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

Analisis Lama Waktu Penyediaan Berkas Rekam Medis Rawat Jalan untuk Pasien Lama Poli Bedah Onkologi di RSAL dr. Ramelan Surabaya Tahun 2020 Bastin Nur Aliefia; Gamasiano Alfiansyah; Indah Muflihatin
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.v2i1.2142

Abstract

Polyclinic at RSAL dr. Ramelan Surabaya which has the most number of patient visits every day is poly surgical oncology than other poly surgery which is ± 55 - 60 patients, here researchers see that with the many requests for medical record files, the supply of medical record files must be as fast as possible and must still meet existing standards. But in reality the supply of medical record files still exceeds the standard. The results of the observations I made to search for 1 file took 5 minutes until the file was recorded in the register of each poly, aiming that the file with no. The RM has been sent and then barcoded or sent via SIMRS, it should be marked that the medical record file must already be in the clinic but here the file is still placed on the table very long which is about 15 minutes and can also be more than it should be sent to the polyclinic. That way the file does not get to the clinic according to the Hospital Minimum Service Standards (SPM). The aim is to find out how long it takes to provide medical records in outpatients for poly surgical oncology patients at RUMKITAL Dr. Ramelan Surabaya. This type of research is qualitative. Data collection techniques in the form of interviews and observations. The population in this study were all outpatient medical record files for oncology surgery patients in March 2020. The results obtained from the study were the length of time the provision of outpatient medical record files for old poly surgical oncology patients exceeded the established standard that required an average time 11 minutes for each file arrived at the polyclinic.
ANALISIS FAKTOR KINERJA PENGISIAN DOKUMEN REKAM MEDIS RAWAT INAP KLINIK dr. M. SUHERMAN JEMBER Aditya Dwi Arimbi; Selvia Juwita Swari; Novita Nuraini; Indah Muflihatin; Gamasiano Alfiansyah
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.v1i2.2238

Abstract

Percentage of incompleteness of filling in the medical records of the Clinic Dr. M. Suherman shows thatthe Minimum Service Standards in the Hospital are not yet 100%. Incomplete data has shown that thecompleteness of filling medical record documents is still not in accordance with the specified standards.The incompleteness of filling out the medical record document may be caused by the performance factorof the officer in completing the inpatient medical record document. The purpose of this study is to analyzethe performance factors in filling out the record documents. The purpose of this study was to analyze theperformance factors in filling out medical records of inpatients at the Clinic dr. M. Suherman Jember. Thisstudy uses qualitative research that aims to identify and analyze performance factors in filling inpatientmedical record documents at the Clinic dr. M. Suherman Jember, who will be associated with performancetheory with personal factors, leadership factors, team factors, system factors, and situational factors, andusing the USG (Urgency, Seriousness, Growth) method to determine the main factors of the 5 factors thataffect performance as well as efforts to correct problems using brainstorming. The results of this studyobtained priority causes of the incompleteness of filling medical records documents for inpatients at theClinic dr. M. Suherman Jember is the lack of awareness of each individual related to filling medical recorddocuments, lack of evaluation and monitoring, lack of socialization, lack of understanding related to SOPfor filling medical record documents because there is no SOP for filling medical record documents, so theClinic, Dr. M. Suherman asked researchers to make SOPs for filling in the records of inpatients. As asuggestion, do a commitment to complete the completeness of filling medical record documents, conductsocialization, evaluation and routine monitoring, as well as making SOP for filling medical recorddocuments.
ANALISIS FAKTOR PENYEBAB TERJADINYA MISSFILE DI BAGIAN FILING PUSKESMAS DRINGU KABUPATEN PROBOLINGGO Nofitalia Sawondari; Efri Tri Ardianto; Atma Deharja; 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.v2i3.2247

Abstract

Kegiatan penyelenggaraan rekam medis di Puskesmas Dringu masih belum optimal. Hal ini dapat dilihat dari belum adanya ruang filing, kurangnya rak rekam medis, serta proses penyimpanan yang belum sesuai dengan SOP sehingga dapat menyebakan terjadinya missfile. Tingkat kejadian missfile di Puskesmas Dringu sebesar 11% pada bulan Juni 2019. Missfile dokumen rekam medis dapat menyebabkan data rekam medis tidak berkesinambungan. Penelitian ini bertujuan untuk menganalisis faktor penyebab terjadinya missfile di Puskesmas Dringu Kabupaten Probolinggo. Jenis penelitian adalah penelitian kualitatif. Pengumpulan data menggunakan wawancara, observasi, dokumentasi dan kuesioner. Subyek penelitian berjumlah 4 orang yang terdiri dari 2 petugas rekam medis, kepala rekam medis serta kepala Puskesmas Dringu. Penentuan prioritas penyebab masalah terjadinya missfile menggunakan USG (Urgency, Seriousness, Growth) dan penentuan solusi menggunakan brainstorming. Hasil penelitian menunjukan bahwa faktor penyebab missfile yaitu ketidakpatuhan petugas dalam menjalankan SOP, kurangnya pengetahuan, tidak adanya tracer dan buku ekspedisi, pendidikan petugas belum sesuai kualifikasi, petugas tidak melakukan penyortiran DRM yang akan disimpan dan petugas tidak melakukan audit penyimpanan secara periodik. Hasil prioritas utama penyebab missfile menggunakan USG yaitu petugas yang tidak patuh terhadap SOP (Standart Operasional Procedure). Upaya penyelesaian masalah tersebut yaitu adanya sosialisasi SOP, pengawasan kinerja petugas, mengadakan evaluasi kinerja dan  adanya punishment dan reward.
PERANCANGAN DAN PEMBUATAN WEBSITE PUSKESMAS NOGOSARI DENGAN MENGGUNAKAN METODE WATERFALL Haris Hammaminata; Feby Erawantini; Novita Nuraini; 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.v2i2.2260

