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All Journal Faktor Exacta Jurnal Manajemen Informasi dan Administrasi Kesehatan Jurnal Manajemen Informasi Kesehatan Indonesia (JMIKI) Indonesian of Health Information Management Journal (INOHIM) Health Sciences and Pharmacy Journal Surya Medika: Jurnal Ilmiah Ilmu Keperawatan dan Ilmu Kesehatan Masyarakat Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Indonesian Journal of Global Health research Jurnal Kesehatan Tambusai J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Jurnal Ilmiah Wahana Pendidikan Nusantara Hasana Journal Open Access Indonesian Journal of Medical Reviews Archives of The Medicine and Case Reports KESANS : International Journal of Health and Science COMSERVA: Jurnal Penelitian dan Pengabdian Masyarakat Indonesian Journal of Health Information Management (IJHIM) Jurnal Ilmiah Kesehatan Masyarakat Jurnal Sains dan Teknologi Sehat Rakyat: Jurnal Kesehatan Masyarakat Journal of Innovation Research and Knowledge Journal of Comprehensive Science Jurnal Rekam Medik & Manajemen Informasi Kesehatan (RAMMIK) Homeostasis: Jurnal Mahasiswa Pendidikan Dokter Jurnal Rumpun Ilmu Kesehatan Cerdika: Jurnal Ilmiah Indonesia Innovative: Journal Of Social Science Research Jurnal Medika Nusantara Medic Nutricia : Jurnal Ilmu Kesehatan Antigen: Jurnal Kesehatan Masyarakat dan Ilmu Gizi Vitamedica: Jurnal Rumpun Kesehatan Umum Vitalitas Medis : Jurnal Kesehatan Dan Kedokteran Quantum Wellness : Jurnal Ilmu Kesehatan Vitamin: Jurnal Ilmu Kesehatan Umum Jurnal Rekam Medic
Yulia, Noor
Universitas Esa Unggul
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Evaluasi Penerapan Sistem Informasi Manajemen Puskesmas (SIMPUS) Ahmad Hikmi Aldio; Deasy Rosmala Dewi; Noor Yulia; Wiwik Viatiningsih
Cerdika: Jurnal Ilmiah Indonesia Vol. 2 No. 4 (2022): Cerdika: Jurnal Ilmiah Indonesia
Publisher : Publikasi Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (3812.735 KB) | DOI: 10.59141/cerdika.v2i4.364

Abstract

In evaluating the implementation of the Puskesmas Management Information System (SIMPUS) at the puskesmas, it is expected to be able to minimize the accumulation of patients the health service procedures at the puskesmas and also to foster more enthusiasm for the officers at the puskesmas so that services become more effective. So it is necessary to evaluate the implementation of the health center management information system (SIMPUS). Objective: evaluate the implementation of the puskesmas management information system (SIMPUS) to find out what methods are used in evaluating the implementation of the puskesmas management information system (SIMPUS). This study uses the google scholar database in computing a literature review search by using the keyword search for this research journal, namely ” Evaluation of applications (SIMPUS) at the puskesmas. Research results in it can be seen that the most dominant SIMPUS evaluation used is Hot-fit while the least is the cloud-based methods in evaluating the implementation of the puskesmas management information system (SIMPUS). The puskesmas management evaluation information system (SIMPUS) has several methods in implementing the SIMPUS evaluation, namely, web-based, hot-fit, and cloud-based.
Tinjauan Prosedur Pendaftaran Pasien Rawat Inap di RSU Bhakti Asih Tangerang Lilin Tata Fandhika; Puteri Fannya; Nanda Aula Rumana; Noor Yulia
Cerdika: Jurnal Ilmiah Indonesia Vol. 2 No. 4 (2022): Cerdika: Jurnal Ilmiah Indonesia
Publisher : Publikasi Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (215.326 KB) | DOI: 10.59141/cerdika.v2i4.375

