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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

Author-ID : 2579342

Religion Arts Humanities Astronomy Chemistry Civil Engineering, Building, Construction & Architecture Computer Science & IT Control & Systems Engineering Decision Sciences, Operations Research & Management Dentistry Economics, Econometrics & Finance Education Electrical & Electronics Engineering Engineering Environmental Science Health Professions Industrial & Manufacturing Engineering Languange, Linguistic, Communication & Media Law, Crime, Criminology & Criminal Justice Library & Information Science Medicine & Pharmacology Nursing Physics Public Health Social Sciences Veterinary Other

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Ketersediaan Rekam Medis di Rumah Sakit Islam Jakarta Sukapura Gina Sonia; Lily Widjaja; Deasy Rosmala Dewi; Puteri Fannya
SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat Vol. 1 No. 2 (2022): April 2022
Publisher : Yayasan Literasi Sains Indonesia

The medical record is an administration system that records all diagnoses and actions followed by the storage of medical records. Medical record retrieval is an important part to support the effectiveness of services in providing medical records for patients who return to the hospital. This research method uses quantitative descriptive and data collection techniques by observation, interviews and literature study. Based on the results of the research, the filing officer of the Islamic Hospital of Jakarta Sukapura often faced problems during retrieval, the results of the study found that 17 (3.4%) medical records were not found and 26 (5.2%) medical records were misplaced. Factors inhibiting the implementation of medical record retrieval include man factors such as the educational background of officers and the habitual factor of officers who do not use tracers when carrying out medical record retrieval that is not in accordance with SPO at the Islamic Hospital of Jakarta Sukapura. The money factor does not affect the implementation of medical record retrieval. The machine factor is the SMART system for medical record data entry that comes off the shelf. The method factor is that the standard operating procedure for retrieval of medical records is not fully appropriate. The material factor is the absence of loan receipts.

Tinjauan Kelengkapan Resume Medis Pasien Rawat Inap di Rumah Sakit Islam Jakarta Sukapura Sansy Dua Lestari; Daniel Happy Putra; Deasy Rosmala Dewi; Laela Indawati
SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat Vol. 1 No. 2 (2022): April 2022
Publisher : Yayasan Literasi Sains Indonesia

Medical discharge is a summary of every action and treatment provided to the patient during hospitalization and must be signed by the DPJP doctor. The purpose of this study was to identify SOPs, determine the percentage of completeness of medical discharge and identify the factors causing the incompleteness. In this study, the method used is quantitative analysis method and data collection techniques are carried out through observation, quantitative analysis and interview guidelines, using the formula for estimating the proportion of the population of hospitalized patients in June and samples taken as many as 62 medical records. Based on the results of research and discussion, the completeness of the medical discharge at the Islamic Hospital of Jakarta Sukapura, the average percentage of completeness of the four components is 85.57% and the average incompleteness is 14.43%. Judging from the 4 components of quantitative analysis, the highest component of completeness analysis was found in the patient identification component 91.94% and the lowest was in the important note component 73.45%. Factors causing the incomplete filling of medical discharges are the absence of policies that regulate filling out medical discharges, the tight schedule of doctor's practice, and the lack of socialization of discipline in filling out medical discharges.

Tinjauan Pendokumentasian Yang Baik Pada Rekam Medis Pasien Rawat Inap Di Rumah Sakit Kanker Dharmais Jakarta Bayu Fajar Ilhami; Lily Widjaja; Deasy Rosmala Dewi; Laela Indawati
SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat Vol. 1 No. 2 (2022): April 2022
Publisher : Yayasan Literasi Sains Indonesia

The contents of the Medical Record are not only data on the treatment of sick patients, but also overall health data so that it is more accurately called Health Records. In general, the Health Record is an overview of the patient's health provided by the service provider/doctor to the patient to become the patient's health record. The purpose of this study was to determine the quality of good documentation in inpatients at Dharmais Cancer Hospital. The research design is cross sectional, namely research conducted at a certain time. Data sources: article searches conducted on Google Scholar to use articles that are in accordance with the research.research method Descriptiveis to describe directly the object under study using a quantitative approach. The results of the study obtained the number of completeness of medical records reached 89.13%. The sample obtained 92 medical record files, with the results of the Initial Medical Assessment Form getting a completeness score of 88.77%, CPPT Form 87.68%, Shift Handover 90.58%, and Consultation Sheets 89.49%. Medical Record Documentation still needs to be improved. Dharmais Cancer Hospital, the number of completeness of medical records needs to be increased so that the documentation of medical records is of higher quality.

