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All Journal Jurnal Epidemiologi Kesehatan Komunitas Jambura Health and Sport Journal JISIP: Jurnal Ilmu Sosial dan Pendidikan JUKEJ: Jurnal Kesehatan Jompa Medika: Jurnal Ilmiah Kesehatan Journal of Education And Research
Yulianti, Mega Sara
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Arts Humanities Economics, Econometrics & Finance Education Health Professions Immunology & microbiology Law, Crime, Criminology & Criminal Justice Medicine & Pharmacology Nursing Public Health Social Sciences Veterinary

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KELENGKAPAN INFORMED CONSENT POLIKLINIK BEDAH UMUM RUMAH SAKIT UMUM DAERAH PROVINSI NUSA TENGGARA BARAT Yanti, Ni Komang Wijiani; Yulianti, Mega Sara
Jambura Health and Sport Journal Vol 6, No 1 (2024): Februari
Publisher : Universitas Negeri Gorontalo

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37311/jhsj.v6i1.23722

Abstract

Rekam medis sangat penting untuk proses informed consent sebagai persetujuan tindakan medis. Ketidaklengkapan dalam pengisian informed concent dapat menghambat proses pengajuan klaim kepada Badan Penyelenggara Jaminan Sosial (BPJS). Tujuan penelitian ini adalah mengetahui kelengkapan informed consent pada poliklinik bedah umum di Rumah Sakit Umum Daerah (RSUD) Provinsi Nusa Tenggara Barat (NTB). Jenis penelitian observasional deskripftif. Data dikumpulkan melalui observasi menggunakan check list lalu dilakukan analisis secara deskriptif. Populasi penelitian yaitu 808 dokumen rekam medis. Sampel yang digunakan sebanyak 89 sampel diambil dengan metode simple random sampling. Penelitian menunjukkan bahwa kelengkapan pengisian formulir informed consent pada item diagnosis 100% lengkap, terdapat kategori tidak lengkap pada tindakan kedokteran, tata cara, indikasi tindakan dan alternatif dan risiko, pemberi produk. Berdasarkan hasil tersebut maka disarankan rumah sakit melakukan sosialisasi kepada tenaga kesehatan khususnya dokter terkait pentingnya kelengkapan pengisian formulir informed consent untuk mencapai standar pelayanan minimal 100% dan mengurangi angka ketidaklengkapan dalam pengisian berkas rekam medis demi meningkatan mutu pelayanan kesehatan di rumah sakit.
ANALISIS WAKTU TUNGGU PE/LAYANAN REKAM MEDIS DI POLI DALAM PENDAFTARAN RAWAT JALAN PADA MASA PANDEMI COVID DI RSUD PATUT PATUH PATJU KABUPATEN LOBAR TAHUN 2022 Yulianti, Mega Sara; Yanti, Ni Komang Wijiani
JISIP: Jurnal Ilmu Sosial dan Pendidikan Vol 6, No 4 (2022): JISIP (Jurnal Ilmu Sosial dan Pendidikan)
Publisher : Lembaga Penelitian dan Pendidikan (LPP) Mandala

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.58258/jisip.v6i4.3754

Abstract

Patient waiting time is one indicator in assessing the quality of service in hospitals, if patient waiting time decreases it will affect the quality of service. The length of patient waiting time reflects how the hospital manages the service components that are tailored to the patient's situation and expectations. Based on a preliminary survey at the Patut Patuh Patju Hospital in 2021, the results obtained from the quality aspect of services, especially outpatient waiting times, only reached 50% of the assessment indicator achievements, which means there is a decrease in outpatient waiting times, in addition to patients who want to get outpatient services on average. The average person often complains that it is difficult to get a queue number, this is due to restrictions on the number of patients served during the Covid-19 pandemic. This study aims to determine the waiting time of outpatients during the Covid-19 pandemic. This research is a descriptive analytic study with a sampling technique using simple random sampling. Data were collected using observation sheets and interviews. Data processing uses editing, coding, data entry, cleaning and data analysis using quantitative analysis with descriptive statistics, frequency distribution of respondent characteristics variables (age, gender, education level, occupation, payment method), patient waiting time in medical record services, status patients, how to register patients, and human resources.
CHARACTERISTICS AND PERFORMANCE OF MEDICAL RECORDING OFFICERS IN THE FILING SECTION OF A REGIONAL GENERAL HOSPITAL OF NUSA TENGGARA BARAT PROVINCE Yanti, Ni Komang Wijiani; Yulianti, Mega Sara
JISIP: Jurnal Ilmu Sosial dan Pendidikan Vol 6, No 2 (2022): JISIP (Jurnal Ilmu Sosial dan Pendidikan)
Publisher : Lembaga Penelitian dan Pendidikan (LPP) Mandala