Abstract

The inpatient registration procedure contains a collection of patient data that is admitted per day, from the existing data registered for inpatient registration, it can be seen the number of patients admitted per day, the number of patients admitted per treatment room. The purpose of this study was to determine the procedure for registering inpatients at Bhakti Asih General Hospital, Tangerang. This type of research uses a qualitative descriptive method. Data collection techniques used are observation and interviews. The results of this study are related to the implementation of inpatient registration procedures, there are obstacles regarding incomplete requirements at the time of registration such as personal identity cards (KTP/KK), patient referral letters and the lack of registration officers so that there is a buildup during inpatient registration. the lack of completeness in the patient identity requirements as a condition for patient registration, therefore the officer must educate the patient to make a statement letter for files that are left behind 2 X 24 hours or before the patient goes home. to be brought as terms and procedures of patient registration at the hospital.
TINJAUAN PELAKSANAAN PENYUSUTAN DAN PEMUSNAHAN REKAM MEDIS DI RSUD KOTA BOGOR Dwi Nurul Fadila; Noor Yulia; Puteri Fannya; Nanda Aula Rumana
Journal of Innovation Research and Knowledge Vol. 2 No. 9: Februari 2023
Publisher : Bajang Institute

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.53625/jirk.v2i9.5048

Abstract

Rekam medis inaktif merupakan rekam medis pasien yang telah tidak aktif selama minimal 5 tahun atau setelah meninggal dunia, yang berarti pasien sudah tidak menggunakan fasilitas pelayanan kesehatan rumah sakit lagi. Rekam medis perlu dilakukan penyusutan, yaitu proses mengurangi dokumen rekam medis dengan memindahan rekam medis inaktif ke ruang inaktif, serta mengevaluasi dan memusnahkan rekam medis yang tidak dipakai lagi. Tujuan penelitian untuk mengetahui pelaksanaan penyusutan dan pemusnahan rekam medis di RSUD Kota Bogor. Metode penelitian deskriptif dengan pendekatan kualitatif yang memaparkan hasil dari observasi di ruang filing dan wawancara. Hasil penelitian rumah sakit sudah memiliki SPO penyusutan rekam medis inaktif, serta SPO pemusnahan. Dalam pelaksanaan, petugas melakukan tindakan penyusutan dan pemusnahan saat jadwal sudah keluar atau setiap ada perintah. Kendala dalam pelaksanaannya yaitu belum ada petugas khusus yang menangani penyusutan dan melaksanakan alih media, jarak dan lokasi penyimpanan rekam medis berbeda gedung, dan belum memiliki sarana untuk alih media. Saran melakukan penyusutan setiap minggu agar rekam medis tidak bertumpuk, ruang rekam medis inaktif terpisah, dan disediakan sarana proses alih media.
Tinjauan Kejadian Misfiled di Rak Penyimpanan Rekam Medis RSUD Dr. Adjidarmo Kab. Lebak Tahun 2022 Nabila Raihani; Wiwik Viatiningsih; Noor Yulia; Deasy Rosmala Dewi
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Vol. 8 No. 1 (2023): 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.v8i1.1123

Abstract

Misfiled is an error in the storage of medical records, or the non-discovery of medical records on the storage shelf. This study aims to determine the description of misfiled events in the medical record storage shelf of RSUD Dr. Adjidarmo Kab. Lebak in 2022. This study uses a descriptive analysis method with a quantitative approach by conducting observations and interviews. The results of the study with 99 samples found that 9 (9.1%) of the misfiled and the non-misfiled were 90 (90,9%). Most of the medical records that occurred were misfiled because it did not fit on the proper shelf or medical record documents located on another shelf. The storage system used is a centralized system and its alignment system uses a digit filing terminal. The first factor causing the misfiled in the hospital is that the medical record officer is not careful in storing medical records, because there are still often errors when reading the numbers written. Another factor is in the facilities and infrastructure of the storage room, because there is no tracer as a substitute for medical records that come out of the shelves. The advice is always to use tracers to replace medical records that come out, so as not to misfiled the alignment of medical records.
Identifikasi Kelengkapan Pengisian Rekam Medis Elektronik Pasien Rawat Inap di RSKD Duren Sawit Jakarta Tahun 2022 Munazhifah Munazhifah; Noor Yulia; Deasy Rosmala Dewi; Puteri Fannya
Sehat Rakyat: Jurnal Kesehatan Masyarakat Vol. 2 No. 1 (2023): Februari 2023
Publisher : Yayasan Pendidikan Penelitian Pengabdian Algero

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.54259/sehatrakyat.v2i1.1467