Tinjauan Kelengkapan Pengisian Lembar Informed Consent Pasien Rawat Inap di RSU Adhyaksa Feni Fajriani; Deasy Rosmala Dewi; Nanda Aula Rumana; Muniroh
SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat Vol. 1 No. 2 (2022): April 2022
Publisher : Yayasan Literasi Sains Indonesia

Informed Consent is an agreement given by the patient or his closest family after receiving a complete explanation regarding the medical or dental action to be performed on the patient. Minimum Service Standards for Hospitals which mention filling out Informed Consent must be 100% complete after receiving clear information. This study was conducted with the aim of obtaining the completeness of filling out the consent form for medical treatment for inpatients at Adhyaksa General Hospital. This study uses a quantitative approach with a descriptive method. Based on the research results, the process of filling out the Informed Consent sheet at Adhyaksa RSU is not complete, from the research results of the Information Provider section on the Declaring Identity component by 75%, Completeness of Important Reports by 64%, Author Authentication by 85%, Good Records by 77%. The Informed Consent section on the Identity component is 95%, the Completeness of Important Reports is 91%, Author Authentication is 93%, Good Records is 84%. Adhyaksa General Hospital does not yet have an SOP. Fill out the informed consent form. The existing SOP on Informed Consent. The author's suggestion is that the hospital must re-socialize it to medical personnel so that the filling out of the medical action approval sheet is more complete according to minimum service standards.

Analisis Ketepatan Istilah Terminologi Medis Penyakit Sistem Respirasi Sesuai Klasifikasi Penyakit ICD-10 di Puskesmas Kecamatan Grogol Petamburan Febri Irawan; Deasy Rosmala Dewi; Nanda Rumana; Muniroh
SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat Vol. 1 No. 2 (2022): April 2022
Publisher : Yayasan Literasi Sains Indonesia

Medical terminology is medical language which is a liaison between health workers' facilities. Medical terminology written on the diagnosis should be written by the right health care worker so that it has informative value in order to assist the coding officer in selecting the lead term for determining the diagnosis code. The purpose of this study was to analyze the accuracy of medical terminology in respiratory system diseases according to the ICD-10 disease classification at the Grogol Petamburan District Health Center. Using a quantitative descriptive research method on 90 samples of medical record cases of the respiratory system in August 2020. The sampling technique used was random sampling. The size was determined randomly using the slovin formula. The results showed that the accuracy of using medical terminology in medical records was 74 (82%) and inaccuracy in the use of medical terminology 16 (18%) using abbreviations, Indonesian language, and letter/spelling errors. Factors causing the inaccuracy. The Puskesmas already has a SOP for recording medical records, but the service points have not been explained in detail according to the SOAP, especially the assessment which requires doctors to write diagnoses using medical terminology according to the ICD-10 disease classification. Then the large number of patients can be a factor causing the doctor's inaccuracy in writing a diagnosis. It is recommended to the head of the medical record to evaluate the accuracy of outpatient medical terminology according to the ICD-10 disease classification, so that there are no inaccuracies in medical terminology using Indonesian language, abbreviations, and spelling errors.

Tinjauan Kelengkapan Berkas Persyaratan Klaim Pasien Rawat Inap Covid-19 di Rumah Sakit Sumber Waras Bahlani; Lily Widjaja; Deasy Rosmala Dewi; Laela Indawati
SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat Vol. 1 No. 2 (2022): April 2022
Publisher : Yayasan Literasi Sains Indonesia

Every hospital organizes a health insurance program, the implementation of the national health insurance program is operated by the Health Office, before the hospital collects payments to the Health Office, a complete inpatient claim requirement file is required, if the inpatient claim requirement file is incomplete it will hamper the process. the health office's claim to the hospital, causing a pending claim. The purpose of this study was to get an overview of the completeness of the claim file requirements for Covid-19 inpatients at Sumber Waras Hospital. The research was conducted using a quantitative descriptive method. The sample in this study was taken from the claim requirements file for Covid-19 inpatients at the Sumber Waras Hospital. Sampling using systematic random sampling. Data was collected using a checklist and interview guidelines submitted to Casmiex officers at Sumber Waras Hospital. Based on the results of a study of 87 files for claim requirements for Covid-19 inpatients, 75.90% were obtained. The factors causing the incompleteness of the Covid-19 inpatient claim file requirements are the Covid-19 inpatient claim requirement file provided by the service officer in hardcopy, the service officer does not provide all the files that exist at the patient's discharge date in that month, the occurrence of errors in inputting patient data and medical support officers do not directly enter the results of laboratory tests. Therefore, it is necessary to disseminate information to service personnel so that they can complete the claim requirements for inpatients in a timely manner.