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.58258/jisip.v6i2.3007

Abstract

Patient waiting time is a tangible manifestation of the performance of human resources. Based on the results of a preliminary study conducted by researchers on November 5, 2021 at the NTB Provincial  Hospital, the problems that exist in the filing are delays in returning medical record files from inpatient care, incorrect file storage, wide medical record filing space, so the waiting time for the provision of medical record files not up to standard. The purpose of the study was to identify the characteristics and performance of medical record officers in the filing section of the NTB Provincial Hospital. This type of research is descriptive with a cross sectional design. The population of all medical record officers is 45 people with a sample of 25 people. The sampling technique used incidental sampling, data collection using a questionnaire. Data processing uses editing, coding, data entry, cleaning and data analysis using quantitative analysis with descriptive statistics, frequency distribution of characteristic variables and performance of medical record officers. The results of the research on the characteristics of medical record officers at the NTB Provincial Hospital showed that the average age was >30 years 60%, female sex 52%, diploma education 60%, training 96%, knowledge 88%, years of service >1 year 96%, and the performance level of medical record officers at the NTB Provincial Hospital in the sufficient category is 64%. The suggestion is that medical record officers need to increase knowledge through education as a medical recorder, the higher the education, the better the performance in carrying out the main tasks and functions included in the administration of medical record services at the NTB Provincial Hospital.
Factors Affecting Delays in Retrieval of Inpatient Medical Record Filesat the West NTB Provincial Hospital Yanti, Ni Komang Wijiani; Yulianti, Mega Sara
JISIP: Jurnal Ilmu Sosial dan Pendidikan Vol 7, No 4 (2023): JISIP (Jurnal Ilmu Sosial dan Pendidikan) (November)
Publisher : Lembaga Penelitian dan Pendidikan (LPP) Mandala

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.58258/jisip.v7i4.5737

Abstract

Every patient comes to visit a health care facility for health service needs so that medical record files must always be available, but medical record files often experience delays in returning them. Delays in the retrieval of inpatient medical record files were caused by duplicate medical record files, incorrectly stored, and not completed by the inpatient doctor. The aim of this study was to determine the factors that influence the delay in the retrieval of inpatient medical record files at the NTB Provincial Hospital. The type of research used is quantitative with cross sectional design. The population in this study were all medical record officers at the NTB Provincial Hospital, totaling 45 people with a total sample of 6 retrieval officers. The sampling technique uses incidental sampling. Data collection was carried out by observing or observing all medical record file retrieval officers using a check list. Data processing is done by editing, coding, data entry, and cleaning. Analysis of the data used is descriptive quantitative analysis. The results of the study based on the medical record file officers were categorized as good 0 (0%), and as many as 3 people (50%) categorized as sufficient, while the medical record file officers were categorized as lacking as many as 3 people (50%). The results of the study based on medical record files were categorized as good with a total of 0 (0%), and categorized as sufficient with a yes answer of 10 items (71.4%), while medical record files were categorized as lacking with 4 items (28.6%). It is necessary to increase medical record officers, especially officers in filing, so that their accuracy is increased in separating medical record numbers before storing them so that medical record files are not misplaced so that services at the hospital run smoothly.
Efektifitas Tindakan Talk Down Terhadap Perilaku Kekerasan Pada Pasien Skizofrenia di Ruang Unit Pelayanan Intensif Psikiatri Rumah Sakit Jiwa Mutiara Sukma Provinsi NTB Aswandi, Joni; Yulianti, Mega Sara; Nadia, Dea
Medika: Jurnal Ilmiah Kesehatan Vol 4 No 2 (2024): Medika: Jurnal Ilmiah Kesehatan
Publisher : Universitas Nahdlatul Ulama Nusa Tenggara Barat

