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All Journal JMMR (Jurnal Medicoeticolegal dan Manajemen Rumah Sakit) Jurnal Penelitian Kesehatan Suara Forikes Jurnal Wiyata : Penelitian Sains dan Kesehatan J-Dinamika: Jurnal Pengabdian Kepada Masyarakat Jurnal Kesehatan ARTERI : Jurnal Ilmu Kesehatan Jurnal Aisyah : Jurnal Ilmu Kesehatan J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Jurnal Rekam Medik & Manajemen Informasi Kesehatan (RAMMIK) PEKAT : Jurnal Pengabdian Kepada Masyarakat DIANKES : Jurnal Pengabdian Teknologi Informasi dan Kesehatan JMMR (Jurnal Medicoeticolegal dan Manajemen Rumah Sakit)
Gamasiano Alfiansyah
Politeknik Negeri Jember
Agriculture, Biological Sciences & Forestry Humanities Civil Engineering, Building, Construction & Architecture Computer Science & IT Dentistry Economics, Econometrics & Finance Education Electrical & Electronics Engineering Environmental Science Health Professions Mathematics Medicine & Pharmacology Nursing Public Health Social Sciences Veterinary Other

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Journal : J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan

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DETERMINAN KEAMANAN DAN KERAHASIAAN DOKUMEN REKAM MEDIS DI RUANG FILING RS X Gamasiano Alfiansyah; Rossalina Adi Wijayanti; Novita Nuraini; Selvia Juwita Swari; Siti Wafiroh
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 2 (2020): March
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v1i2.1961

Abstract

Rumah Sakit X menerapkan pengelolaan rekam medis sebagai penunjang medis. Dokumen rekam medis belum terjaga keamanan dan kerahasiaannya, dimana banyak petugas medis lain keluar masuk ruang filing, terdapat petugas makan dan minum diruang filing, penyimpanan masih di rak terbuka, dan petugas atau mahasiswa penelitian membocorkan isi rekam medis pasien.  Tujuan dari penelitian ini adalah mengetahui determinan keamanan dan kerahasiaan dokumen rekam medis di Rumah Sakit X. Jenis penelitian yang digunakan dalam penelitian ini adalah penelitian kualitatif menggunakan metode brainstorming dengan teknik wawancara, observasi dan dokumentasi. Hasil yang didapatkan dalam penelitian ini adalah faktor karakteristik petugas terdiri dari tingkat pendidikan terakhir petugas SMA, umur petugas 32-38 tahun, dan jenis kelamin laki-laki. Faktor psikologi meliputi attitude seperti petugas masih makan dan minum, petugas medis lain keluar masuk, membuka dokumen rekam medis tanpa izin dan terdapat pembocoran isi dokumen rekam medis. Faktor motivasi meliputi petugas merasa puas dan kompetitif dalam bekerja. Faktor organisasi meliputi penghargaan berupa pujian dan kepemimpinan belum dilakukan pemberian petunjuk pergantian dokumen rekam medis yang hilang. Hasil brainstorming yang menjadi penyebab utama yaitu tingkat pendidikan petugas yang masih rendah yaitu SMA. Saran yang diberikan meliputi pendidikan lanjutan atau pelatihan, memberi evaluasi secara rutin dan piagam kepada petugas. Kata kunci : keamanan, kerahasiaan, penyimpanan
Tinjauan Pelaksanaan Pemeliharaan Dokumen Rekam Medis di Ruang Filling RSUP Dr. Sardjito Tias Agustin Ayuningrum; Gamasiano Alfiansyah; Sugeng Sugeng; Sustin Farlinda
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 2 No 1 (2020): December
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v2i1.1983

Abstract

The implementation of maintenance medical record documents in RSUP Dr. Sardjito is not optimal. This statement was proven by the damage of medical record documents about 35,05%. The purpose of this research is to review the implementation of maintenance medical record documents uses management elements 5M (man, money, material, machine, and method). The research type is qualitative and the data collection techniques use interviews, observations, and documentations. The subjects of this research are filling officers. The result from man factor shown that filling officers have not received maintenance medical record documents training, meanwhile money factor shown that filling officers did not know about the budget management of maintenance medical record documents. The result from material factor show that the materials for medical records forms and folders have been provided optimally, meanwhile machine factor shown that the type of rack from combination of iron and wood was less suitable because it can made medical record documents were damage. The result from method factor show that standard operational procedure about implementation of maintenance medical record documents was not available. The solutions are giving socialization about implementation of maintenance medical record documents to filling officers, providing standard operational procedure about implementation of maintenance medical record documents, coating around the sharp part of rack using rubber tires that can prevent the damage of medical record folder.
Hubungan Kepuasan Kerja dengan Kinerja Petugas Rekam Medis di RSUP Dr. Sardjito Yogyakarta Desy Rachmawati; Sustin Farlinda; Sugeng Sugeng; Gamasiano Alfiansyah
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 2 No 2 (2021): March
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v2i2.1984

