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All Journal Faktor Exacta Jurnal Manajemen Informasi dan Administrasi Kesehatan Jurnal Kesehatan Indonesia Jurnal Manajemen Informasi Kesehatan Indonesia (JMIKI) Indonesian of Health Information Management Journal (INOHIM) Surya Medika: Jurnal Ilmiah Ilmu Keperawatan dan Ilmu Kesehatan Masyarakat Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Community Development Journal: Jurnal Pengabdian Masyarakat Jurnal Kesehatan Tambusai J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Open Access Indonesian Journal of Medical Reviews Educivilia: Jurnal Pengabdian Pada Masyarakat KESANS : International Journal of Health and Science Indonesian Journal of Health Information Management (IJHIM) Gemakes: Jurnal Pengabdian Kepada Masyarakat Jurnal Ilmiah Kesehatan Masyarakat Sehat Rakyat: Jurnal Kesehatan Masyarakat Journal of Innovation Research and Knowledge Jurnal Sosial dan Sains Journal of Hospital Management Journal of Artificial Intelligence and Digital Business Student Scientific Creativity Journal Cerdika: Jurnal Ilmiah Indonesia Innovative: Journal Of Social Science Research Jurnal Medika Nusantara Vitamin: Jurnal Ilmu Kesehatan Umum Jurnal Siti Rufaidah Jurnal Rekam Medic Jurnal Ilmu Kedokteran dan Kesehatan Indonesia Klinik: Jurnal Ilmiah Kedokteran dan Kesehatan
Dewi, Deasy Rosmala
Prodi Rekam Medis Dan Informasi Kesehatan, Fakultas Ilmu-Ilmu Kesehatan, Universitas Esa Unggul, Jakarta, Indonesia
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Tinjauan Penyebab Peserta Non Aktif Bpjs di Puskesmas Kecamatan Cengkareng Navry Nanda Aprilian; Deasy Rosmala Dewi; Puteri Fannya; Daniel Happy Putra
Jurnal Siti Rufaidah Vol. 2 No. 3 (2024): Jurnal Siti Rufaidah
Publisher : PPNI UNIMMAN

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.57214/jasira.v2i3.101

Abstract

Abstract: The Social Security Administering Body (BPJS) is an organizing body whose membership is mandatory. Every company is required to register its workers for a minimum of 6 months, while those who do not work for a company are required to register themselves and their family members with BPJS. Each BPJS participant will be charged a contribution, the amount of which will be determined later. Inactive BPJS membership is a participant whose registration process is hampered and services become payable independently. The aim of the research is to review the causes of Non-active BPJS participants in Cengkareng sub-district. The research method is a quantitative approach. The technique uses saturated sample observations. The research results showed that there were 75 Non-active participants. Of the 75 samples, there were 34 participants who were inactive due to premiums (45.33%), 13 participants because they left of their own accord (17.33%), 7 participants because their children were PPU> 21 years (9.33%), 10 participants were not covered (13 .33%), 11 participants with double data (14.66%). Follow-up of Inactive BPJS membership at the Cengkareng Community Health Center, there were 65 participants (86.67%) taking care of returning BPJS participants and 10 participants (13.33%) continuing at their own expense. Of the number of BPJS participants who registered for treatment at the Cengkareng sub-district health center, their membership status was inactive due to premiums being one of the highest. The follow-up is to pay all arrears and take care of returning the membership to the nearest BPJS. Suggestions In accordance with the vision and mission of BPJS Health to be able to improve the quality of service to participants, BPJS Health must be able to improve the quality of service, especially in the field of information technology which can be made to remind BPJS Health participants, especially those whose membership status is inactive, by using E-mail and Whatsapp.
Analisis Ketepatan Kode Cedera dan Penyebab Luar Cedera pada RME Rawat Darurat di RSIJ Sukapura Fazra Nanda; Deasy Rosmala Dewi; Noor Yulia; Bangga Agung Satrya
Jurnal Ilmiah Kedokteran dan Kesehatan Vol. 4 No. 2 (2025): Mei : Jurnal Ilmiah Kedokteran dan Kesehatan
Publisher : Lembaga Pengembangan Kinerja Dosen