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.69503/medika.v4i2.960

Abstract

Schizophrenia is a psychotic condition that affects individual functioning characterized by disorganized thinking, delusions, hallucinations, and maladaptive behavior. Common symptoms of schizophrenia include excessive behavioral changes such as sudden anger, screaming, and even violent behavior. The risk of violent behavior indicates the ability to harm oneself, others, and the environment. In Indonesia, the risk of violent behavior is 0.8% out of 10,000 people. With such a high rate, if left untreated, it can lead to harmful consequences such as self-injury, harm to others, and harm to the environment. Therefore, there is a need for new method or approach to prevent and reduce agitation and aggressiveness in violent behavior and to increase feelings of being cared for, respected, and honored, namely through Talk Down intervention. This study aimed to determine the effectiveness of Talk Down intervention on violent behavior in schizophrenia patients. The research design was quasi-experimental with an experimental approach using pre- post-test with a control group, with a sample size of 70 respondents selected through purposive sampling. Data were collected through questionnaires using interview and observation techniques. The results of the study showed that in the treatment group, before Talk Down intervention, the mean score was 18.26, and after Talk Down, it was 5.20. In the control group, before intervention, the mean score was 18.67, and after, it was 13.8. The Mann-Whitney U test calculation yielded an Asymp. Sig. (2-tailed) of 0.000 < 0.05. It can be concluded that Talk Down intervention is effective in reducing signs of violent behavior symptoms in schizophrenia patients in the UPIP ward of Mutiara Sukma Mental Hospital, NTB Province. It is hoped that Talk Down can be used as a nursing therapy for violent behavior patients.
Analisis Kelengkapan Resume Medis dan Akurasi Koding Terhadap Ketepatan Klaim BPJS Di RSUD Provinsi NTB Tahun 2024 Yulianti, Mega Sara; Urrahmah, Husnuzzia
JUKEJ : Jurnal Kesehatan Jompa Vol 4 No 1 (2025): JUKEJ: Jurnal Kesehatan Jompa
Publisher : Yayasan Jompa Research and Development

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.57218/jkj.Vol4.Iss1.1561

Abstract

Ketidaklengkapan resume medis menjadi salah satu penyebab tertundanya klaim BPJS yang berdampak pada keterlambatan pembayaran dan potensi kerugian finansial bagi rumah sakit. Kelengkapan dokumen serta keakuratan kode diagnosis merupakan komponen penting dalam mempercepat pengajuan dan pencairan klaim sesuai ketentuan INA-CBGs. Penelitian ini bertujuan untuk mengetahui persentase kelengkapan resume medis rawat inap dan keakuratan kode diagnosis terhadap ketepatan waktu klaim BPJS di RSUD Provinsi NTB. Penelitian menggunakan metode deskriptif kuantitatif dengan pendekatan cross-sectional. Populasi sebanyak 7.885 resume medis pasien rawat inap Oktober–Desember 2023, dengan sampel 99 dokumen. Data dikumpulkan melalui observasi dan dianalisis menggunakan SPSS. Kelengkapan tertinggi tercatat pada aspek tidak adanya tipe-x sebesar 100%, sedangkan ketidaklengkapan tertinggi pada autentikasi nama dan gelar dokter sebesar 53,5%. Keakuratan kode diagnosis menunjukkan 84 dokumen (84,7%) dikode benar, 3 dokumen (3,1%) tidak sesuai, dan 12 dokumen (12,1%) tidak dikode. Ketepatan waktu klaim BPJS menunjukkan 84 dokumen (84,7%) tepat waktu dan 15 dokumen (15,3%) terlambat. Kelengkapan autentikasi dan akurasi kode diagnosis masih belum optimal dan menjadi faktor yang memengaruhi ketepatan waktu klaim. Disarankan untuk menyusun dan menerapkan SOP pengisian resume medis yang menekankan autentikasi dan akurasi kode diagnosis. Perlu dilakukan pelatihan rutin bagi dokter dan petugas rekam medis sesuai standar verifikasi BPJS. Audit internal berkala juga perlu dilakukan untuk memastikan kesesuaian resume medis dengan standar INA-CBGs dan PMK No. 76 Tahun 2016.
Studi Tentang Kinerja Petugas Rekam Medis di Rumah Sakit Umum Daerah Provinsi NTB Yanti, Ni Komang Wijiani; Yulianti, Mega Sara
Medika: Jurnal Ilmiah Kesehatan Vol 2 No 1 (2022): Medika: Jurnal Ilmiah Kesehatan
Publisher : Universitas Nahdlatul Ulama Nusa Tenggara Barat

