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All Journal VISIKES Jurnal Transformatika HIGEIA (Journal of Public Health Research and Development) Jurnal Mantik Abdimasku : Jurnal Pengabdian Masyarakat Jurnal Ilmu Kesehatan Masyarakat Jurnal Rekam Medic

Retno Astuti Setijaningsih

Dosen Fakultas Kesehatan Universitas Dian Nuswantoro

Author-ID : 2404400

Astronomy Computer Science & IT Economics, Econometrics & Finance Education Environmental Science Health Professions Industrial & Manufacturing Engineering Languange, Linguistic, Communication & Media Medicine & Pharmacology Nursing Public Health Social Sciences

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Praktik Penerapan Protokol Kesehatan pada Praktisi Rekam Medis di Masa Pandemi Covid-19 Saptorini, Kriswiharsi Kun; Fani, Tiara; Setijaningsih, Retno Astuti
HIGEIA (Journal of Public Health Research and Development) Vol 5 No 4 (2021): HIGEIA: Oktober 2021
Publisher : Jurusan Ilmu Kesehatan Masyarakat, Fakultas Ilmu Keolahragaan, Universitas Negeri Semarang, Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.15294/higeia.v5i4.51007

Abstrak Risiko pajanan petugas rekam medis terhadap paparan Covid-19 dapat terjadi karena praktisi rekam medis melakukan pengelolaan dokumen rekam medis, termasuk pada pasien Covid-19. Berdasarkan penelitian, prevalensi Covid-19 pada praktisi rekam medis adalah 15,3%. Penelitian ini bertujuan mengidentifikasi praktik penerapan protokol kesehatan pada praktisi rekam medis. Peneltian ini adalah penelitian cross sectional terhadap 124 praktisi rekam medis di Provinsi Jawa Tengah pada bulan Januari-Juni 2021. Hasil penelitian menurut jenis kelamin terbanyak adalah perempuan (65,3%), berusia 31 tahun (51,6%), pendidikan diploma (73,4%), bekerja di rumah sakit tipe C (58,9%), di bagian pendaftaran (33,9%), memiliki riwayat infeksi Covid-19 (15,3%) pada Desember 2020 (26,2%). Praktik terkait protokol kesehatan secara umum tergolong baik (83,1%), praktik terkait prosedur khusus di unit rekam medis tergolong baik (69,4%). Terdapat hubungan antara jenis kelamin dengan praktik penerapan protokol kesehatan secara umum (p value =0,034). Oleh karena itu, disarankan fasilitas kesehatan perlu memperhatikan pengendalian infeksi, riwayat kontak staf dan kepatuhan penggunaan APD. Abstract The risk exposure of medical record practitioners to Covid-19 exposure occurs because the main task is to manage medical record documents. Based on research, the prevalence of Covid-19 in medical record practitioners is 15,3%. This research objectives to identify health protocols implementation practices among medical record practitioners. This is a cross-sectional study that observed 124 medical record practitioners in Central Java Province in January-June 2021. Most of them are female (65,3%), 31 years old (51,6%), diploma education (73,4%), work in type C hospital (58,9%), in the registration section (33,9%), have a history of Covid-19 infections (15,3%) in December 2020 (26,2%). Practices related to health protocols are generally classified as good (83,1%), practices related to special procedures in the medical record unit are classified as good (69,4%). There is an association between gender and the practice of implementing health protocols in general (p value = 0,034). Therefore, suggestion for health facilities need to pay attention to infection control, contact history, and compliance with the use of PPE. Keyword: Health Protocol, Practices, Medical Records Practitioners

STANDAR PENYUSUTAN DOKUMEN REKAM MEDIS DI PUSKESMAS KEDUNGMUNDU KOTA SEMARANG TAHUN 2019 Retno Astuti Setijaningsih; Jaka Prasetya
VISIKES: Jurnal Kesehatan Masyarakat Vol 18, No 2 (2020): VISIKES (SUPLEMENT)
Publisher : Dian Nuswantoro Semarang

