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Adiputra, I Made Sudarma
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Analisis Kelengkapan Pengisian Identitas Pasien Pada Formulir Lembar Masuk Dan Keluar Pasien Rawat Inap Rumah Sakit Wangaya Nuralim, Ristu Airul; Purwanti, Ika Setya; Adiputra, I Made Sudarma
Jurnal Bahana Kesehatan Masyarakat (Bahana of Journal Public Health) Vol 9 No 1 (2025): Jurnal Bahana Kesehatan Masyarakat (Bahana of Journal Public Health)
Publisher : Poltekkes Kemenkes Jambi

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.35910/jbkm.v9i1.804

Abstract

Background: Incompleteness in filling out medical record files will result in the records contained being out of sync and the patient's previous health information being difficult to identify. This study aims to determine the completeness of filling in the patient's identity on the inpatient admission and discharge form. Method: The research method used is quantitative descriptive. The sample used was 237 medical records of inpatients in October taken by simple random sampling. Results: The research results showed that 152 sheets of the entry and exit summary forms were complete (64.14%) and 85 sheets of the entry and exit summary forms were incomplete (35.86%). The reason for the incomplete filling in of the patient's identity on the admission and discharge summary form is because the implementation of standard operational procedures has not been optimal. What the hospital needs to do next is carry out outreach regarding filling in patient identity and immediately implement electronic medical records. Conclusion: There are still incompleteness in filling in the medical resume for the identity of inpatients at Wangaya Hospital.
Tingkat Kelengkapan Rekam Medis di Puskesmas I Denpasar Timur : Pendekatan Kuantitatif Indraswari, Made Ayu Savitri; Adiputra, I Made Sudarma; Faidah, Nurul
Jurnal Akademika Baiturrahim Jambi Vol. 14 No. 2 (2025): September
Publisher : Universitas Baiturrahim

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.36565/jab.v14i2.958

Abstract

Medical records are essential documents that serve as a means of communication among healthcare professionals and form the basis for service planning, evaluation, and legal evidence within the healthcare system. The completeness of medical record documentation is a key indicator in ensuring the quality of healthcare services. This study aims to analyze the completeness level of outpatient medical records at UPTD Puskesmas I, East Denpasar District Health Office. A quantitative descriptive approach was used with random sampling techniques applied to 372 medical record files out of a total population of 5,251. Data collection was conducted using a checklist that assessed four main aspects: patient identification, essential reports, authentication, and proper documentation. The data were analyzed using univariate analysis. The results showed that the average completeness for patient identification was 67.3%, essential reports 95.38%, authentication 50%, and documentation 100%. Overall, the completeness of medical records has not fully met the established standards, particularly in legal and administrative aspects. This incompleteness may lead to serious consequences, such as errors in medical service delivery, weak legal accountability, and reduced quality of healthcare services. Therefore, this study highlights the need to strengthen internal supervision, conduct regular training for healthcare workers on proper medical record documentation, and implement routine evaluations to improve service quality and regulatory compliance
Gambaran Perancangan Desain User Interface Ekspedisi Elektronik Dokumen Rekam Medis Rawat Inap NI MADE PIAR GRISTIARI; I Made Sudarma Adiputra; Made Wahyu Aditya
Jurnal Manajemen Informasi Kesehatan Indonesia (JMIKI) Vol 13 No 2 (2025)
Publisher : Asosiasi Perguruan Tinggi Rekam Medis dan Informasi Kesehatan Indonesia- APTIRMIKI

