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Journal : Journal of Community Empowerment

PENINGKATAN AKURASI PENGODEAN DIAGNOSIS CEDERA PENYEBAB LUAR MELALUI SOSIALISASI MANAJEMEN INFORMASI ASUHAN KEPERAWATAN PASIEN GAWAT DARURAT PADA MAHASISWA PROFESI NERS Nurdiyansyah, Andi Karisma; Darussalam, Miftafu; Asgiani, Piping; Praptana, Praptana
Journal of Community Empowerment Vol 4, No 2 (2025): September
Publisher : Universitas Muhammadiyah Mataram

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31764/jce.v4i2.34427

Abstract

ABSTRAK                                                    Analisis Situasi: Pengodean penyakit, khususnya external cause (penyebab luar) dalam rekam medis pasien gawat darurat, sangat esensial namun sering terkendala akurasinya karena kurang optimalnya kelengkapan dokumentasi asuhan keperawatan oleh perawat. Permasalahan ini menuntut peningkatan kompetensi manajemen informasi pada calon tenaga kesehatan. Tujuan: Pengabdian ini bertujuan meningkatkan pemahaman mahasiswa Profesi Ners UNJAYA tentang pentingnya manajemen informasi asuhan keperawatan dalam mendukung akurasi diagnosis cedera luar. Metode: Kegiatan dilaksanakan melalui penyuluhan berbasis transfer ilmu pengetahuan dan teknologi. Mitra Sasaran: Mitra kegiatan ini adalah 51 mahasiswa Profesi Ners UNJAYA. Evaluasi peningkatan pemahaman dilakukan menggunakan metode pre-test dan post-test. Hasil Kegiatan: Terjadi peningkatan pemahaman yang signifikan. Akurasi rata-rata kelas meningkat dari 91% menjadi 100%, disertai penurunan waktu pengerjaan rata-rata dari 2 menit 48 detik menjadi 1 menit 21 detik. Luaran kegiatan ini adalah publikasi artikel ilmiah pada jurnal terakreditasi dan peningkatan kompetensi mahasiswa dalam pengelolaan informasi klinis.. Kata Kunci: Manajemen Informasi Asuhan Keperawatan; Akurasi Diagnosis; Cedera Luar ABSTRACTSituation Analysis: Disease coding, particularly for external causes in emergency patient medical records, is essential but its accuracy is often challenged due to suboptimal completeness of nursing care documentation. This issue necessitates increasing the information management competency of Professional Nursing students, as they are future healthcare personnel. Objective: This community service program aimed to enhance the understanding of UNJAYA Professional Nursing students regarding the importance of nursing care information management in supporting the accuracy of external injury diagnoses. Implementation Method: The activity was carried out through training and counseling based on the transfer of knowledge and technology. Target Partner and Participants: The partner for this activity was 51 Professional Nursing students at UNJAYA. Evaluation of understanding improvement was conducted using pre-test and post-test methods. Activity Results: The program achieved a significant increase in understanding. The class-average accuracy improved from 91% to 100%, accompanied by a decrease in the average completion time from 2 minutes 48 seconds to 1 minute 21 seconds. The outputs of this activity are the publication of a scientific article in an accredited journal and a measurable increase in student competence in clinical information management.Keywords: Nursing Information Management; Diagnosis Accuracy; External Injury; Professional Nursing Students
PERAN MONITORING DAN EVALUASI DALAM MENGUATKAN KINERJA STAF DAN MUTU LAYANAN REKAM MEDIS Asgiani, Piping; Nurdiyansyah, Yuli; Karisma, Andi Astuti; Praptana, Praptana; Aninda, Ida
Journal of Community Empowerment Vol 4, No 2 (2025): September
Publisher : Universitas Muhammadiyah Mataram

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31764/jce.v4i2.34399

Abstract

ABSTRAK                                                                            Permasalahan dalam unit kerja rekam medis di beberapa rumah sakit masih sering ditemukan, terutama terkait kurangnya monitoring dan evaluasi (monev) kinerja staf yang berdampak pada ketidakseimbangan beban kerja, kesalahan pengkodean diagnosis, serta kendala koordinasi antar staf. Tujuan kegiatan pengabdian ini adalah meningkatkan pemahaman staf rekam medis mengenai pentingnya monev sebagai upaya mendukung mutu pelayanan rumah sakit. Kegiatan dilaksanakan di RS Mitra Paramedika pada tanggal 5 Agustus 2025 dengan metode sosialisasi, diikuti oleh 10 partisipan dari unit kerja rekam medis. Tahapan kegiatan meliputi: (1) koordinasi awal dengan manajemen rumah sakit dan unit rekam medis; (2) penyusunan materi dan instrumen evaluasi; (3) pelaksanaan sosialisasi dan diskusi partisipatif; (4) pelaksanaan pretest dan posttest; serta (5) monitoring dan evaluasi tindak lanjut hasil kegiatan. Evaluasi dilakukan melalui pretest dan posttest untuk mengukur peningkatan pengetahuan, serta diskusi partisipatif untuk mengidentifikasi permasalahan aktual di lapangan. Hasil kegiatan menunjukkan adanya peningkatan pemahaman peserta sebesar 13,6% dari hasil pretest ke posttest, serta lahirnya rekomendasi perlunya instrumen monev yang lebih spesifik sesuai job description staf rekam medis, forum evaluasi rutin, serta pemanfaatan digitalisasi agar hasil monitoring lebih akurat dan mudah ditindaklanjuti. Dengan demikian, kegiatan ini berkontribusi dalam peningkatan softskill manajerial staf rekam medis dan mendukung tercapainya mutu pelayanan rekam medis yang lebih optimal. Kata kunci: rekam medis; monitoring; evaluasi kinerja; mutu pelayanan; pengabdian masyarakat ABSTRACTProblems within medical record units in several hospitals are still frequently encountered, particularly related to the lack of monitoring and evaluation (monev) of staff performance. This situation leads to an imbalance of workload, errors in diagnostic coding, and difficulties in staff coordination. The aim of this community service activity was to enhance the understanding of medical record staff regarding the importance of monitoring and evaluation as an effort to support the quality of hospital services. The activity was carried out at Mitra Paramedika Hospital on August 5, 2025, using a socialization method and was attended by 10 participants from the medical record unit. The stages of the activity included: (1) initial coordination with the hospital management and the medical record unit; (2) preparation of materials and evaluation instruments; (3) implementation of socialization and participatory discussions; (4) administration of pre-test and post-test; and (5) monitoring and evaluation of the follow-up actions. Evaluation was conducted through pre-test and post-test to measure knowledge improvement and participatory discussions to identify actual problems in the field. The results showed an increase in participants’ understanding by 13.6% from pre-test to post-test, and produced recommendations such as the need for more specific monitoring and evaluation instruments tailored to the job descriptions of medical record staff, the establishment of regular evaluation forums, and the utilization of digitalization to ensure that monitoring results are more accurate and easier to follow up. Thus, this activity contributed to improving the managerial soft skills of medical record staff and supported the achievement of more optimal quality in medical record services. Keywords: medical records; monitoring; performance evaluation; service quality; community service