Show Abstract | Download Original | Original Source | Check in Google Scholar

Abstract

Rekam medis merupakan salah satu bukti tertulis tentang proses pelayanan yang yang berisi tentang data klinis pasien selama proses diagnosis dan pengobatan. Pengelolaan rekam medis di rumah sakit adalah untuk menunjang tercapainya tertib administrasi dalam rangka upaya mencapai tujuan rumah sakit, yaitu peningkatan mutu pelayanan kesehatan di rumah sakit. Tujuan penelitian ini adalah menggambarkan kinerja petugas pengelola data rekam medis di ruang penyimpanan Rumah Sakit Umum Daerah Provinsi NTB. Metode penelitian ini menggunakan metode deskriptif. Populasi penelitian adalah seluruh petugas rekam medis dengan sampel berjumlah 25 responden dengan teknik sensus. Teknik analisis menggunakan analisis deskriptif. Hasil penelitian menunjukkan bahwa kinerja petugas rekam medis yang terdiri dari kualitas pekerjaan, kuantitas pekerjaan, kehadiran, supervisi dan konservasi diketahui bahwa sebanyak 9 petugas (36%) mempunyai kinerja yang baik sedangkan sebanyak 16 petugas rekam medis (64%) mempunyai kinerja yang cukup.
Faktor Penyebab Waktu Tunggu Pelayanan Rekam Medik di Pendaftaran Rawat Jalan Pada Masa Pandemi Covid-19 di RSUD Patut Patuh Patju Kabupaten Lobar Tahun 2022 Yulianti, Mega Sara; Yanti, Ni Komang Wijiani
Medika: Jurnal Ilmiah Kesehatan Vol 2 No 1 (2022): Medika: Jurnal Ilmiah Kesehatan
Publisher : Universitas Nahdlatul Ulama Nusa Tenggara Barat

Show Abstract | Download Original | Original Source | Check in Google Scholar

Abstract

Pandemi Covid-19 menyebabkan gangguan di seluruh sektor kehidupan. Penyebaran virus yang sangat cepat menyebabkan angka morbiditas dan mortalitas meningkat dengan pesat, untuk mengurangi kontak di Rumah Sakit diberlakukan pembatasan jumlah kunjungan untuk poli rawat jalan, serta pada masa pandemi dibutuhkan waktu lebih lama untuk menjalankan protokol kesehatan, hal ini mengakibatkan waktu tunggu pelayanan rawat jalan tidak maksimal. Tujuan penelitian ini adalah untuk mengetahui rata-rata waktu tunggu dan menggambarkan ketepatan kedatangan jadwal dokter bertugas sebagai factor yang mempengaruhi waktu tunggu pasien. Metode penelitian ini menggunakan metode deskriptif dengan kombinasi pendekatan kuantitatif dan kualitatif (mix mhetod). Besarnya sampel dalam penelitian ini ditetapkan dengan rumus Slovin sebanyak 97 sampel. Teknik analisis menggunakan analisis deskriptif. Hasil penelitian menunjukkan bahwa Rata-rata waktu tunggu pelayanan rekam medis di pendaftaran rawat jalan pada masa pandemi Covid di RSUD Patut Patuh Patju Kabupaten Lobar Tahun 2022 adalah 1 jam 33 menit.
Analisis Kelengkapan Dokumen Rekam Medis Pada Formulir Ringkasan Masuk dan Keluar Kasus Poli Penyakit Dalam Pasien Rawat Inap di Rumah Sakit Umum Daerah Provinsi NTB Yanti, Ni Komang Wijiani; Yulianti, Mega Sara
Medika: Jurnal Ilmiah Kesehatan Vol 3 No 1 (2023): Medika: Jurnal Ilmiah Kesehatan
Publisher : Universitas Nahdlatul Ulama Nusa Tenggara Barat