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.55606/klinik.v4i2.3904

Abstract

The accuracy of the diagnosis code is a statement that shows a code for a convincing diagnosis, and has been said to be certain and clear according to the ICD-10 guidelines. The purpose of this study was to obtain an overview of the analysis of the accuracy of injury codes and external causes of injury in emergency care electronic medical records at the Jakarta Islamic Hospital Sukapura. This research is descriptive research with a Mix Methode approach. Data collection techniques using observation and interview methods. Samples were taken using saturated sampling techniques totaling 81 electronic medical records of emergency care patients. The accuracy of the injury code is 22% correct, and the accuracy of the external cause of injury code incorporated in traffic accident cases and other accident cases is 0% correct. The low accuracy of injury codes was due to not adding character 5, block code errors, and errors in determining code categories. The results of the accuracy of the external cause of injury code obtained were 0% correct because 80 electronic medical records of emergency care patients did not contain the code for the external cause of injury. Factors that hinder the accuracy of injury codes and external causes of injury are influenced by man factors, namely high workload, dependence on ICD-10 codes on doctors, and lack of feedback audits. Then the influence of material factors, namely the incompleteness of supporting documents, lack of detail in diagnosis, and lack of chronological letters of events. Then the influence of method factors, namely unsupportive policies and procedures, lack of training and understanding, and weak application of external cause of injury codes.
Tinjauan Kelengkapan Pengisian Resume Medis Berdasarkan Elemen Penilaian Akreditasi SNARS 1.1 di RSUD Kembangan Muammar Dzachwani; Deasy Rosmala Dewi; Puteri Fannya; Laela Indawati
Indonesian Journal of Health Information Management Vol. 2 No. 1 (2022)
Publisher : Sekolah Tinggi Ilmu Kesehatan Mitra Husada Karanganyar

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.54877/ijhim.v2i1.37

Abstract

Ringkasan pulang ( resume atau discharge summary) adalah ringkasan dari seluruh masa perawatan dan pengobatan pasien sebagaimana yang telah diupayakan oleh para tenaga kesehatan dan pihak terkait, lembar resume medis harus ditandatangani oleh dokter penanggung jawab pasien. Kelengkapan resume medis digunakan untuk dasar pembuatan laporan intern dan ekstern rumah sakit. Tujuan dari penelitian ini adalah untuk mengetahui gambaran kelengkapan pengisian resume medis berdasarkan elemen penilaian akreditasi SNARS 1.1. Metode penelitian yang digunakan adalah metode analisis deskriptif dan teknik pengumpulan data adalah observasi, analisis kuantitatif, dan pedoman wawancara. Berdasarkan hasil penelitian mengenai Standar Prosedur Operasional pengisian resume medis di RSUD Kembangan Jakarta sudah ada, dimana terdapat 3 prosedur yang belum dijalankan yaitu tidak adanya buku catatan yang mencatat mengenai resume yang belum diisi, melengkapi resume medis dilakukan di ruang rawat inap, belum tersedianya buku catatan yang mencatat resume medis yang belum diisi. Kelengkapan resume medis berdasarkan elemen penilaian akreditasi SNARS 1.1 91,59% dari 90 resume medis dan tidak lengkap 8,41%. Dampak dari ketidaklengkapan resume medis membuat angka review rekam medis menjadi tidak bagus, bagi pasien bpjs klaim menjadi terhambat, membuat proses kelanjutan pengobatan terganggu karna riwayat pengobatan pasien tidak lengkap, tidak lengkap resume juga berpengeraruh terhadap akreditasi rumah sakit. Perlunya disosialisasikan kembali mengenai Standar Operasional Prosedur dan perlu ketegasan dari pihak Direktur rumah sakit agar tingkat kedisiplinan dalam pengisian resume medis dapat terlaksana dengan baik dan tepat waktu.
Literature Review Desain Formulir Rekam Medis Di FASYANKES Fatkur Ridho; Wiwik Viatiningsih; Deasy Rosmala Dewi; Noor Yulia
Indonesian Journal of Health Information Management Vol. 2 No. 2 (2022)
Publisher : Sekolah Tinggi Ilmu Kesehatan Mitra Husada Karanganyar