Public Health Center (PHC) is a central development in the working area. Its orientation is the safety of the patient. For it takes depreciation medical record documents to reduce the burden of storage and workload file clerk. Therefore, medical record documents more easily and quickly traceable.It is associated with patient’s medical record documentstracking speed. Result for The PHC obtained their medical record documents missfile accident due to stacking file. The research desain is a case study. Cross sectional approaching with observation and interviews as the method of collecting data. Processing data using collecting, editing, and tabulating. Then the data were analyzed descriptively. Generally, numbering system with applied to the patient’s family health centers folder is Unit Numbering System (UNS). PHC, in general, already implementing Terminal Digit Filing (TDF) alignment system, but in Puskesmas Kedungmundu still apply Straight Numerical Filing (SNF). The retention system is decentralization. While Puskesmas Kedungmundu peciathas implemented centralized. Depreciation medical record documents has not been routinely performed and without documentation. Several PHC even do not perpetuate medical record documents as regulated on The Permenkes Nomor 269/Menkes/PER/III/2008. Medical record documents depreciation required the disease index, patient index, standard operating procedure, record retentions schedules and documentation. In addition, need to reform the medical record documents management to facilitate the implementation of depreciation. Keywords : medical record document, depreciation, public health center

IMPLEMENTATION OF MEDICAL INFORMATION RELEASE FOR COMMERCIAL INSURANCE PURPOSES AT RSI SULTAN AGUNG SEMARANG IN 2021 suyoko suyoko; Novika Gema Palupi; Maulana Tomy Abiyasa; Retno Astuti Setijaningsih
VISIKES: Jurnal Kesehatan Masyarakat Vol 20, No 2 (2022): VISIKES (SUPLEMEN)
Publisher : Dian Nuswantoro Semarang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33633/visikes.v20i2Supp.5785

ABSTRACTLaw No. 44 of 2009 concerning Hospitals, states that hospitals are obliged to respect and protect the rights of patients. The early survey found that completion time in the implementation of the release of medical information for claims was constrained, depend on the presence and willingness of doctors to fill out medical information. These obstacles can possibly cause the loss for patients. The purpose of this study was to analyze the implementation of the release of medical information for commercial insurance claims at RSI Sultan Agung Semarang.The type of this research is descriptive qualitative with a cross sectional approach. The research was conducted on May-June 2021 with 2 subjects, namely the insurance officer and the head of the medical record unit. The data were collected by online interviews and analyzed descriptively based on regulations of the Sultan Agung Hospital and the legal aspects of health and then conclusions were drawn.The results showed that the implementation of information release has maintained patient privacy, every release of medical information is followed by permission from the patient/family, release to third parties accompanied by a power of attorney, release of medical information is given by the DPJP doctor. However, the release of medical information has not been involved the director and the regulation on completion time standards has not been implemented optimally. Suggestions from this study is to evaluate the applicable regulations.Keywords: Release of Medical Information, Medical Records, Commercial Insurance

PERAN PENANGGUNG JAWAB REKAM MEDIS (PJRM) UNTUK PENINGKATAN KETEPATAN KLAIM BPJS PASIEN RAWAT INAP DI RSUD KRMT WONGSONEGORO (RSWN) KOTA SEMARANG Retno Astuti Setijaningsih; Suyoko - -; Nova Dhea Ammar N; Supriyatiningsih - -
VISIKES: Jurnal Kesehatan Masyarakat Vol 19, No 01 (2020)
Publisher : Dian Nuswantoro Semarang