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33560/jmiki.v13i2.721

Abstract

Pencatatan peminjaman serta pengembalian dokumen rekam medis yang dilakukan manual dengan buku ekspedisi menyebabkan beberapa kendala, seperti kelengkapan data peminjaman serta pengembalian dokumen rekam medis lebih dari 24 jam, serta keterlambatan pengembalian dokumen rekam medis. Selain itu, menggunakan buku ekspedisi secara manual kurang efektif dan efisien. Tujuan penelitian ini yaitu Untuk mengetahui gambaran perancangan desain user interface ekspedisi elektronik dokumen rekam medis rawat inap. Jenis Penelitian yang digunakan yaitu metode kualitatif deskriptif dengan metode perancangan waterfall serta menggunakan uji SUS (System Usability Scale) pada desain user interface. Hasil penelitian menunjukkan tingkat penerimaan pengguna pada desain user interface termasuk dalam kategori yang dapat diterima (Acceptable). Hal ini mengindikasikan bahwa desain user interface untuk sistem rekam medis rawat inap elektronik ekspedisi ini memiliki tingkat ketergunaan yang baik. Dengan mendapatkan nilai skor rata-rata 90, yang berarti desain user interface ini tidak perlu dilakukan sebuah perbaikan yang dapat dikatakan bisa menjadi rekomendasi kepada Rumah Sakit Umum Dharma Yadnya.
The Role of the Family Companion Team (TPK) in Finding New Cases of Families at Risk of Stunting Oktaviani, Ni Putu Wiwik; Adiputra, I Made Sudarma; Trisnadewi, Ni Wayan
Indonesian Journal of Global Health Research Vol 5 No 4 (2023): Indonesian Journal of Global Health Research
Publisher : GLOBAL HEALTH SCIENCE GROUP

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37287/ijghr.v5i4.2483

Abstract

Increasing human resources is one of Indonesia's efforts to build a golden Indonesia in 2045. Stunting is the current nutritional issue that Indonesia is dealing with. The Indonesian government has created a national strategy to accelerate stunting reduction through families involving health workers known as the Family Companion Team (TPK). According to the results of the evaluation of stunting prevention programs, most local governments have been unable to implement activities to accelerate stunting reduction. This research aims to determine the role of the family companion team in finding new cases of families at risk of stunting. Data collection in this study was carried out using multiple random sampling techniques, distributing questionnaires to 62 TPK in the working area of Puskesmas II Blahbatuh, the inclusion criteria for this study were TPK who had been listed in the Regent's Decree (SK), domiciled in the working area of the puskesmas II Blahbatuh and willing to be a respondent. This research hypothesis test uses Chi square. The results of this study show that there is no significant relationship between the role of TPK in finding new cases of families at risk of stunting and a p value > 0.05. The family approach is a good strategic innovation in providing assistance to families at risk of stunting, but it is not optimal in identifying new findings.
TINJAUAN ANALISIS KUANTITATIF KELENGKAPAN REKAM MEDIS KASUS SECTIO CAESAREA Sanjaya, I Made Manu; Devhy, Ni Luh Putu; Adiputra, I Made Sudarma
Jurnal Manajemen Informasi dan Administrasi Kesehatan Vol. 6 No. 1 (2023): JMIAK
Publisher : Program Studi D3 Rekam Medis dan Informasi Kesehatan

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.32585/jmiak.v6i1.3705

Abstract

Kelengkapan rekam medis memiliki peranan penting di rumah sakit, jika rekam medis tidak lengkap maka informasi yang dihasilkan tidak lengkap juga, sehingga akan mengakibatkan terhambatnya proses klaim asuransi yang diajukan dan terhambatnya proses tertib administrasi. Penelitian ini bertujuan untuk mengetahui kelengkapan pengisian rekam medis pasien rawat inap kasus sectio caesarea di Rumah Sakit Umum Daerah (RSUD) Wangaya Kota Denpasar berdasarkan analisis kuantiatif rekam medis. Metode penelitian yang digunakan yaitu deskriptif dengan jumlah sampel 35 rekam medis menggunakan Simple Random Sampling. Hasil dari penelitian menunjukkan kelengkapan pengisian rekam medis pasien rawat inap kasus sectio caesarea di Rumah Sakit Umum Daerah Wangaya Kota yaitu pada identifikasi diperoleh hasil kelengkapan terendah pada item tanggal lahir/umur sebesar 34 (99,1%). Pada item review pelaporan penting diperoleh persentase kelengkapan terendah terdapat pada item general consent 24 (68,6%) rekam mdis. Pada item autentifikasi diperoleh persentase kelengkapan n terendah pada item tanda tangan dokter 23 (65,7%) rekam medis. Pada item pendokumentasian yang benar diperoleh jumlah terendah kelengkapan pada item pencatatan yang jelas sebesar 25 (71,4%). Dapat disimpulkan bahwa kelengkapan pengisian rekam medis di RSUD Wangaya Kota Denpasar belum mencapai 100%, disarankan untuk melakukan Concurrent Analysis secara berkala untuk menggambarkan kelengkapan rekam medis berdasarkan komponen analisis kuantitatif rekam medis.
Effectiveness of a Family Unit Empowerment Model in Improving Diabetes Management, Family Empowerment, and Family Support among Adults with Type 2 Diabetes Mellitus: A Quasi-Experimental Study Trisnadewi, Ni Wayan; Adiputra, I Made Sudarma; Oktaviani, Ni Putu Wiwik
Journal of Applied Nursing and Health Vol. 8 No. 2 (2026): Journal of Applied Nursing and Health
Publisher : Chakra Brahmanda Lentera Institute