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.54877/ijhim.v2i2.59

Abstract

Abstrak Desain formulir merupakan suatu kegiatan yang bertujuan melakukan proses perancangan formulir menggunakankreativitas seseorang untuk menghasilkan fungsi dan nilai keindahan pada formulir. Penelitian ini dilakukan untuk mengetahui kesesuaian desain formulir rekam medis berdasarkan aspek anatomi, aspek isi, serta aspek fisik yang terdapat pada desain formulir rekam medis di fasilitas pelayanan kesehatan dengan menggunakan metode literature review terhadap 10 jurnal. Hasil dari penelitian ini ditinjau dari aspek anatomi pada komponen heading dengan sub komponen tanggal penerbitan semua jurnaltidak memiliki tanggal penerbitan, sedangkan pada komponen body dengan sub komponen type style dan cara pencatatan semua jurnal memiliki type style dan cara pencatatan yang sesuai serta pada komponen introduction, instruction, dan closing terdapat jurnal yang sesuai dan tidak sesuai dengan prinsip desain formulir. Ditinjau dari aspek fisik pada komponen tinta semua jurnal memiliki tinta yang sesuai sedangkan pada komponen warna, bahan, dan ukuran terdapat jurnal yang sesuai dan tidak sesuai dengan prinsip desain formulir. Ditinjau dari aspek isi pada komponen kelengkapan butir atau item formulir dan terminologi data terdapat jurnal yang sesuai dan tidak sesuai dengan prinsip desain formulir. Abstract Form design is an activity that aims to carry out the form design process using one's creativity to produce the function and aesthetic value of the form. This study was conducted to determine the suitability of the mediscal record form design based on anatomical aspects, content aspects, and physical aspects contained in the mediscal record form design in health care facilities using the literature review method of 10 journals. The results of this study are viewed from the anatomical aspect of the heading component with the publishing date sub-component, all journals do not have a publication date, while the body component with the style type sub-component and the recording method of all journals has the style type and the appropriate recording method and the introduction component instruction, and closing there are journals that are appropriate and not in accordance with the principles of form design. Judging from the physical aspect of the ink component, all journals have the appropriate ink while on the color, material, and size components there are journals that are appropriate and not in accordance with the principles of form design. Judging from the content aspect of the component of completeness of items or form items and data terminology, there are journals that are appropriate and not in accordance with the principles of form design.
Faktor-Faktor Penyebab Terjadinya Duplikasi Penomoran Rekam Medis Rawat Jalan Berdasarkan Aspek 5M di Puskesmas Bringin Kabupaten Semarang Tahun 2021 Sheren Hana Abriva; Deasy Rosmala Dewi; Noor Yulia; Nanda Aula Rumana
Sehat Rakyat: Jurnal Kesehatan Masyarakat Vol. 5 No. 2 (2026): Mei 2026
Publisher : Yayasan Pendidikan Penelitian Pengabdian Algero

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.54259/sehatrakyat.v5i2.7198

Abstract

Based on preliminary studies conducted by the author at the Bringin Community Health Center, 35 duplicate outpatient medical records were found in 2020.  The purpose of this study was to identify the factors causing the duplication of outpatient medical record numbers at the Bringin Community Health Center. This study used a qualitative method with a descriptive approach. The sample in this study consisted of 4 medical record officers. The results of the study in February-March 2021 showed that there were two duplicate medical record numbers. The causes of duplicate medical record numbering were based on the 5M aspects (Man, Material, Method, Machine, Money). The man factor was related to the limited number of staff. The material factor was related to patients who did not bring their medical treatment identity card when visiting. The method factor indicates the lack of specific standard operating procedures regarding medical record numbering. The machine factor indicates that the system is still manual. The money factor indicates a lack of funds needed to add medical record staff. The recommendation to the Bringin Community Health Center is to create standard operating procedures for Medical Record Numbering and provide training for staff who are not medical record graduates.
PENGUATAN KOMPETENSI TERMINOLOGI KLINIS MELALUI SNOMED-CT MASTERY BAGI MAHASISWA DAN TENAGA KESEHATAN: STRENGTHENING CLINICAL TERMINOLOGY COMPETENCY THROUGH SNOMED-CT MASTERY FOR STUDENTS AND HEALTH WORKERS Deasy Rosmala Dewi; Nanda Aula Rumana; Laela Indawati; Nur Ratri Annisa Putri; Chinta Fourdy Wantika; Emilia Karin Dwi Liani; Mutia Mariyam; Eza Nurkholifa; Anisa Anisa
GEMAKES: Jurnal Pengabdian Kepada Masyarakat Vol. 6 No. 1 (2026): GEMAKES: Jurnal Pengabdian Kepada Masyarakat
Publisher : Politeknik Kesehatan Kemenkes RI Jakarta I

