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Nina Rahmadiliyani Rahmadiliyani
STIKes Husada Borneo
Health Professions Medicine & Pharmacology

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Implementasi Electronic Health Record (EHR) Pada Poli Rawat Jalan Di Rumah Sakit Umum Daerah Ratu Zalecha Martapura Nina Rahmadiliyani Rahmadiliyani; Putri Putri; Rina Gunarti
Jurnal Kesehatan Indonesia Vol 9 No 3 (2019): Juli
Publisher : HB PRESS

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (83.046 KB) | DOI: 10.33657/jurkessia.v9i3.186

Abstract

A system of Electronic Health Record (EHR) is an activity computerized the contents of the medical record and process related. Based on the preliminary studies in Hospital of Ratu Zalecha Martapura obtained that already some clinics that implement EHR systems and for some clinics will get their turn to apply the system. The purpose of this research was to identify the security system (security), clinical support (clinical support), and reports (report) on the system of the EHR. The method of this research uses descriptive research with qualitative analysis. Research instrument this is manual observation and interview guidelines. This research was conducted to 8 informant head installation medical record, IT officers, three doctors and three nurses. The results of research at in Hospital of Ratu Zalecha Martapura to be able to access the EHR user must use a username and password. Username and password are made according to their respective limits and authority. Clinical support in the system is good, doctors and nurses fill their own diagnoses into EHR applications, service time is more effective and more efficient so as to improve patient services. Reports produced were reports of 10 major outpatient diseases, outpatient visit reports, daily outpatient census reports, RL1, RL2, RL3, RL4 and RL5.
Pemeliharaan dan Pengendalian Pencegahan Infeksi Rekam Medis COVID-19 oleh Petugas Rekam Medis Nina Rahmadiliyani Rahmadiliyani; Najla Shaffiya Putri
Jurnal Kesehatan Indonesia Vol 11 No 3 (2021): Juli 2021
Publisher : HB PRESS

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33657/jurkessia.v11i3.442

Abstract

The coronavirus can last between four and five days in various objects aluminum, wood, paper, plastic, and glass objects. It is spread through paper (especially medical record documents) and still becoming a risk. Maintenance of COVID-19 medical records had not been carried out according to the PORMIKI’s instructions. The records were not put in plastics or containers and not stored in a special place. This study aimed to determine the maintenance and control of COVID-19 infection prevention by medical record officers in 2021. This study used a qualitative descriptive method. The main informants were coding officers, and the triangulation informants were the head of the medical record installation and the isolation room administration officer. The research instruments were observation and interview guidelines. We used descriptive analysis. The results showed that Standard Operational Procedure (SOP) of the COVID-19 medical records maintenance at Idaman Hospital, Banjarbaru, was not yet available. The observation results showed that the officers obeyed to wear masks during working, wash hands routinely using hand rub, clean the tables or other flat surfaces before and after working, and minimize the contact between patients or their families and medical records. However, some procedures were not carried out (e.g., did not put the medical records in yellow plastics, container boxes, or a special place. The hospital should make an SOP regarding the maintenance of medical records for COVID-19 patients that the officers should comply with and anticipate the potential for workers to have COVID-19.
A Ketepatan Penentuan Kode Diagnosis Utama Penyebab Kematian Pada Kasus Stroke Di RSUD Brigjend H. Hasan Basry Kandangan Nina Rahmadiliyani Rahmadiliyani; Aida Fitria
Jurnal Kesehatan Indonesia Vol 9 No 2 (2019): Maret
Publisher : HB PRESS

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (124.286 KB) | DOI: 10.33657/jurkessia.v9i2.165

Abstract

World Health Information (WHO) establishes a set of rules or procedures that must be followed for granting kodefikasi UCoD determination of the code on certificate of death must pay attention to the sequence of events leading to the death of the disease and the cause of the beginning of the sequence such. Some hospitals are not doing the coding causes of death and inaccuracies in coding causes of death data produces the wrong health. This research aims to know the description of accuracy determination of main diagnosis codes cause of death in the case of a stroke in a hospital Brigjend H.Hasan Basry Kandangan. This research use descriptive qualitative research methods with quantitative studies. This research was conducted with observation 68 medical record documents and interviewing doctors, koder and head installation medical record as supporting in this research. In this research note the hospital does not have an SOP and the absence of writing the cause of death on a death certificate so as not to kodefikasi the implementation and reporting of the implementation of the hospital not be RL4 about mortality reporting.
Implementasi Electronic Health Record (EHR) Pada Poli Rawat Jalan Di Rumah Sakit Umum Daerah Ratu Zalecha Martapura Nina Rahmadiliyani Rahmadiliyani; Putri Putri; Rina Gunarti
Jurnal Kesehatan Indonesia Vol 9 No 3 (2019): Juli
Publisher : HB PRESS