Medical Record Document (MRD) guarantees patient safety. Besides, it related to claim accuracy to BPJS (Badan Penyelenggara Jaminan Sosial) as patient health insurance operator. In fact, from the survey conducted with 15 inpatients as the subjects, 10 MRD approved (approximately 66.67%) and the other 5 MRD or about 33.34% rejected. This happened as the consequences of whether supporting examination result which is not being submitted on 2 MRD (40%), 1 MRD or 20% hold incomplete BPJS document and other 40% caused by the inaccurate operation code in MRD. Hence, the aim of this study is to analyze the role of Person In Charge in Medical Record Department to improve MRD comprehensiveness to reach BPJS claim accuracy.The type of this study is qualitative with cross-sectional approach. Primary and secondary source observation and interview are used in collecting data. Purposive sampling with four interviewees from Person In Charge in Medical Record Department, and as the main interviewee is the head of Medical Record Department also one employee of BPJS Rumah Sakit Wongsonegoro as the triangulator.So, the main function of assembling employee is to ensure the quality of Medical Record Document (MRD), quantitatively and qualitatively. Whereas, RSWN already applied Person In Charge of Medical Record Department with concurrent analysis in controlling MRD comprehensiveness concept. According to observational result of 15 inpatients, found incomplete MRD, 13% occurs in identity section, also 13% each found both in recording and reporting. While, the authentication completes 100%. From consistency analyzing result discovered inconsistency recording about 13%. Main diagnose and inform consent recording reached 100% in consistency and 0% things that can cause loss.That is, the role of Person In Charge in Medical Record of inpatient unit needs yo be improved. The main and assembling function performs by PIC in Medical Record is both coding and indexing. Input standard, Standard Operational Procedures (SOP) and minimum services standard are already available and applied to control PIC in Medical Record performance quality. However, input, process and the output are not focus in controlling MRD comprehensiveness yet, especially in BPJS participant patient. So that, to control BPJS inpatient MRD quality, needs operational standard in methods and comprehensiveness control procedures, considered with PIC in Medical Record also performing ICD code and Medical Record Document quality requires coordination of all parties.The researchers suggest to add more points in controlling incomprehensiveness BPJS Medical Record Document procedures. Furthermore, enhance input in standard structure, operational job description in Standard Operational Procedure, also minimum services standard comprehensiveness which applied has to be reached 100% qualitatively and quantitatively.Keywords: PIC in Medical Record, BPJS claim, quantitative comprehensiveness, qualitative comprehensiveness

Analisis Prosedur Penyusutan Dokumen Rekam Medis di Puskesmas Rawat Inap di Kota Retno Astuti Setijaningsih; Jaka Prasetya
VISIKES: Jurnal Kesehatan Masyarakat Vol 15, No 1 (2016): Visikes
Publisher : Dian Nuswantoro Semarang

Public Health Center (PHC) is a central health development in its working area. The orientation of PHC is the patient safety, so medical records have to be kept safely in the appropriate order. Therefore, medical record documents can be traced easily and quickly. For maintaining medical records documents in a particular numbers in the spaces, it needs medical record documents retention to reduce the burden of storage and workload of file officer, that is associated with patientâ€™s medical record documents tracking speed. There were some medical record documents missfile incidences due to stacking file.The research desain was a case study with cross sectional approach. Data was collected byÂ observation and interviews and analyzed by descriptive analysis. The result showed that the numbering system that applied on the patientâ€™s family folder was Unit Numbering System (UNS). Generally, PHCs implemented Terminal Digit Filing (TDF) system, but Puskesmas Tlogosari Kulon still applied Straight Numerical Filing (SNF). The retention system was decentralization, while Tlogosari Kulon implemented centralized. The retention of medical record documents was not scheduled routinely and there was no documentation. Several PHCs did not perpetuate medical record documents as regulated on The Permenkes Nomor 269/Menkes/PER/III/2008. Medical record documents retention required the disease index, patient index, standard operating procedure, record retentions schedules and documentation. In addition, it needs to reform the medical record documents management to facilitate the implementation of retention system.Keywords: medical record document, retention, public health center (PHC)

FManajemen Retensi Dokumen Rekam Medis Nonaktif Kasus Tb Paru Di Puskesmas Halmahera Kota Semarang Tahun 2019 Nanda Dhea Aparanita; Retno Astuti Setijaningsih
VISIKES: Jurnal Kesehatan Masyarakat Vol 19, No 2 (2020)
Publisher : Dian Nuswantoro Semarang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33633/visikes.v19i2.4012

Medical records at non-hospital health care facilities are stored for at least 2 years after the last date of treatment. Halmahera Primary Health Care (PHC) has never done retention or destruction of medical record documents for pulmonary TB cases. The study aims to determine the factors that were obstacles in the retention of pulmonary TB cases at Halmahera PHC. This research is descriptive qualitative research with cross sectional approach. Data collection by observation and interviews. The subjects of this study were 5 filing officers. The object of this study were medical record documents of pulmonary TB patients, the policy of medical record document retention for pulmonary TB cases, the standard of medical record document retention for pulmonary TB cases. Based on the results of the study, 3 out of 5 filing staff understood retention of medical record documents in general, The filing storage systems was centralized but medical record documents for pulmonary TB cases were not included into the family folder, there were no policies and standards regarding retention of medical record documents for pulmonary TB cases, there is no facilities for medical record document retention for pulmonary TB cases. The obstacle in the implementation of medical record document retention for pulmonary TB cases were the unavailability of retention facilities, no schedule for archive retention, no place to store the inactive medical record documents, and excessive staff workload. Suggestions, The PHC need to make standards about document retention for pulmonary TB cases, provide information and technical guidance to filing staff about medical record document retention.Keywords: filing staff knowledge, storage system, retention standard Literature : 15 (2001 – 2020)