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.36082/gemakes.v6i1.2935

Abstract

Transformasi sistem kesehatan nasional menuntut tersedianya data klinis yang terstandar, akurat, dan dapat dipertukarkan antar fasilitas pelayanan kesehatan melalui rekam medis elektronik. Salah satu tantangan utama dalam proses ini adalah rendahnya kompetensi mahasiswa dan tenaga kesehatan dalam penggunaan terminologi klinis standar, khususnya Systematized Nomenclature of Medicine Clinical Terms (SNOMED-CT), akibat keterbatasan pelatihan praktis dan media pembelajaran kontekstual. Kegiatan pengabdian kepada masyarakat ini bertujuan untuk memperkuat kompetensi terminologi klinis melalui pelaksanaan SNOMED-CT Mastery Program bagi mahasiswa Program Studi Rekam Medis dan Informasi Kesehatan serta tenaga kesehatan dari berbagai fasilitas pelayanan kesehatan. Metode pelaksanaan menggunakan pendekatan pelatihan terstruktur yang mengombinasikan sosialisasi, pembelajaran teori, praktik langsung pengodean dan pemetaan kasus klinis, serta evaluasi melalui pre-test dan post-test. Hasil evaluasi terhadap 101 peserta menunjukkan adanya peningkatan skor pengetahuan yang signifikan setelah pelatihan, yang mengindikasikan peningkatan pemahaman dan kesiapan peserta dalam menerapkan terminologi klinis standar pada sistem rekam medis elektronik. Pembahasan menunjukkan bahwa pendekatan pembelajaran berbasis praktik dan studi kasus klinis riil efektif dalam menjembatani kesenjangan antara pemahaman teoritis dan kebutuhan implementasi di lapangan. Kesimpulannya, program ini berhasil meningkatkan kompetensi peserta dan berpotensi mendukung peningkatan kualitas serta interoperabilitas data kesehatan nasional melalui penguatan kapasitas sumber daya manusia.
Analisis Kebutuhan SDM Rekam Medis Sebelum dan Sesudah Implementasi RME dengan Metode ABK-Kes Selvi Dwi Lestari; Laela Indawati; Daniel Happy Putra; Deasy Rosmala Dewi
Sehat Rakyat: Jurnal Kesehatan Masyarakat Vol. 5 No. 3 (2026): Agustus 2026
Publisher : Yayasan Pendidikan Penelitian Pengabdian Algero

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.54259/sehatrakyat.v5i3.8042

Abstract

Healthcare human resource planning is crucial for determining current and future staffing needs and availability. Therefore, healthcare workload analysis is essential in the healthcare sector for evaluating healthcare human resources. The objective of this study is to determine the staffing needs for medical record technicians and health information officers at a hospital in East Jakarta. This study is a quantitative descriptive study conducted through direct field research to determine the required number of medical records staff based on data from interviews and observations. The results of this study indicate that the Available Work Time (AWT) is 1,200 hours/year or 72,000 minutes/year. The Support Task Factor (STF) is 14% and the Support Task Standard (STS) is 1.16, resulting in a requirement for 15 medical records staff. There are currently 10 medical records staff members, so an additional 5 staff members are needed to meet staffing requirements. However, if a hospital in East Jakarta were to fully implement Electronic Medical Records (EMR), the staffing requirement would be reduced to 6 staff members, resulting in a surplus of 4 staff members since some tasks would be performed electronically via the system. The recommendation for the hospital is to accelerate the full implementation of Electronic Medical Records (EMR) to improve work efficiency and reduce the workload in certain departments. Staff who do not yet meet the qualifications are advised to pursue education in medical records and receive training to enhance their knowledge and skills in line with advancements in technology and modern healthcare systems.
Analisis Beban Kerja dan Kebutuhan Petugas Unit Rekam Medis di RSUP Dr. Sitanala Nabila Zahara Ramadan; Puteri Fannya; Deasy Rosmala Dewi; Daniel Happy Putra
Jurnal Ilmu Kedokteran dan Kesehatan Indonesia Vol. 5 No. 2 (2025): Juli : Jurnal Ilmu Kedokteran dan Kesehatan Indonesia
Publisher : Lembaga Pengembangan Kinerja Dosen