Abstract

Job satisfaction is an important factor that can affect employee performance. If the employee feel satisfiedwith their work, the employee will produce good performance, and vice versa. Based on observations andinterviews with one of the medical recorders, it is known that they never get a reward if they work well inaccordance with applicable procedures. In addition, facilities that support their work such as dumbwaiter andtroli sometimes suffer damage. This condition resulted in work performed by medical recorders at RSUP Dr.Sardjito Yogyakarta is not optimal, so it will affect job satisfaction. The impact of this condition was found alateness providing the patient's medical record to the health services unit or sometimes wrong distribution ofmedical record files that are not in accordance with the patient's destination services unit. This conditioncauses the examination of patients by health professional also hampered. The purpose of this research is toidentify the relationship of job satisfaction with medical recorder at RSUP Dr. Sardjito Yogyakarta. The methodof data collection in this research is a questionnaire. Analysis of the data used is univariate analysis andbivariate analysis using the Spearman rank correlation test. The results showed that the level of jobsatisfaction of medical recorders at RSUP Dr. Sardjito Yogayakarta is classified as moderate (83.3%), whilethe level of performance of the medical records officer at RSUP Dr. Sardjito Yogyakarta is classified as high(50%). Spearman rank correlation test results indicate that there is a relationship with a moderate categorybetween job satisfaction with the performance of medical recorders at RSUP Dr. Sardjito Yogyakarta with asignificance value or p value 0.006 and a correlation coefficient of 0.487.
Gambaran Stres Kerja Petugas Pendaftaran Rawat Jalan di RSUP Dr. Sardjito Yogyakarta Risma Dwi Ambarwati; Gamasiano Alfiansyah; Sustin Farlinda; Sugeng Sugeng
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 2 No 2 (2021): March
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v2i2.1998

Abstract

Occupational stress is recognized as a global health issue that affects all professions, no other profession inthe health field i.e. medical record registration section. RSUP Dr. Sardjito Yogyakarta has a total data visitannually on an outpatient registration, which is in 2018 as much as 469813 and in 2019 as many as 518806.The number of visits explained at least the registration staff should serve 200-300 patients every day. Knownerrors that occur in SIMETRISS also harm the officer because inevitably officers should double job. TheStress of work felt by the officers of the list is often felt muscle tension, feel tension, fast anger, feel anxiety,and difficulty concentrating in the work. Stressful work if not resolved will have an impact on activities in thescope or out of work. The research aimed to figure out the work stress overview of the registration officers inRSUP Dr. Sardjito Yogyakarta. The collection methods used are interviews. The analysis of the data used inthis study was qualitative. The results of the study showed work stress experienced by outpatient registrationofficers, that is caused by a physical work environment that was less comfortable so later would cause a lackof concentration by the officers and the declining of officers performance; the conflict between family demandsand the institution demands such as the lack of break time and the presence of a sustained shift; performancedemands to work quickly and precisely however the support facilities, Simetriss, which was still error alsoraised the pressure for the worker. RSUP Dr. Sardjito Yogyakarta has reduced some problems by conductingeffective consultation on outpatient registration officers.
TINJAUAN PELAKSANAAN PENGAMBILAN DOKUMEN REKAM MEDIS BERDASARKAN UNSUR MANAJEMEN 5M DI BAGIAN FILLING RSAL DR.RAMELAN SURABAYA Septin Diah Triwardhani; Niyalatul Muna; Gamasiano Alfiansyah
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 2 No 3 (2021): June
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v2i3.2003