Abstract

Medical records must be made in writing, complete, and clear or electronically. Electronic health record is an electronic medical record which is an access in managing patient health information that is generated every time a patient accesses medical care. Medical records must be completed within 24 hours with a 100% completeness percentage. This study aims to determine the percentage of completeness of electronic medical records of inpatients at Duren Sawit Hospital, Jakarta. The research method uses a descriptive method with a quantitative analysis approach. A sample of 77 electronic medical records of inpatients uses a purposive sample (consideration sample). The results of the study: there is no Standard Operating Procedure for Electronic Medical Records that serves as a guide in working. From the analysis, it was found that the completeness of filling was 84% ​​and the incompleteness was 16%. It has not reached the minimum standard that has been set by the Ministry of Health, which is 100%. (The most complete component is the patient identity component with a percentage of 100%, while the lowest completeness is an important report component 65%). Several factors cause incomplete medical records, namely: The large number of patients, senior doctors who do not understand technology, and computer systems and networks that sometimes error/down. Suggestions are made for Standard Operating Procedures for filling out Electronic Medical Records, mentoring and socializing to senior doctors and officers contacting related parties so that they can complete medical records immediately (< 24 hours).
Tinjauan Duplikasi Nomor Rekam Medis Di Puskesmas Kelurahan Jatinegara Kaum Kecamatan Pulogadung Elsa Nindia Safitri; Wiwik Viatningsih; Noor Yulia; Daniel Happy Putra
Cerdika: Jurnal Ilmiah Indonesia Vol. 3 No. 3 (2023): Cerdika : Jurnal Ilmiah Indonesia
Publisher : Publikasi Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (290.501 KB) | DOI: 10.59141/cerdika.v3i3.545

Abstract

Berdasarkan Permenkes No. 269 Tahun 2008 dijelaskan bahwa rekam medis merupakan berkas yang terdiri dari catatan dan dokumen mengenai identitas pasien, pemeriksaan, pengobatan, tindakan dan pelayanan lain yang telah diberikan kepada pasien. Nomor rekam medis berperan penting dalam membedakan rekam medis pasien yang satu dengan lainnya dan memudahkan pencarian rekam medis, apabila pasien kemudian dateng kembali berobat disarana pelayanan kesehatan serta untuk kesinambungan informasi dan mencegah terjadinya nomor rekam medis. Duplikasi penomoran rekam medis adalah perulangan, keadaan rangkap atau nomor rekam medis ganda yang dimana satu nomor rekam medis memiliki beberapa pasien. Penelitian ini dilaksanakan untuk melihat adanya duplikasi dalam penomoran rekam medis. Metode penelitian menggunakan metode deskriptif dengan pendekatan analisa kuantitatif dan kualitatif, informan dalam penelitian ini adalah kepala rekam medis, Hasil penelitian dapat disimpulkan bahwa di bulan Desember Tahun 2021 terdapat duplikasi nomor rekam medis sebanyak 17 (1,4%) dikarenakan kurangnya petugas dan beberapa pasien lupa membawa Kartu Indeks Berobat (KIB) pada waktu kunjungan. Duplikasi terjadi karena oleh beberapa faktor 5M yaitu manusia (man) dikarenakan kurangnya petugas dan beberapa pasien lupa membawa Kartu Indeks Berobat (KIB) pada waktu kunjungan
Tinjauan Pelaksanaan Retensi Dokumen Rekam Medis di Rumah Sakit Medistra Jakarta Selatan Dewi Kisaputri; Noor Yulia; Nanda Aula Rumana; Puteri Fannya
SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat Vol. 2 No. 2 (2023): April 2023
Publisher : Yayasan Literasi Sains Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.55123/sehatmas.v2i2.1754