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.55018/janh.v8i2.634

Abstract

Background: Diabetes mellitus (DM) remains a major public health challenge in Indonesia, with its prevalence continuing to increase. Although incurable, effective long-term management can maintain patients' quality of life. Family involvement is essential in supporting adherence to diabetes management, yet evidence on structured family-unit empowerment interventions, particularly in community settings, remains limited. Therefore, this study aimed to evaluate the effectiveness of the Family Unit Empowerment Model in improving diabetes management, family empowerment, and family support among patients with type 2 diabetes mellitus (T2DM). Methods: This study employed a quasi-experimental one-group pre-test–post-test design and followed the TREND (Transparent Reporting of Evaluations with Nonrandomized Designs) reporting guideline. A total of 140 patients with T2DM registered at the Blahbatuh 2 Gianyar Community Health Center were recruited through purposive sampling between December 2022 and July 2023. Inclusion criteria included a confirmed T2DM diagnosis, residence with family, ability to communicate effectively, and provision of informed consent. The independent variable was the Family Unit Empowerment Model; dependent variables were diabetes management, family empowerment, and family support, measured using the Summary of Diabetes Self-Care Activities (SDSCA), the Family Empowerment Scale (FES), and the Diabetes Family Support Scale, respectively (all Cronbach’s α ≥ 0.70). The intervention consisted of four structured weekly family-based health education sessions delivered over one month. Data were analyzed using the Wilcoxon Signed-Rank Test, with a significance level of p < 0.05. Results: Statistically significant improvements in median scores were observed for all three outcome variables following the intervention. The proportion of families in the good empowerment category increased from 37.1% to 55.7% (p < 0.001, r = 0.54). For family support, the proportion reporting high support increased from 44.3% to 49.3%, with a significant rise in median scores (p < 0.001, r = 0.49). Diabetes management improved, with poor-category cases decreasing from 40.7% to 27.9% (p < 0.001, r = 0.33). Conclusion: Participation in the Family Unit Empowerment Model was associated with statistically significant improvements in diabetes self-management behaviors, family empowerment, and family support among patients with T2DM. Because the single-group design and reliance on self-reported outcomes preclude causal attribution, these findings should be interpreted as preliminary. They provide promising support for family-centered empowerment approaches in community-based diabetes care and a rationale for evaluation in adequately powered, controlled, multicenter trials that incorporate objective clinical outcomes before broad implementation is recommended.
Registration Officers' Perception Towards The Implementation Of The Electronic Medical Record System At RSAD TK.II Udayana, Denpasar City Cok Istri Nadya Anastashya Valensy; I Made Sudarma Adiputra; Anak Agung Gde Oka Widana
International Journal of Health Engineering and Technology Vol. 5 No. 2 (2026): Vol 5. No. 2 JULY 2026
Publisher : CV. AFDIFAL MAJU BERKAH

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.55227/ijhet.v5i2.993

Abstract

The implementation of electronic medical records in all health care facilities is required to implement an electronic-based medical record system, as regulated in the Minister of Health Regulation Number 24 of 2022 concerning Medical Records. The purpose of this study was to determine the perceptions of registration officers regarding the implementation of the electronic medical record system at RSAD Level II Udayana, Denpasar City. This study used a qualitative approach with an in-depth interview method based on the Technology Acceptance Model (TAM) theory, which includes perceptions of ease of use, perceptions of benefits, attitudes toward use, and intentions to use the electronic medical record system. The results showed that the electronic medical record system was considered relatively easy to use after going through the adaptation and training process, and provided benefits in the form of increased work efficiency. Officers' attitudes toward using the system tended to be positive because they felt comfortable and helped in their work, and their intention to continue using the system was also high, driven by policies and developments in digital technology, despite technical obstacles such as internet network disruptions. From this study, it can be concluded that the acceptance of the electronic medical record system is influenced by a combination of ease of use, perceived benefits, and organizational and infrastructure support. Therefore, system quality improvement and ongoing training are needed to optimize implementation.
Patient Perceptions And Expectations Regarding Satisfaction With Online Outpatient Registration Services At Karangasem Regional General Hospital (RSUD Karangasem) Ni Kadek Sulastri; I Made Sudarma Adiputra; Nurul Faidah
International Journal of Health Engineering and Technology Vol. 5 No. 2 (2026): Vol 5. No. 2 JULY 2026
Publisher : CV. AFDIFAL MAJU BERKAH