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.55606/jikki.v5i2.6865

Abstract

Hospitals, as healthcare service providers, are required to improve the quality and efficiency of their services, one of which is through the implementation of Electronic Medical Records (EMR). This transformation impacts the workload of staff, particularly in the Medical Records Unit. This study aims to analyze the workload and staffing needs of the Medical Records Unit at Dr. Sitanala Central General Hospital using a descriptive quantitative approach with the Health Workload Analysis (ABK-Kes) method. Data were collected through observation and interviews with six staff members using observation sheets, interview guidelines, and informed consent forms. The results show that the Available Working Time (AWT) is 72,000 minutes per year, exceeding the national standard. There are 11 core tasks and 3 supporting tasks, with the highest Standard Workload (SWL) found in the recording and filing activity (72,000), and the Standard Supporting Task (SST) value is 1.2. Based on achievements, SWL, and SST, a total of four staff members are needed to balance the workload. Currently, only one staff member remains due to staff rotation, resulting in a shortage of three personnel. Therefore, Dr. Sitanala Hospital needs to recruit three additional medical record officers with a minimum qualification of a D3 in Medical Records to maintain optimal service and manageable workloads.
Co-Authors -, Muniroh Adelia Anggraini Adham, Yunan Adijaya, Nuryansyah Adil Hidayat Ahmad Hikmi Aldio Ahmad Ripki Al Faqih, M. Rolan Tiro Aldio, Ahmad Hikmi Almahshunatul Hanifah Alumni STIKES Husada Borneo Anastasyannisa Ramadhanty Angela Marsiana Siki Angelina, Noviana Dian Anggraini, Adelia Ani Kipatul Hidayah Anisa Anisa Anisa Anisa Anisa Batunnajariah Anisa Nur Safitri Anjar Retno Astrini Ardianti, Tita Arip Budiana Athirah Iwani Rahman Athiyyah, Hanifatul Bahlani Bangga Agung Satrya Bayu Fajar Ilhami Budiana Gustiara Carono Chinta Fourdy Wantika Cindi Trisa Olivia Daniel Happy Putra Daniel Happy Putra Dede Lisda Nurjanah Dede Lisda Nurjanah Deta Nurfena Nurfena Diah putri Ayu Islammia Dian Nur Muslimah Dianty, Gebbrien Anggia Dinda Melani Safitri Dion Angger Priyatama Diva Angelita Dwijayanti, Risma Mei Edi Kurnianto Elina Intan Apzari Emilia Karin Dwi Liani Endang Palupi Ningsih Eza Nurkholifa Fannya, Puteri Fatimah, Dwiyani Nur Fatkhurohman, Mohammad Fajri Fatkur Ridho Fauzan Habibilah Fauziah Irfany Fazra Nanda Febri Irawan Febriyan Awi Pasa Feni Fajriani Fingky Rizki Wulandari Fitria Atmojowati Gina Sonia Gussa Azizah Hardi Arissaputra Hari Rinaldi Ilham Abdurohman Ilhami, Bayu Fajar Iman Harapan Jaya Zalukhu Indawati, Laela Indrawati, Laela Intan Novarinda Iqbal, Muhammad Fuad Kirani, Niken Leni Karunia Septiani Liani, Emilia Karin Dwi Mariyam, Mutia Mekhtildis Suryati Muammar Dzachwani Muhamad Al Imran Rangga Putra Munazhifah Munazhifah Muniroh Muniroh - Muniroh Muniroh Muniroh Muniroh Muniroh, Muniroh Mutia Mariyam Nabila Raihani Nabila Zahara Ramadan Nanda Aula Romana Nanda Aula Rumana Nanda Rumana Navry Nanda Aprilian Noviana Dian Angelina Nur Fadilah Nur Ratri Annisa Putri Nurasiyah Nurfena, Deta Nurfena Nurhaliza Putrikama Nurkholifa, Eza Nurmalasari, Dinda Nurmalasari, Mieke Paryati Paryati Purwoko, Agus Putri, Alifatul Aulia Sagita Putri, Dwi Tania Putri, Nur Ratri Annisa Putri, Sisilia Raru, Amida Morina Ratna Auliyana Retno Juwita Rianta Sari Gultom Rosa Patricia Safitri, Dinda Melani Salsabella, Pradita Sansy Dua Lestari Selvi Damayanti Selvi Dwi Lestari Sheren Hana Abriva Silfa Haniasti Siswati Siswati Siva Maulia Fauziah Sri Kholifatun STIKES Husada Borneo Suprobowati Suprobowati Suryati, Mekhtildis Sutarto, Mutia Syafitri, Umi Syifa Erintan Temesvari, Nauri Anggita Umi Syafitri Vania Rachma Putri Viatiningsih, Wiwik Wahyudi Prasetyo Wantika, Chinta Fourdy Widjaja, Liliy Widjaja, Lily Willy Haposan Winda Indri Anggraeni Windiana Mega Sukmawati Wini Wini Yeni Safitri Yulia, Noor