Abstract

Retention is an activity to reduce medical record documents from storage shelves by moving inactive medical record documents from active file shelves to inactive file shelves by sorting them on storage shelves according to the year of visit. Inactive medical records are medical record documents that have reached 5 years and are never used again because the patient does not visit the hospital for treatment. This research method uses qualitative analysis. Based on observations and interviews at Medistra Hospital. Currently, the South Jakarta Medistra Hospital is carrying out retention of medical records, but it has not been completed due to a lack of medical record personnel, there is no distribution of retention scheduling and the large number of medical records has piled up, making it difficult for officers to carry out retention. Medistra Hospitals already have an active DRM In Retention/ Shrinkage SPO, but there is no special officer in the filling section who is also the distribution executor. Suggestions should the implementation of depreciation and destruction of medical records be carried out routinely and make a division of schedules for officers who will carry out the retention of inactive medical records..
TINJAUAN KEBUTUHAN TENAGA ALIH MEDIA REKAM MEDIS DI RSIJ CEMPAKA PUTIH JAKARTA Almahshunatul Hanifah; Noor Yulia; Laela Indawati; Deasy Rosmala Dewi
Journal of Innovation Research and Knowledge Vol. 2 No. 11: April 2023
Publisher : Bajang Institute

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.53625/jirk.v2i11.5475

Abstract

Alih media rekam medis merupakan proses pemindahan rekam medis inaktif berbasis kertas ke dalam bentuk file (micro film, file dalam hard disk, file dalam compact disc) dengan tujuan agar lebih efisien. Metode ABK-Kes adalah suatu metode perhitungan kebutuhan SDMK berdasarkan pada beban kerja. Penelitian ini mengenai Tinjauan Kebutuhan Tenaga Alih Media Rekam Medis di RSIJ Cempaka Putih Jakarta menggunakan metode ABK-Kes. Tujuan penelitian menghitung kebutuhan tenaga alih media rekam medis. Penelitian menggunakan metode ABK-Kes. Dengan sampel yang berjumlah 100 berkas rekam medis yang telah dihitung menggunakan rumus slovin. Hasil penelitian Standar Prosedur Operasional (SPO) Alih Media masih mengacu kepada SPO Retensi, karena SPO pada bagian Alih Media belum tersedia. Jam kerja petugas dari pukul 07.30-16.30 WIB atau setara dengan 40 jam/minggu. Sementara hasil perhitungan standar beban kerja petugas yaitu 662.840. Faktor Tugas Penunjang sebesar 2,34% dan Standar Tugas Penunjang sebesar 1,02. Hasil kesimpulan Rekapitulasi SDMK Alih Media Rekam Medis yang dibutuhkan berjumlah 6 orang sedangkan saat ini petugas hanya 1 orang. Saran sebaiknya ada penambahan SDM alih media sebanyak 5 orang dengan kriteria minimal lulusan D3 Perekam Medis dan Informasi kesehatan sesuai kompetensinya.
TINJAUAN DATA SOSIAL UNTUK ENTRY DATA IDENTITAS PASIEN DI RSI JAKARTA SUKAPURA Lisa Anggun Magdalena Gea; Noor Yulia
Journal of Innovation Research and Knowledge Vol. 2 No. 12: Mei 2023
Publisher : Bajang Institute

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.53625/jirk.v2i12.5623

Abstract

Social data is used to complete the RME when officers identify new patients into the medical record database. social data helps fill in electronic medical record data. The purpose of this study is to review filling in social data to complete the identity of patients at the Islamic Hospital of Jakarta Sukapura. The research method used descriptive method with quantitative analysis of 81 samples of new outpatient identities. The results of the study There are already standard operating procedures for outpatient registration of new patients, the average completeness of social data for new patients is 62 samples (76%) and 19 samples are incomplete (24%), complete average RME data is complete 65 samples (80%) and incomplete 16 samples (20%). the filling of social data and RME is not in accordance with the minimum service standards set by PERMENKES, which is 100% filled. social data does not include all patient identity data in the RME. Identity data in RME is more complete than social data, in social data there are 21 items while in RME there are 25 items. Conclusion: social data has not been able to fully assist officers in completing electronic medical record patient identity data.
Overview of Waiting Time for Provision of Outpatient Medical Records Based on Minimum Service Standards (SPM) at dr. Mintohardjo Hospital, Jakarta, Indonesia Azhar Muttaqin; Lily Widjaja; Laela Indawati; Noor Yulia
Archives of The Medicine and Case Reports Vol. 4 No. 6 (2023): Archives of The Medicine and Case Reports
Publisher : HM Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37275/amcr.v4i6.397