Abstract

AbstrakTersedianya berkas rekam medis secara tepat pada saat pelayanan kesehatan yang diberikan kepada pasien akan menjadikan mutu dalam pelayanan rumah sakit menjadi lebih baik. Sebaliknya jika pelayanan kepada pasien yang terlalu lama akan berdampak buruk pada mutu pelayanan pasien. Berdasarkan hasil observasi yang dilakukan petugas pada bagian filling Rumkital Dr.Ramelan Surabaya tidak menggunakan tracer sesuai dengan prosedur yang ada pada SPO, hal ini berdampak pada kesalahan letak, misfile, dan mempersulit pengembalian berkas rekam medis sesuai dengan urutan nomornya. Penelitian ini bertujuan untuk mengetahui pelaksanaan pengambilan dokumen rekam medis berdasarkan SPO di bagian filling RUMKITAL Dr.Ramelan Surabaya. Penelitian ini menggunakan metode unsur manajemen 5M  antara lain (Man, Money, Material, Method, Machine). Pengumpulan data menggunakan wawancara dan observasi. Berdasarkan unsur man yaitu kurangnya pengetahuan petugas terkait penggunaan tracer. Unsur money yaitu penyusunan dana yang dilakukan tidak secara insidental. Variabel material yaitu terdapat dua jenis tracer yang digunakan di bagian filling RUMKITAL Dr. Ramelan Surabaya, yang pertama berwarna merah dengan bahan plastik tebal terdapat saku untuk menyisipkan kertas tracer  sedangkan yang kedua terbuat dari bahan kertas buffalo yang mudah robek. Variabel method yaitu SPO pengambilan berkas rekam medis tidak bejalan dengan baik. Variabel machine penggunaan tracer dan buku ekspedisi yang belum optimal. Kata Kunci : Filling, pengambilan berkas rekam medis, 5M
ANALISIS KUANTITATIF KELENGKAPAN PENGISIAN RESUME MEDIS DI RUMKITAL DR. RAMELAN SURABAYA Nofitalia Sawondari; Gamasiano Alfiansyah; Indah Muflihatin
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 2 No 2 (2021): March
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v2i2.2008

Abstract

The medical resume form is a summarize of all the patient's treatment that is conducted by healthcareworkers and signed by a doctor. The filling completeness of the medical resume at RUMKITAL Dr.Ramelan Surabaya only reached 82.5%. The purpose of this research was to analyze e the completenessof medical resumes in RUMKITAL Dr. Ramelan Surabaya. This research was qualitative descriptive. Thedata collection used observation. The sample of this research as many as 20 medical resume forms inFebruary of 2020. The research results indicated the highest percentage of patient identification reviewincompleteness is 45% which is the inpatient’s rank or class item. The highest percentage ofincompleteness on important report's review is 55% which is the inpatient’s duration item. The highestpercentages of incompleteness on authentication are the patient's date item, the filling time, the patient’sor family’s name, also the patient’s or family’s signature. The highest percentage of incompleteness oncorrect documentation review is 20% which is the plain and legible registration. In conclusion, the highestincompleteness is in the identification review and the correct documentation. The research suggestion is tocreate the SOP of medical resume, the SPO socialization, and to sign a commitment about theconsistency of filling medical resumes.
Faktor Penyebab Tidak Tersedianya Berkas Rekam Medis Di Bagian Filling Pada Saat Pelayanan Di Rumkital Dr. Ramelan Surabaya Ani Nuraini; Gamasiano Alfiansyah; Indah Muflihatin
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 2 No 2 (2021): March
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v2i2.2016

Abstract

Based on a preliminary study at RUMKITAL Dr. Ramelan Surabaya in March 2020, there was a problemwith the unavailability of medical record files in the filling due to files not returned from poly, and there weremisfiles. It caused longer file provisioning time and delayed service in poly because the officer needs timeto search files that did not exist in storage. The purpose of this study was to determine the factors causingthe unavailability of medical record files in storage. The type of research used a qualitative method. Datacollection techniques used interviews and observation. The results obtained; the factors that causeunavailability of medical record files in the filling seen from 5M factor were as follows. Based on man factor,there is education and officer work experience. The money factor, there is no special fund for providing lostfile folders. The method factor, there is medical record missfile. The material factor, there are broken filefolders so that the contents of these folders could be separated from the file folders. The machine factor,tracer utilization is not optimal. So, the suggestion is to add the color code on the numbering section ofmedical record folder so that it will be easier to store and align medical record documents
Analisis Penyebab tidak Ditemukannya Dokumen Rekam Medik Bagian Riset RSUPN dr. Cipto Mangunkusumo Jakarta Widiyanto Widiyanto; Gamasiano Alfiansyah; Demiawan Rachmatta Putro Mudiono
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 3 (2020): June
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v1i3.2046

Abstract

Provision of medical record documents in the medical record research center Dr. Hospital CiptoMangunkusumo is still not in accordance with the number of requests needed, in October there were 4,836requests, 3,953 documents were available, in November there were 3,823 requests and 2,977 documentswere available, in December there were 4,151 requests and 3,143 documents were available. The purpose ofthis study was to analyze the absence of medical record documents in the research section. This type ofresearch is a qualitative study using interview, observation and documentation data collection techniquesinvolving 3 respondents. The results of the study showed that the cause of the absence of medical recorddocuments was that the officers' knowledge was still low, the attitude of the officers who were still lacking indiscipline, supporting facilities and infrastructure were lacking and there was no motivation. Improvementefforts to overcome these problems are providing training, disciplinary officers need to be improved, do systemdesign, provide awards and conduct monitoring and evaluation.
Tinjauan Pelaksanaan General Consent pada Pasien Baru Rawat Jalan RSUP dr. Sardjito Bhre Diansyah; Gamasiano Alfiansyah; Sustin Farlinda
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 3 (2020): June
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v1i3.2084