EVALUASI MANAJEMEN DOKUMEN REKAM MEDIS DI FILING AKTIF RUMAH SAKIT SWASTA KABUPATEN SEMARANG Bobby Anggara Laksana; Retno Astuti Setijaningsih
VISIKES: Jurnal Kesehatan Masyarakat Vol 20, No 1 (2021): VISIKES
Publisher : Dian Nuswantoro Semarang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33633/visikes.v20i1.4522

Missfile can inhibit medical services provided to patients without information about history. From the initial survey, it found 90 missile incidents (4.7%) from 2000 medical record documents, the second survey found 578 incidents from 7000 medical record documents with 9.0% missfile. This study aims to identify the medical records management in the outpatient filing section of The Private Hospital, Semarang Regency in 2019. This research is a mix methode study. Data collection by observation and interview methods with a cross-sectional approach. The research subjects were 3 filing officers. The research objects to the management of medical record documents in the outpatient filing section. The research instrument used in this research were interview and observation guidelines.The number of polyclinics at The Private Hospital in Semarang Regency is 20 polyclinics. There should be a submission terminal so staff will not be tired. The hospital management facilities were adequate but have not been properly utilized by the officers, the officers should use these facilities to facilitate document tracking. The Hospital should make a policy regarding the management of medical record documents and use colour codes on the documents so that the staff can understand and carry out their duties properly.Key Word : medical record management, storage systems, management standards

ANALISIS DESAIN FORMULIR KARTU PENGOBATAN PENCEGAHAN TB (TB 01 P) UNTUK KELENGKAPAN DATA DI PUSKESMAS TAHUN 2019 Suyoko suyoko; Retno Astuti Setijaningsih; Wahyu Setiyowati
VISIKES: Jurnal Kesehatan Masyarakat Vol 18, No 2 (2020): VISIKES (SUPLEMENT)
Publisher : Dian Nuswantoro Semarang

Tuberculosis is an infectious disease which becomes a global problem. The increase in TB case is caused by inadequate monitoring of treatment, unavailability of standardized recording and reporting system. This research was conducted to evaluate the completeness TB form design in providing more complete information. This research was administered in the form of a case study. Interviews were done to 3 nurses and 1 doctor and TB Form (TB.01P) was observed at Miroto Health Center. The completeness of 33 TB form filling (TB.01P) at the Malmahera Health Center was also evaluated. The obtained data were descriptively analyzed. The results showed the completeness of identification review reached 96%, recording review of 90%, reporting review of 64%,and 0% for authentication review. Incomplete information led to inaccurate TB control information. This incompleteness was associated toimproper design of the form, especially the unavailability of form filling instructions, names and signatures of officersin the anatomic aspect. In the aspect of content, lack of clinical data was also found. Regarding to the results of this research, revision in the design of TB Treatment and Prevention Card is needed in order to accommodate the data completeness of TB patients. This research also proposed a better design of TB Treatment and Prevention Card Keywords : Quantitative Completeness, Tuberculosis, Form Design, TB Treatment Card (TB.01P)

HUBUNGAN ANTARA PERSEPSI WANITA YANG MENIKAH DINI (< 20 TAHUN) TENTANG PERAN PETUGAS KESEHATAN DENGAN USIA MENIKAH WANITA DI DESA KEBUMEN KECAMATAN TERSONO KABUPATEN BATANG 2011 Ifa Kurnia Wati; Eti Rimawati; Retno Astuti Setijaningsih
VISIKES: Jurnal Kesehatan Masyarakat Vol 12, No 2 (2013): Visikes
Publisher : Dian Nuswantoro Semarang

