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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
Dewi, Deasy Rosmala
Prodi Rekam Medis Dan Informasi Kesehatan, Fakultas Ilmu-Ilmu Kesehatan, Universitas Esa Unggul, Jakarta, Indonesia
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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 Dewi, Deasy Rosmala; Rumana, Nanda Aula; Indawati, Laela; Putri, Nur Ratri Annisa; Wantika, Chinta Fourdy; Liani, Emilia Karin Dwi; Mariyam, Mutia; Nurkholifa, Eza; 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.
Kelengkapan Rekam Medis Rawat Inap di Rumah Sakit Islam Jakarta Sukapura Susilawati, Susilawati; Rumana, Nanda Aula; Dewi, Deasy Rosmala; Muniroh, Muniroh
Journal of Hospital Management Vol 5, No 01 (2022): Journal of Hospital Management
Publisher : Lembaga Penerbitan Universitas Esa Unggul

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.47007/.v5i01.5419

Abstract

Rekam medis adalah catatan yang berisi antara lain identitas pasien, hasil pemeriksaan, pengobatan, serta tindakan dan pelayanan lain yang diberikan kepada pasien. Tujuan dari penelitian ini yaitu mengetahui gambaran kelengkapan rekam medis rawat inap di Rumah Sakit Islam Jakarta Sukapura, Jenis penelitian yang digunakan yaitu deskriptif kuantitatif dengan populasi dan sampel 96 rekam medis rawat inap bulan mei 2021. Metode pengumpulan data dalam penelitian ini yaitu dengan observasi dan wawancara, berikut hasil penelitian yang telah dilakukan di rumah sakit Islam Jakarta Sukapura terhadap 96 rekam medis identifikasi pasien 100%, catatan / laporan yang penting 77%, autentikasi penulis 74% dan catatan yang baik 100% dan didapatkan rata rata nilai kelengkapan terendah yaitu 88%. Faktor ketidaklengkapan rekam medis rawat inap yaitu kurangnya pengetahuan terhadap tata cara pengisian rekam medis dikarenakan tidak adanya standar prosedur operasional di rumah sakit Islam Jakarta Sukapura, Kurang pedulinya dokter untuk mengisi lembar rekam medis yang seharusnya diiisi dengan lengkap. Oleh karena itu perlu dibuat Standar Prosedur Operasional yang mengatur khusus pengisian rekam medis dan sosialisasi tentang pengisian kelengkapan rekam medis di Rumah Sakit Islam Jakarta Sukapura.
The Design of Medical Record Retention Implementation Guidelines at RSUD Balaraja Kabupaten Tangerang Fatimah, Dwiyani Nur; Dewi, Deasy Rosmala
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Vol. 11 No. 1 (2026): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Februari
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v11i1.1924

Abstract

RSUD Balaraja Kab. Tangerang already has an SPO for the retention of active medical record files into inactive medical records and an SPO for the destruction of medical record files, there is no archive retention schedule yet. For the implementation of the reduction of medical records according to schedule, a procedure guideline is made. This study aims to design a procedure guideline for the reduction of medical records using the Delphi method which was carried out in October 2024 - November 2024. Data collection through observation of the medical record room, interviews with the head of the medical record installation and a questionnaire for the application of the Delphi method, with 5 stakeholders consisting of the Head of Medical Services, the Medical Service Operational Work Team, the Public Relations and Program Planning Administration Work Team, the Treasurer, and the Head of the Medical Record Installation. The results of this study describe the facilities and infrastructure and procedures for implementing the reduction of medical records at RSUD Balaraja Kab. Tangerang, preparing a guideline for the management of medical record reduction, verifying the results of filling out the questionnaire that has been agreed upon by stakeholders with a standard deviation of 0 which means there is no difference of opinion and proposing the design of a guideline for the management of medical record reduction consisting of chapter 1 definition, chapter 2 scope, chapter 3 procedures, and chapter 4 documentation. The conclusion is a draft design of a guideline for the management of medical record reduction which contains the procedures and schedule for the implementation of medical record reduction at RSUD Balaraja Kab. Tangerang.
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.
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 Batunnajariah Anisa Nur Safitri Anjar Retno Astrini Ardianti, Tita Arip Budiana Athirah Iwani Rahman Athiyyah, Hanifatul Bahlani Bayu Fajar Ilhami Budiana Gustiara Carono Cindi Trisa Olivia 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 Endang Palupi Ningsih Fannya, Puteri Fatimah, Dwiyani Nur Fatkhurohman, Mohammad Fajri Fatkur Ridho Fatkur Ridho Fauzan Habibilah Fauziah Irfany 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 Muammar Dzachwani Muhamad Al Imran Rangga Putra Munazhifah Munazhifah Muniroh Muniroh - Muniroh Muniroh Muniroh Muniroh Muniroh Muniroh Muniroh, Muniroh Nabila Raihani Nabila Zahara Ramadan Nanda Aula Romana Nanda Aula Rumana Nanda Rumana Navry Nanda Aprilian Noviana Dian Angelina Nur Fadilah 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 Silfa Haniasti Siswati Siswati Siswati Siswati Siswati Siva Maulia Fauziah Sri Kholifatun STIKES Husada Borneo Suprobowati Suprobowati Suryati, Mekhtildis Susilawati, Susilawati 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