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.55227/ijhet.v5i2.1015

Abstract

The advancement of digital systems in healthcare has prompted hospitals to implement online registration systems to enhance service effectiveness, reduce waiting times, and improve patient satisfaction. However, implementation challenges persist, such as scheduling mismatches for follow-up visits, data verification issues, and the need for patients to queue again at the registration counter. This study aims to examine patient perceptions and expectations regarding satisfaction with the outpatient online registration service at RSUD Karangasem. A qualitative method with a descriptive approach was employed, utilizing purposive sampling with nine participants. Data were collected through interviews and observations, using interview guides and observation sheets as research instruments. Interview data analysis involved data reduction, data presentation, and conclusion drawing. The results indicate that patient perceptions of the online registration system are generally positive due to the convenience, time efficiency, and flexibility it offers. Nevertheless, obstacles remain, including network disruptions, system errors, and suboptimal supporting facilities. These conditions create a gap between patient perceptions and expectations; patients desire a system that is more stable, fast, and accurate. In conclusion, while the outpatient online registration system at RSUD Karangasem has provided benefits, it has not yet fully met patient expectations. Therefore, continuous improvement of the system and supporting facilities is necessary to enhance patient satisfaction.
Development of a Web-Based Medical Terminology Learning Application Integrating Medical Term Components and Definitions Ayuk Era Edwina Noviana; I Made Sudarma Adiputra; Made Wahyu Aditya
Jurnal Infokes Vol 16 No 2 (2026): Jurnal Ilmiah Rekam Medis dan Informatika Kesehatan
Publisher : Universitas Duta Bangsa Surakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.47701/qtv9kb45

Abstract

Background: Medical terminology is an essential competency for Medical Records and Health Information students because it supports accurate clinical documentation and diagnosis coding. However, students often experience difficulties in understanding medical terms and identifying their constituent elements, including prefixes, roots, and suffixes. Currently, few web-based medical terminology applications integrate medical term definitions together with prefix, root, suffix, and meaning information stored in a database into a single platform. This study aimed to develop a web-based medical terminology application as a learning medium. Methods: This study employed a Research and Development (R&D) approach using the Waterfall software development model. The application was developed using PHP and MySQL. User-entered medical terms were searched against a relational database containing predefined medical terms and prefix, root, suffix, and meaning information stored in the database. Matching records were retrieved and displayed, whereas unavailable terms generated search suggestions. The application was evaluated for functionality, interface design, and usability using black-box testing, interface design assessment, and the System Usability Scale (SUS) by two media experts and nine Medical Records and Health Information students. Results: The application achieved an average black-box testing score of 98%, indicating very valid functionality. Black-box testing confirmed that the application functioned as intended by retrieving and displaying predefined medical terminology records (e.g., bronchitis and rhinoplasty) together with the corresponding prefix, root, suffix, and meaning information stored in the database, while generating search suggestions for unavailable terms. The interface design assessment scored 96%, while the System Usability Scale achieved a score of 93, corresponding to Grade A+ with a Best Imaginable user experience. Conclusion: The developed application is feasible as a learning medium for medical terminology. The application assists users in understanding medical terms by displaying medical term definitions together with prefix, root, suffix, and meaning information stored in the database.
Pengaruh Senam Bugar Terhadap Tekanan Darah Lansia dengan Hipertensi : Studi Quasi Eksperimental Adiputra, I Made Sudarma; Sunariati, Ni Luh Gede Ita; Trisnadewi, Ni Wayan; Oktaviani, Ni Putu Wiwik
Jurnal Kesehatan Vokasional Vol 6, No 4 (2021): November
Publisher : Sekolah Vokasi Universitas Gadjah Mada

