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Tinjauan Penyebab Terjadinya Misfile Dokumen Rekam Medis Rawat Jalan Di RSUD Kabupaten Jombang Tahun 2020 Krisnita Dwi Jayanti; Ratna Frenty Nurkhalim; Ninda Mulya Ike Ardila; Budi Pranoto; Indra Setyawan; Indah Susilowati
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Vol. 7 No. 2 (2022): 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.v7i2.950

Abstract

Medical record outpatient and emergency must be accompanied and completed after service to patiens the same day. This study aims to find out the factors that cause misfile from the management aspects of man, method, machine, and material in Jombang District Hospital. This research is descriptive qualitative with a case study approach. The sample in this study were 11 officers. Data collection techniques used are questionnaires and observation sheets. The results showed that in the man element, it was found that the problem of the absence of medical record officers with a background in medical record education where it is also a trigger for misfile in the filing room, the absence of training for medical record officers due to the lack of programs related to medical record training in Jombang District Hospital, and officers have never been rewarded in any form such as praise or incentives and penalties to be motivated to work better. In the method element found the problem of the absence of the implementation of medical record documents investigation activities every day periodically by officers to prevent the occurrence of misfile. On the machine element found problems of not using tracer and outguide. In the material element found the problem is that the color code in Jombang District Hospital is not applied in its entirety because of the lack of importance of color coding officers to prevent misfiles. It can be suggested that leaders should provide rewards and punishments, participate in training, make policies related to DRM investigation activities, tracer implementation, and color coding on DRM covers.
TINJAUAN PROSEDUR KELENGKAPAN PENCATATAN DATA DEMOGRAFI PASIEN BARU DI RSUD X TRENGGALEK Indah Susilowati; Ratna Frenty Nurkhalim; Latifah Hasanah
Jurnal Wiyata Penelitian Sains dan Kesehatan Vol 9, No 1 (2022)
Publisher : LP2M IIK (Lembaga Penelitian dan Pengabdian Masyarakat Institut Ilmu Kesehatan) Bhakti Wiy

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.56710/wiyata.v9i1.597

Abstract

Latar belakang: Bentuk dokumentasi pertama kali dalam rekam medis dimulai dengan pencatatan data demografi pasien baru yang pertama kali datang ke rumah sakit. Isian data demografi mencakup identitas diri yang lengkap serta merupakan penentu upaya pemberian layanan kesehatan. Saat survei ditemukan kekosongan data identitas pasien yang dapat mempengaruhi isi dan kualitas rekam medis, secara keseluruhan bisa mengaburkan identifikasi pasien yang sesuai identitasnya. Tujuan :Penelitian ini adalah untuk meninjau prosedur mengenai  kelengkapan pencatatan data demografi pasien rawat jalan baru di RSUD X Trenggalek. Metode :Penelitian ini termasuk deskriptif kuantitatif, dengan 96 sampel yang diambil secara accidental sampling,  variabel penelitiannya kebijakan, standar operasional prosedur dan formulir pendaftaran pasien baru rawat jalan Hasil: Terdapat kebijakan dan standar operasional prosedur yang mengatur tentang pencatatan data demografi pasien, namun pelaksanannya masih ditemukan ketidaklengkapan formulir pendaftaran pasien baru rawat jalan sebesar 31,25%, yang sudah lengkap pengisiannya adalah 68,75%. Saran: perbaikan melakukan sosialisasi untuk pemahaman prosedur yang sudah ditentukan, evaluasi berkala pencatatan dan melengkapi formulir pendaftaran pasien baru rawat jalan
OVERVIEW OF SERVICE ADMINISTRATION CONDITIONS BPJS OUTCOME PATIENTS AT X JOMBANG HOSPITAL Indah Susilowati; Bela Maulidiah Ishak; Ninda Mulya Ike Ardilla; Nurhadi
Jurnal Kesehatan Mahardika Vol. 9 No. 1 (2022): Jurnal Kesehatan Mahardika
Publisher : LPPM ITEKES Mahardika

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.54867/jkm.v9i1.90

Abstract

The administrative requirements for registration of outpatients specifically for BPJS users, must be brought in full when visiting a hospital for a health check. The problem is from the number of 8 patients who visited the hospital including 2 patients who did not bring a control letter, 2 patients did not bring a photocopy of their ID card, 3 patients did not bring a photocopy of BPJS, and 1 patient came who had not been scheduled for control. The purpose of this study was to determine the suitability of the administrative requirements for outpatient registration of BPJS users at Hospital X Jombang. Descriptive research method with a cross sectional approach, the variables are policy regulations, standard operating procedures, administrative completeness of patient registration. The population of BPJS outpatients is 26,654, the sample is 30 by quota sampling and 1 respondent is the Head of Medical Records. As a result, policies and standard operating procedures have been implemented, administrative compliance is not complete, such as a control letter (20%), photocopy of ID card (56.7%), and photocopy of BPJS (53.3%). The conclusion is that the implementation of the outpatient registration procedure for BPJS users at Hospital X Jombang is not in accordance with the rules, because the patient administration requirements are not complete. This can cause the waiting time for the destination poly to be longer and hamper the service process at the patient registration area and cancel BPJS claims at the hospital. Suggestions for making information facilities related to completeness for outpatient registration requirements.
Tinjauan Kebijakan Pengamanan Fisik Dokumen Rekam Medis dari Faktor Ekstrinsik dan Intrinsik Di RSU X Kediri Indah Susilowati; Sahitya Nashiroh
Jenggala : Jurnal Riset Pengembangan dan Pelayanan Kesehatan Vol 1 No 1 (2022): JUNI 2022
Publisher : Fakultas Teknologi dan Manajemen Kesehatan