Abstract

One of the accreditation instruments is Patient and Family Rights (HPK) 6.3 which states that patients andtheir families were provided with an explanation of the scope of the general consent. Based on preliminaryresearch at the outpatient registration unit at RSUP dr. Sardjito Yogyakarta, the average new registeredpatients reached 43.25 patients per day and 89% of them did not receive an explanation about thecontents of the general consent form. This research aims to identify the current general consent form foroutpatients in 2020, identify the procedure applied in delivering information of the general consent foroutpatients, and identify factors obstructing the application of the general consent. This research wasqualitative. The data were collected through interviews and observations. The subjects of the researchinvolved officers of the inpatient registration unit at RSUP dr. Sardjito Yogyakarta and the head of themedical record and health information department. The results of this research show that the registrationofficers do not inform the general consent information for new patients because they have more concernon the speed of registration process without telling the content of general consent and unavailability ofSOP in providing general consent information that cause less proper work implementation.
Analisis Faktor Penyebab Keterlambatan Pengembalian Berkas Rekam Medis Rawat Jalan di RSUPN Dr. Cipto Mangunkusumo Rizky Farah Dilla; Demiawan Rachmatta Putro Mudiono; Gamasiano Alfiansyah
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 4 (2020): September
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v1i4.2085

Abstract

Keterlambatan pengembalian berkas rekam medis dapat mempengaruhi pelayanan rekam medis dan akan menghambat kegiatan selanjutnya, seperti kegiatan assembling, koding, analisis, indeks. Pengembalian berkas rekam medis rawat jalan di RSUPN Dr. Cipto Mangunkusumo masih mengalami keterlambatan. Pada bulan januari sampai dengan februari total berkas rekam medis rawat jalan yang terlambat sebanyak 282 berkas (0,016%) dari 17.616 berkas. Tujuan dari penelitian adalah menganalisis faktor  penyebab keterlambatan pengembalian berkas rekam medis rawat jalan di RSUPN Dr. Cipto Mangunkusumo. Jenis penelitian yang digunakan adalah kualitatif. Teknik pengumpulan data berupa wawancara dan observasi. Subjek penelitian ini adalah Kepala Rekam Medis, Petugas Penanggung Jawab Operasional Unit Rekam Medis, Petugas Filling, Petugas Pengembalian Berkas. Penelitian  dilakukan pada bulan februari sampai bulan maret 2020. Hasil dari penelitian yang didapatkan yaitu pengetahuan dan sikap beberapa petugas masih belum paham dengan SOP pengembalian berkas rekam medis dan kepatuhan sikap petugas pengembalian masih kurang baik. Sarana dan prasarana sudah mendukung, hanya kurangnya ketelitian pada sumber daya petugas pengembalian. Sudah diberikan motivasi oleh koordinator pelayanan Unit Rekam Medis, dan sudah terdapat (SOP) pengembalian berkas rekam medis. Upaya yang dilakukan adalah memberi tahu perawat tentang batas waktu pengembalian berkas rekam medis rawat jalan, kepala rekam medis memberi teguran kepada perawat yang terlambat mengembalikan berkas rekam medis, memberikan motivasi kerja dan sering melakukan sosialisasi SOP terkait pengembalian berkas rekam medis rawat jalan.
Co-Authors Aditya Dwi Arimbi Afrizal Himawan Alvira Nafisah Eky Mulia Andar Sifa’il Fajeri Angga Rahagiyanto Ani Nuraini Anisa Istiqomah Atma Deharja Bastin Nur Aliefia Bhre Diansyah Dahlia Indah Amareta, Dahlia Indah Demiawan Rachmatta Putro Mudiono Desy Rachmawati Dinda Darmawati Efri Tri Ardianto Faizatun Nikmah Feby Erawantini Haris Hammaminata Hikmah, Faiqatul Indah Muflihatin Iqbal Ramadhan Suryawiyanto Iqbal Rhamadhan Suryawiyanto Irene Ratri Andia Sasmita Isye Isyanti Dewi Maya Weka Santi Mudafiq Riyan Pratama Niyalatul Muna Nofitalia Sawondari Novita Nuraini Rachmawati, Ervina Ria Chandra Kartika Risma Dwi Ambarwati Rizky Farah Dilla Rossalina Adi Wijayanti Rowinda Dwi Kurniawati Sabran Sabran Sakinah Salsabila Selvia Juwita Swari Selvia Juwita Swari Septin Diah Triwardhani Siti Wafiroh Sugeng Sugeng Sugeng Sugeng Sugeng Sugeng Sustin Farlinda Tias Agustin Ayuningrum Wahyu Hidayati Widiyanto Widiyanto Yusfa Ike Rustiana