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

Abstract

A system of Electronic Health Record (EHR) is an activity computerized the contents of the medical record and process related. Based on the preliminary studies in Hospital of Ratu Zalecha Martapura obtained that already some clinics that implement EHR systems and for some clinics will get their turn to apply the system. The purpose of this research was to identify the security system (security), clinical support (clinical support), and reports (report) on the system of the EHR. The method of this research uses descriptive research with qualitative analysis. Research instrument this is manual observation and interview guidelines. This research was conducted to 8 informant head installation medical record, IT officers, three doctors and three nurses. The results of research at in Hospital of Ratu Zalecha Martapura to be able to access the EHR user must use a username and password. Username and password are made according to their respective limits and authority. Clinical support in the system is good, doctors and nurses fill their own diagnoses into EHR applications, service time is more effective and more efficient so as to improve patient services. Reports produced were reports of 10 major outpatient diseases, outpatient visit reports, daily outpatient census reports, RL1, RL2, RL3, RL4 and RL5.
Pemeliharaan dan Pengendalian Pencegahan Infeksi Rekam Medis COVID-19 oleh Petugas Rekam Medis Nina Rahmadiliyani Rahmadiliyani; Najla Shaffiya Putri
Jurnal Kesehatan Indonesia Vol 11 No 3 (2021): Juli 2021
Publisher : HB PRESS

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

Abstract

The coronavirus can last between four and five days in various objects aluminum, wood, paper, plastic, and glass objects. It is spread through paper (especially medical record documents) and still becoming a risk. Maintenance of COVID-19 medical records had not been carried out according to the PORMIKI’s instructions. The records were not put in plastics or containers and not stored in a special place. This study aimed to determine the maintenance and control of COVID-19 infection prevention by medical record officers in 2021. This study used a qualitative descriptive method. The main informants were coding officers, and the triangulation informants were the head of the medical record installation and the isolation room administration officer. The research instruments were observation and interview guidelines. We used descriptive analysis. The results showed that Standard Operational Procedure (SOP) of the COVID-19 medical records maintenance at Idaman Hospital, Banjarbaru, was not yet available. The observation results showed that the officers obeyed to wear masks during working, wash hands routinely using hand rub, clean the tables or other flat surfaces before and after working, and minimize the contact between patients or their families and medical records. However, some procedures were not carried out (e.g., did not put the medical records in yellow plastics, container boxes, or a special place. The hospital should make an SOP regarding the maintenance of medical records for COVID-19 patients that the officers should comply with and anticipate the potential for workers to have COVID-19.
A Ketepatan Penentuan Kode Diagnosis Utama Penyebab Kematian Pada Kasus Stroke Di RSUD Brigjend H. Hasan Basry Kandangan Nina Rahmadiliyani Rahmadiliyani; Aida Fitria
Jurnal Kesehatan Indonesia Vol 9 No 2 (2019): Maret
Publisher : HB PRESS

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

Abstract

World Health Information (WHO) establishes a set of rules or procedures that must be followed for granting kodefikasi UCoD determination of the code on certificate of death must pay attention to the sequence of events leading to the death of the disease and the cause of the beginning of the sequence such. Some hospitals are not doing the coding causes of death and inaccuracies in coding causes of death data produces the wrong health. This research aims to know the description of accuracy determination of main diagnosis codes cause of death in the case of a stroke in a hospital Brigjend H.Hasan Basry Kandangan. This research use descriptive qualitative research methods with quantitative studies. This research was conducted with observation 68 medical record documents and interviewing doctors, koder and head installation medical record as supporting in this research. In this research note the hospital does not have an SOP and the absence of writing the cause of death on a death certificate so as not to kodefikasi the implementation and reporting of the implementation of the hospital not be RL4 about mortality reporting.
Co-Authors Aida Fitria Najla Shaffiya Putri Putri Putri Rina Gunarti