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.22146/jkesvo.66441

Abstract

Latar Belakang: Hipertensi pada lansia merupakan peningkatan tekanan darah yang terjadi pada lanjut usia. Senam bugar merupakan aktivitas fisik dengan gerakan yang ringan dan sangat tepat bila dilakukan pada lansia hipertensi.Tujuan: Mengetahui pengaruh senam bugar lansia terhadap tekanan darah lansia dengan hipertensi.Metode: Jenis penelitian ini adalah Quasi Experiment dengan rancangan Non-Equivalent Control Group Design. Jumlah responden yang berpartisipasi sebanyak 36 orang. Penelitian ini dibagi menjadi dua kelompok yaitu kelompok intervensi dan kelompok kontrol, pemilihan sampel diambil dengan teknik Purposive Sampling. Data dianalisis  menggunakan Wilcoxon dan Mann-Whitney.Hasil: Hasil penelitian ini menunjukkan pada kelompok perlakuan nilai rata-rata tekanan darah sistole saat pre-test 168,1 mmHg dan post-test 153,4 mmHg sedangkan diastole pre-test 95,56 mmHg dan post-test 82,67 mmHg, pada kelompok perlakuan secara statistik mengalami penurunan tekanan darah setelah senam bugar lansia dengan p-value <0.001 uji beda dua kelompok didapatkan hasil p-value <0.001, dari hasil ini terlihat ada perbedaan tekanan darah antara kelompok perlakuan dan kontrol.Kesimpulan: Hal ini menunjukkan ada pengaruh yang signifikan senam bugar lansia terhadap tekanan darah lansia dengan hipertensi. Diharapkan lansia berperan aktif dalam mengikuti kegiatan senam dari posyandu lansia secara rutin untuk membantu menurunkan serta mengontrol tekanan darah tinggi.
Co-Authors A A Istri Dalem Hana Yundari Arianta, I Made Dwi Ayuk Era Edwina Noviana Bayu Anggileo Pramesona Cok Istri Nadya Anastashya Valensy Damayanti, Putu Sri Dewa Putu Dwita Gde Ngurah Idraguna Pinatih Gristiari, Ni Made Piar Gusti Ayu Ketut Putri Widnyani I Dewa Agung Sudarsana I Gusti Agung Ngurah Putra Pradnyantara I Komang Suastika I Made Dwi Arianta I Made Manu Sanjaya I MADE SUTARGA I Nyoman Asdiwinata Indraswari, Made Ayu Savitri Kadek Intan Puspita Sari Kadek Mahendra Novita Rahayu Komalasari, Ni Luh Putu Ratih Made Wahyu Aditya Arta Mitayanti, Ni Kadek Ni Kadek Muliawati Ni Kadek Muliawati Ni Kadek Pon Widiastuti Ni Kadek Sulastri Ni Luh Ayu Yustikarini Ni Luh Gede Ita Sunariati Ni Luh Gede Puspita Yanti Ni Luh Gede Puspita Yanti Ni Luh Putu Devhy Ni Luh Putu Devhy Ni Luh Putu Devhy, Ni Luh Putu Ni Made Candra Dewi Sudana Ni Made Periani NI MADE PIAR GRISTIARI Ni Made Septyari Ni Nyoman Meryadi Ni Putu Mia Devihapsari Ni Putu Wiwik Oktaviani Ni Putu Wiwik Oktaviani Ni Putu Wiwik Oktaviani Ni Putu Wiwik Oktviani Ni Wayan Trisnadewi Ni Wayan Trisnadewi Ni Wayan Trisnadewi, Ni Wayan Nopindrawati, Ni Putu Nuralim, Ristu Airul Nurul Faidah Nurul Faidah Oktaviani, Ni Putu Wiwik Oktaviani, Ni Putu Wiwik Oktaviani, Ni Putu Wiwik Oktaviani Oktviani, Ni Putu Wiwik Parlin, Gusti Ayu Ketut Utari Pinatih, G. N. Indraguna Pinatih, Gede Ngurah Indraguna Pramesti, Theresia Anita Sanjaya, I Made Manu Sunariati, Ni Luh Gede Ita Theresia Anita Pramesti Urmilasari, Ni Putu Yessi Wahyudi, Hendro Widana, Anak Agung Gde Oka Widiastuti, Dewa Ayu Putri