Abstract

Submission of information at Nogosari Public Health Center was done by sticking announcements in the cornerof the wall and bulletin board. Nogosari Public Health Center’s queue registration system was still offline-based.People could only get this information and take the queue if they came to the public health center. This researchaimed to design and create Nogosari Public Health Center’s website using waterfall method. The approach ofthis research was Research and Development (R & D). Data collection techniques used interviews andobservations. The analysis unit of this research were the head of the Nogosari Public Health Center Jember, ahealth promotion officer, an environmental health officer, a surveillance officer, a KIA-KB-Nutrition serviceofficer, a medical record officer, and 2 patients in Nogosari Public Health Center Jember. The results showedNogosari Public Health Center’s website accompanied by additional features include online queuing features,suggestion box facilities, and question and answer pages. Suggestions from researchers are the system shouldbe developed into an integrated service system by adding customize features to existing services. NogosariPublic Health Center Jember need a domain host so that this website can be accessed by the internet.
Strategi Percepatan Waktu Distribusi Dokumen Rekam Medis di RSU dr. H. Koesnadi Bondowoso Isye Isyanti Dewi; Feby Erawantini; dr. Novita Nuraini; Gamasiano Alfiansyah
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 2 No 4 (2021): September
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v2i4.2456

Abstract

Pendistribusian dokumen rekam medis adalah suatu kegiatan mendistribusikan dokumen rekam medis ke poliklinik setelah pasien registrasi. Keterlambatan pendistribusian dokumen rekam medis rawat jalan sering dijumpai pada kegiatan penyelenggaraan rekam medis. Batas waktu pendistribusian dokumen rekam medis rawat jalan di RSU dr. H. Koesnadi Bondowoso yaitu ≤ 10 menit setelah pasien mendaftar. Data keterlambatan yang dilakukan pada survey awal bulan November 2019 mencapai 53,5%. Tujuan dari penelitian ini adalah menyusun strategi untuk melakukan perbaikan keterlambatan pendistribusian dokumen rekam medis rawat jalan di RSU dr. H. Koesnadi Bondowoso. Penelitian ini merupakan penelitian kualitatif dengan metode Action Research. Teknik pengumpulan data menggunakan wawancara mendalam, observasi dan brainstorming. Hasil penelitian ini diketahui bahwa faktor penyebab keterlambatan pendistribusian dokumen rekam medis rawat jalan yaitu pengetahuan petugas tentang SOP kurang, kedisiplinan petugas yang masih kurang disiplin, tidak terdapat petugas khusus pendistribusian dokumen rekam medis, tidak terdapat tracer pada rak penyimpanan, petugas filing tidak pernah mendapatkan reward dari pimpinan dan belum pernah diadakan sosialisasi SOP. Berdasarkan hal tersebut upaya penyelesaian masalah yang peneliti sarankan pada pihak RSU dr. H. Koesnadi Bondowoso dengan merevisi SOP dan sosialisasi SOP secara berkala.
Analisis Faktor Penyebab Kerusakan Berkas Rekam Medis di Puskesmas Nogosari Kabupaten Jember Selvia Juwita Swari; Sakinah Salsabila; Maya Weka Santi; Angga Rahagiyanto; Gamasiano Alfiansyah
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 5 No 3 (2024): June
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v5i3.3924

Abstract

Medical records at The X Community Health Center are easily torn due to overfilled filing racks, making it difficult to retrieve medical record files. Forcing the files out can result in torn records. Approximately 7.35% of medical records were found to be damaged. The aim of this study was to analyze the factors causing damage to medical records based on the 7M aspects. The research was qualitative, with data collected through interviews, observations, and documentation. The research subjects consisted of 1 registration officer, 1 filing officer, 1 administrative staff member, 1 head of administration, and the Head of the X Community Health Center. Data were analyzed through data reduction, data presentation, and conclusion drawing. The results showed that the damage to medical records was caused by several factors, including man (education level, lack of knowledge, and no training), machines (insufficient number of medical record storage racks), methods (no SOP for medical record maintenance), materials (medical record folder materials), media (physical environment), motivation (no rewards or punishments), and money (insufficient budget for procuring medical record folders). It is recommended that The X community health center provide medical record maintenance training and develop and implement SOP for medical record maintenance.