Tinjauan Waktu Pengembalian Berkas Rekam Medis Pasien Covid Di Rumah Sakit Sumber Waras Dede Lisda Nurjanah Dede Lisda Nurjanah; Daniel Happy Putra; Puteri Fannya; Deasy Rosmala Dewi
SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat Vol. 1 No. 2 (2022): April 2022
Publisher : Yayasan Literasi Sains Indonesia

The return of patient documents is a component part that has a role for medical records. Standard Operating Procedures (SOP) for Sumber Waras Hospital for the standard time for returning patient documents is 1 x 24 hours after the patient is declared home. The return of patient documents at the Sumber Waras Hospital in March - April 2021 for Covid patients is known from 80 medical record documents the rate of inaccuracy of returns is 25 (31.25%). So the reason for this research is to find out the timeliness of returning the medical record documents of Covid patients at Sumber Waras Hospital. This research uses quantitative descriptive method. The sample in this observation was obtained from the length of time the medical record was returned to the medical record unit. Sampling using Simple Random Sampling. Information was collected using checklists, expedition books and interview guides. The factor causing the inaccuracy of the medical record documents for Covid patients at the Sumber Waras Hospital is the 5M component with the delay in returning medical records. This problem will cause delays in services for Covid patients who will carry out re-control. Therefore, it is necessary to disseminate the Standard Operating Procedure (SOP), with the aim that the reporting of patient medical data can run well.

Readiness to change associated with job performance among health information management professionals during the covid-19 pandemic Nauri Anggita Temesvari; Mieke Nurmalasari; Deasy Rosmala Dewi; Suprobowati Suprobowati
Jurnal KESANS : Kesehatan dan Sains Vol 1 No 9 (2022): KESANS : International Journal of Health and Science
Publisher : Rifa'Institute

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.54543/kesans.v1i9.84

Health information management professionals (HIM professionals) are one of the essential health workers during the Covid-19 pandemic in managing patient data in hospitals. Changes in both policies and work systems were felt by HIM professionals during the Covid-19 pandemic. The impact of these changes influences the job performance of HIM professionals. This study aimed to assess the association between readiness to change and job performance among HIM professionals during the Covid-19 pandemic in RSAB Harapan Kita, Indonesia. The indicators of job performance are quality, timeliness, need for supervision, responsibility, cost-effectiveness, quantity, interpersonal impact, and empathy. The readiness to change in this study seen from self-efficacy, appropriateness, management support, and personal benefits. This study applied a mixed-methods design to assess the association between readiness to change and job performance in which respondents fill out a questionnaire independently via Google Form. Furthermore, a focus group discussion was conducted to probe deeper into what changes occurred during the Covid-19 pandemic and how these changes related to the job performance of HIM professionals. The questionnaire used in previous research has been validated. The samples used were all 27 HIM professionals and 11 of them agreed to continue the focus group discussion. Statistical analysis used the chi-square test on SPSS version 26 to assess the association between variables. The results show that readiness to change indicated significant association with job performance (p=0.001). Informants stated that changes that occurred during the Covid-19 pandemic included the use of personal protective equipment, spraying disinfectants on medical forms and workspaces, and adding Covid-19 reporting both internally and externally.

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

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.

Gambaran Ketepatan Waktu Penyediaan Rekam Medis Rawat Jalan Di RSUP Fatmawati Tahun 2021 Arip Budiana; Deasy Rosmala Dewi; Laela Indawati; Lily Widjaja
Sehat Rakyat: Jurnal Kesehatan Masyarakat Vol. 1 No. 1 (2022): Februari 2022
Publisher : Yayasan Pendidikan Penelitian Pengabdian Algero

The hospital as a public health service institution is an important part that provides complete individual health services and provides inpatient, outpatient, and emergency services. Provision of medical records is a process of providing medical records starting from searching for medical records to sending medical records to the intended polyclinic for health services in accordance with health service standards. The purpose of this study was to get an overview of the timeliness of providing outpatient medical records at Fatmawati Hospital. In this study the authors decided to use a qualitative descriptive method which aims to describe the situation or field conditions regarding the occurrence of inaccuracies in the provision of outpatient medical records at Fatmawati Hospital. Based on Standard Operating Procedures, the provision of outpatient medical records at Fatmawati Hospital is <30 minutes (maximum 30 minutes), in this study it was found that the timely provision was 75.55%. With an average delivery time of 27,96 minutes. From this it is known that there is a gap related to the time delay in the process of providing medical records. Delays in the process of providing outpatient medical records are caused by factors including factors in the 5M management element which include man, machine, material, money, method. The staff's knowledge factor needs to be improved, the discipline of the supply officer is good but not optimal, the officer has not attended training on the timeliness of providing good medical records. The machine factor is the lack of number of outpatient medical record storage racks, and the lack of a trolley for the provision of medical records. The method factor is the need for periodic socialization of SOPs to remind officers' performance. The matherial factor requires trolly rejuvenation and good maintenance in order to function as it should. The money factor is that the budget should always be a priority that can be a support for the creation of good health services.

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

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