Pernikahan dini terjadi karena kurangnya pengetahuan tentang kesehatan reproduksi. Masalah di Desa Kebumen, Kecamatan Tersono adalah meningkatnya jumlah perempuan muda yangtelah menikah sebelum berusia 20 tahun. Pada tahun 2009, ada 8 wanita yang menikah sebelum usia 20 tahun. Tahun 2010 menjadi 19 orang dan tahun 2011 sebanyak 31 orang. Penelitian ini adalah untuk mengetahui hubungan antara persepsi wanita tentang peran petugas kesehatan dalam kesehatan reproduksi dengan usia pernikahan.Tujuan penelitian ini adalah penelitian Explanatory dengan metode Cross Sectional. Data diperoleh dengan mewawancarai 30 perempuan yang menikah sebelum 20. Uji Chi Square digunakan untuk menganalisis data.Hasil penelitian menunjukkan bahwa wanita memiliki persepsi negatif pada petugas kesehatan (60 %) dan berpikir bahwa petugas tidak berbagi informasi tentang konsekuensi biologis(50,0%), tidak pernah berbagi konsekuensi psikologis pernikahan dini (46,7%), tidak pernah memberikan informasi tentang dampak perilaku seksual jarang (46,7%), tidak pernahmemberikan dampak ekonomis karena pernikahan dini (56,7%), dan tidak pernah berbagi informasi tentang dampak pernikahan dini terhadap bayi (53,7%). Sebagian besar responden menikah pada usia dini (usia 13-18 tahun) sebanyak 76,7%. Tidak ada korelasi antara peran petugas kesehatan dengan usia perkawinan (p value 0.392 > 0,05 ).Dari hasil tersebut, disarankan agar petugas kesehatan memberikan informasi tentang kesehatan reproduksi bagi perempuan yang menikah sebelum usia 20 tahun sehingga para wanita akan memiliki informasi yang tepat tentang usia yang direkomendasikan untuk menikah dan punya anak.Kata kunci : Peran petugas kesehatan, usia pernikahan

THE MANAGEMENT OF MEDICAL REPORT COMPLETENESS FOR THE LEGALITY OF MEDICAL RECORD DOCUMENTS AT RSUD KRMT WONGSONEGORO (RSWN) SEMARANG CITY Suyoko suyoko; Aylin Ivana; Arinda Juwita; Retno Astuti Setijaningsih
VISIKES: Jurnal Kesehatan Masyarakat Vol 20, No 2 (2021)
Publisher : Dian Nuswantoro Semarang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33633/visikes.v20i2.5069

ABSTRACTBackground: Quality hospital services is reflected in the achieving of medical records. Improper medical record documentation would negatively affect the quality of service delivered to patients and it would disadvantage the hospital when medical disputes occur.Objective:Analyzing the management of medical record completeness at RSWN to guarantee the legality of medical record documents and its effect in supporting the completeness of medical record documents.Method:In this qualitative research, observation and interviews were conducted to 60 PJRM officers in the Arimbi ward, Banowati, Nakula I and Prabukresna. The obtained data were qualitatively and quantitatively analyzed based on several underlying theories.Results:The results showed that the completeness of some aspects includinghuman, money, method, material and machine elements was proper. The quantitative analysis showed 100%, while the qualitative analysis showed a percentage of 100% with the exception on the informed consent component with the potential for loss of 99%.Conclusions:The human element required periodic outreach to PPA. In the machine element, special computerswere needed for PJRM officers, and the importance of informed consent for patients undergoing hemodialysis to obtain medical records with strong legal force. Key Words :Management, Medical Record Completeness, Legality of Medical Records.

Co-Authors Agiwahyuanto, Faik Albadi’i, Hibban Izqo Aries Setiawan Arinda Juwita Ashari, Ayu Aylin Ivana Bobby Anggara Laksana Budi Widjajanto Eti Rimawati Ida Farida Ifa Kurnia Wati Ifan Rizqa Imam Nuryanto Jaka Prasetya Jaka Prasetya Juli Ratnawati Kriswiharsi Kun Saptorini Kriswiharsi Kun Saptorini Lewa, Andi Hallang Maulana Tomy Abiyasa Nanda Dhea Aparanita Nimas Arum Titisari Nova Dhea Ammar N Novika Gema Palupi Oki Setiono Pembayun, Yovita Manuella Kusuma Prihandono, Adi Puji Purwatiningsih, Aris Sasono Wibowo Setiawan, Aries Supriyatiningsih - - Suyoko Suyoko suyoko suyoko Tarigan, Roy Ebenezer Saputra Tasya Aulia Trengga Dewi Tiara Fani Tiara Fani Tuplikhatun Tuplikhatun Wahyu Setiyowati Wildanil Ghozi Zaenal Sugiyanto

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