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

Abstract

Dokumen rekam medis mempunyai peran penting karena merupakan dokumentasi serta informasi riwayat penyakit pasien sehingga harus terjaga keamanannya dari kerusakan, kehilangan dan bahaya lain agar kesinambungan data kesehatan terlindungi. Fisik dokumen rekam medis dapat mengalami kerusakan seperti kertas sobek dan berjamur, untuk itu perlu perawatan agar kondisinya terpelihara dalam kurun waktu tertentu.  Tujuan penelitian mengetahui pelaksanaan pengamanan fisik dokumen rekam medis di ruang filing tahun 2020 RSU X Kediri. Metode penelitian cross-sectional dengan pendekatan retrospektif. Populasi sejumlah 15.935 dengan sampel 100 dokumen rekam medis. Pengumpulan data dengan pengamatan dan wawancara petugas di ruang filing. Hasil penelitianya, Kebijakan dan SPO terkait pengamanan fisik dokumen rekam medis belum ada. Pengamanan fisik dokumen rekam medis meliputi faktor instrinsik dan ekstrinsik. Faktor instrinsik penyebab kerusakan adalah kertas sampul yang tipis. Faktor ekstrinsik terdiri dari faktor fisik, biologi dan kimia. Faktor fisik menyebabkan kerusakan rekam medis adalah rembesan air dan rak filing penuh, faktor biologi adalah serangga dan tikus, serta faktor kimia yaitu ada debu yang menempel pada rekam medis. Kesimpulannya, RSU X Kediri tersedia kebijakan instalasi rekam medis dan SPO tentang Pengamanan Dokumen Rekam Medis. Pengamanan fisik dokumen rekam medis dari faktor instrinsik yang belum sesuai kertas yang tipis, dari faktor ekstrinsik yang belum sesuai rak penuh, rembesan air, debu dan serangga. Penyebab kerusakan dokumen rekam medis karena faktor  instrinsik dan ekstrinsik serta sarana prasarana yang belum memadai. Sarannya membuat aturan terkait pengamanan fisik dokumen rekam medis, memperbaiki sarana dan prasarana ruang filing, secara bertahap memasukkan  dokumen rekam medis yang rusak ke komputer
Legal Responsibility in Handling Medical Cases: Assessing Health Insurance Policies in Indonesia Ninda Mulya Ike Ardilla; Indah Susilowati
Ipso Jure Vol. 2 No. 2 (2025): Ipso Jure - March
Publisher : PT. Anagata Sembagi Education

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.62872/63vstb03

Abstract

The increase in medical dispute cases in Indonesia reflects the disparity between patient expectations of health services and the standards applied by medical personnel. The main factors causing disputes include medical negligence, lack of informed consent, and limited transparency in the treatment process. Regulations such as Law No. 29 of 2004 on Medical Practice and Law No. 36 of 2009 on Health have regulated the responsibilities of medical personnel, but their implementation still faces challenges. On the other hand, national health insurance schemes such as BPJS Kesehatan also face obstacles in ensuring a balance of legal protection for patients and medical personnel. The INA-CBGs payment system often does not reflect the complexity of medical cases, thus impacting the quality of health services. The inconsistency of regulations between Law No. 40 of 2014 on Insurance and Law No. 36 of 2009 on Health also causes legal uncertainty in the resolution of medical disputes. This study uses normative juridical methods with legislative, conceptual, and case approaches to analyze related regulations and legal practices. The results of the study show the need for policy reforms that balance economic efficiency and legal protection. With the strengthening of regulations, transparency, and fairer dispute resolution mechanisms, it is hoped that the health law system in Indonesia can run more effectively and fairly.
Legal Policy as a Tool to Control the Circulation of Illegal Drugs and Their Impact on Public Health Djembor Sugeng Walujo; Indah Susilowati
Ipso Jure Vol. 2 No. 4 (2025): Ipso Jure - May
Publisher : PT. Anagata Sembagi Education

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.62872/xcs3y465

Abstract

The circulation of illegal drugs in Indonesia continues to increase quantitatively and qualitatively, targeting not only urban areas but also rural areas and educational institutions. Law Number 35 of 2009 concerning Narcotics should be the main foundation in controlling narcotics trafficking, but its implementation has not been effective. This study uses a normative juridical method by analyzing laws and regulations and law enforcement practices in the field. It was found that weak coordination between institutions, overlapping authority, and lack of rehabilitation facilities were the main obstacles. The legal approach that is still dominant is repressive in nature, but it actually worsens the condition, because it emphasizes more punishment for users than rehabilitation as a health approach. In addition, public awareness of the dangers of illegal drugs is still low due to the lack of community-based education. This condition shows that the existing legal policy has not been able to answer the complexity of the narcotics problem as a public health crisis. Comprehensive reforms in policy design, strengthening institutional synergies, and a more humanistic and preventive approach are needed to protect public health in a sustainable manner. This study recommends the transformation of the narcotics law paradigm from a punitive approach to a recovery and education-oriented public health protection approach.