical test p value of 0.014 which shows that there are differences in the level of statisfication of BPJS patients and Public Services at Sari Mutiara Lubuk Pakam Hospital in 2022.
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 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.
Co-Authors Alna, Jihan Ardanta, Yanda Christy, Johanna Cosmas Samuel Daeli Erlindai, Erlindai Haruman, Sakinah Tasya Rifhan, Zanurul Ritonga, Zulham Andi Rotonga, Zulham Andi Sabela Hasibuan, Ali Siddik Karo-Karo Simanjuntak, Marta Siregar, Rabia Ulfa Sitompul, Osayku Inesa Sitorus, Mei Sryendang Theresia Hutasoit Valentina Valentina, Valentina Zulfahmi Zulfahmi