Abstract

Timely provision of outpatient medical records results in quality medical record services. The time for providing outpatient records according to minimum service standards is ≤ 10 minutes. This study aimed to determine the length of waiting time for outpatient medical records at dr. Mintohardjo Hospital. The method in this research uses a descriptive method with a quantitative approach. The sampling technique used accidental sampling with a sample size based on an estimated proportion of 106 medical records. The research results showed that 14 medical records (13.2%) were on time and 92 medical records (86.8%) were not on time, most of which were not on time, namely > 31-40 minutes, 31 medical records (29.2%). In identifying the causes of delays in providing outpatient medical records, researchers used the 5M factors. Man factor of occurrence of misfile, there are medical records that have not been returned from the polyclinic or inpatient room, and there is a lack of knowledge and education. The money factor has not yet been budgeted for repairing the Roll O Pack. The material factor for printing loan receipts and medical records is not automatic in the SIMRS application, and only 1 printer machine is available out of 7 computers, so the number of printers needs to be increased. Machine factor occurs Roll O Pack damage and interference with software from downtime (the time when a system, application, and service cannot be accessed/does not function) in the SIMRS application. The method factor is that there is no SOP for providing outpatient medical records.
Co-Authors Adi Widodo Adi Widodo Adi Widodo Ahmad Hikmi Aldio Al Faqih, M. Rolan Tiro Aldio, Ahmad Hikmi Almahshunatul Hanifah Ambarwati Anastasyannisa Ramadhanty Aneu Rosliana Angelina, Noviana Dian Anisa Dewi Wahyuni Annisa Azzahra, Annisa Arif Ibnu Fadillah Aringgi Al Pasya Darwis Armila Astiyana Triadi Aurelius Anugerah Harvey Pepo Azhar Muttaqin Azhar Muttaqin Bangga Agung Satrya Bella Safitri Daniel Happy Putra Darmawan, Rifqi Helmi Dewi Kisaputri Dewi, Deasy Rosmala Dianty, Gebbrien Anggia Dina Sonia Dinda Fidia Ardiani Dwi Nurul Fadila Elina Intan Apzari Elsa Nindia Safitri Endah Wardani Endang Palupi Ningsih Erviana, Erviana Fandhika, Lilin Tata Fannya, Puteri Fatimatuzzahra, Joevancha Livancha Fatkur Ridho Febriyan Awi Pasa Fitria Atmojowati Fitria, Annah Fredrika Welhelmina Gita Sugiarti Hari Dwi Cahya Hosizah Hosizah Indahwati, Laela Indawati, Laela Intan Rusdiana Dewi Iqbal, Muhammad Fuad Ivan Permana Leni Karunia Septiani Lia Yulia Budiarti Lilin Tata Fandhika Lily Widjaya Lisa Anggun Magdalena Gea Maeimunah, Siti Magdalena, Selvy Maria Ferawaty Parera Mekhtildis Suryati Mordekhai Immanuel Sitorus Muhammad Arif Sutrasno Munazhifah Munazhifah Muniroh, Muniroh Muzdalifah, Ifah Nabila Raihani Nabilah Khairunisa Nadia Sintia Nanda Aula Rumana Nerissa Adha Andrania Nindia Safitri, Elsa Novia Nurhikmah Sari Noviana Dian Angelina Octa Rina Sari Pangesti, Wulan Aprilia Pinkan, Lia Putri, Dwi Tania Putri, Sisilia Rabnah Rani Yulistianingsih Raysha Dheamalia Muchtar Revina Purnaningrum Rezal, Muhammad Rifqi Fauzan Risma Ayu Fitriyani Risma Sisni Fadilla Rizky Khaerunnisa Setiawan Irwansyah Shafa Aulia Ananda Hermanto Siswati Siswati Siswati Siswati Siswati Siti Kaidah Siti Nur Azizah Jamil Sri Kholifatun Sri Mulya Surlialy, Dewi Suryati, Mekhtildis Sutarto, Mutia Sutrasno, Muhammad Arif Syahrul Dwi Ramadhani Syarif, Hilwa Syifa Erintan Uli Shalatiya uli Viatiningsih, Wiwik Viatningsih, Wiwik Widjaja, Liliy Widjaja, Lily Willy Haposan Winda Febriarini Wiwik Viatningsih Yeni Safitri Yoga Septian Bayu Ariyanto Yunita Fauzia A.