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.69503/medika.v3i1.344

Abstract

Rekam medis yang tidak diisi dengan lengkap maka akan berdampak pada keakuratan isi dan aspek kelegalan rekam medik tersebut menjadi tidak sah. Selain itu, akan berdampak pada fungsi dari rekam medik yaitu administratif, legal, financial, research, education, documentation. Formulir ringkasan masuk dan keluar termasuk salah satu formulir rekam medis yang diabadikan artinya formulir yang bernilai guna, yang tidak dimusnahkan. Tujuan penelitian ini untuk mengetahui kelengkapan dokumen rekam medik rawat inap pada formulir ringkasan masuk dan keluar kasus Poli Penyakit Dalam di Rumah Sakit Umum Daerah Provinsi NTB. Jenis penelitian ini deskriptif dengan sampel berkas rekam medis sebanyak 32 berkas. Pengumpulan data menggunakan lembar observasi. Analisis data yang digunakan adalah analisis kuantitatif. Hasil penelitian menunjukan persentase ketidaklengkapan tertinggi pada review identifikasi pasien, yaitu pada item umur, agama, alamat, pendidikan dan status perkawinan sebesar 100%. Persentase ketidaklengkapan tertinggi pencatatan yang baik yaitu pada item pembetulan kesalahan 22%. Pada review laporan yang penting persentase ketidaklengkapan tertinggi yaitu pada item kondisi keluar dan cara bayar sebesar 22% dan persentase ketidaklengkapan tertinggi autentikasi yaitu pada item tanda tangan perawat 100%. Disarankan perlu ditindak lanjut berupa sosialisasi dan adanya ketegasan dari pihak rumah sakit agar dokumen rekam medik khususnya formulir ringkasan masuk dan keluar menajdi lengkap.
Characteristics in Maternal Case During COVID-19 in The Work Area of Patut Patuh Patju Hospital Yulianti, Mega Sara; Yanti, Ni Komang Wijiani
Medika: Jurnal Ilmiah Kesehatan Vol 1 No 1 (2021): Medika: Jurnal Ilmiah Kesehatan
Publisher : Universitas Nahdlatul Ulama Nusa Tenggara Barat

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Abstract

The Covid-19 pandemic has caused disruptions in all sectors of life. The rapid spread of the virus causes morbidity and mortality rates to increase rapidly. Pregnant women are listed as one of the vulnerable groups at risk of being infected with Covid-19 because during pregnancy physiological changes occur which result in a partial decrease in immunity and can have serious consequences for pregnant women. The purpose of this study was to find out the characteristics of the mother in maternal cases during the Covid-19 pandemic at the Patut Patuh Patju Hospital in 2021. This research method uses a quantitative descriptive method with a retrospective approach in the Covid-19 Isolation Room at the Patut Patju Regional General Hospital, Lombok Regency. West from January 2021 to December 2021. The sample size in this study was 157 samples using total sampling. The analysis technique uses descriptive analysis. The results showed that the characteristics of mothers with the most productive age (20-35 years) were 96 (61.5%), the highest high school graduates were 73 (46.5%) and working mothers were 87 (55.1%) . The frequency of maternal cases during the Covid-19 pandemic with the most cases were KPD with 47 cases (29.9%), former SCs with 32 (20.4%) and incomplete abortion with 28 cases (17.8%).
Co-Authors Aditiyani Nugraha Pertiwi Apriani, Lia Apriawan, Andika Aswandi, Joni Ayuningtyas, Parihayani Dian Neni Naelasari Dwi Andayani, Dwi Farida, Warni Fatuhu, Muhamad Siladani Irawansyah Irawansyah Megawati - Muhamad Sadli Muhammad Syukri Nadia, Dea Ni Komang Wijiani Yanti Urrahmah, Husnuzzia Yanti, Ni Komang Wijiyani