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Literatur Review : Pengelolaan Assembling Rekam Medis Rawat Inap di Rumah Sakit Noor Yulia; Erviana, Erviana; Laela Indawati; Muniroh, Muniroh
SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat Vol. 3 No. 1 (2024): Januari 2024
Publisher : Yayasan Literasi Sains Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.55123/sehatmas.v3i1.3157

Abstract

Assembling is an important part of medical records to examine the correctness of recording, control the use of medical record numbers and control the use of medical record forms. In order for assembling to be carried out well, the medical records unit creates Standard Operating Procedures (SOP) for the assembling section and medical records officers managing assembling must follow the SOP. The aim of the research is to find out the management of assembling inpatient medical records in hospitals using the Literature Review method or also called Narrative Review by collecting several journals using the Bolean System from the Google Scholar Database, to identify and conclude the analysis of the management of assembling inpatient medical records in hospitals From these journals, researchers obtained a sample of 16 journals. The results of the research showed that there were several factors in managing assembly in hospitals, namely: 40% of hospitals did not use medical record SOPs according to established regulations, 73% of medical record files were still incomplete in hospitals, 73% of medical record files were returned to the medical records room. in hospitals it is still not on time 100%, and the factor that causes Assembling not to be in accordance with SOPs using Fishbone theory which has the most influence is the Man factor which is related to the lack of discipline of Medical Records officers in hospitals as much as 100%.  
Analisis Faktor Keterlambatan Pengembalian Rekam Medis Rawat Inap Di Rumah Sakit (Literature Review) Risma Sisni Fadilla; Puteri Fannya; Noor Yulia; Lily Widjaja
Vitalitas Medis : Jurnal Kesehatan dan Kedokteran Vol. 1 No. 3 (2024): Juli : Vitalitas Medis : Jurnal Kesehatan dan Kedokteran
Publisher : Lembaga Pengembangan Kinerja Dosen

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.62383/vimed.v1i3.556

Abstract

Prompt return of patient medical records is an important step in the health records processing workflow. Speed is the key to meeting quality processing standards. The hospital sets a deadline for returning medical records within 2x24 hours after the patient is discharged. Delays can be caused by various factors, which are classified under the 5M management elements: man, materials, machines, methods, and money. The aim of this research is to identify aspects that are the root of the problem in delays in the process of returning medical records to the hospital. The methodology used is a literature review, with analysis of 17 journal articles from the Google Scholar database. The study results showed that human factors such as staff shortages, incomplete doctor signatures, and inadequate staff educational qualifications were the main causes of delays. Material factors often result in incomplete documents. The machine factor is related to the significant distance between the inpatient department and the medical records department. Meanwhile, the method factor, namely SPO socialization has not been carried out and the implementation of job descriptions has not been maximized.
Identifikasi Penyelenggaraan Rekam Medis Elektronik pada Klinik Penyakit Dalam di RSUD Kembangan Syahrul Dwi Ramadhani; Noor Yulia; Puteri Fannya; Dina Sonia
Quantum Wellness : Jurnal Ilmu Kesehatan Vol. 1 No. 2 (2024): Juni: Quantum Wellness : Jurnal Ilmu Kesehatan
Publisher : Lembaga Pengembangan Kinerja Dosen

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.62383/quwell.v1i2.251

Abstract

The rapid development of information technology has penetrated into various sectors of life, including in the health sector, which has also had an impact on the development of computer-based medical record systems. The purpose of this study was to determine the implementation of Electronic Medical Records at the Internal Medicine Clinic at Kembangan Hospital. The research method uses descriptive methods with qualitative analysis on 10 informants by means of observation and interviews which will provide an overview and see directly a situation when the use of electronic medical records is carried out. The results showed that the hospital already had an SOP for filling in electronic medical records, which was not implemented according to what the officers did. The use of Electronic Medical Records, especially in the Internal Medicine Polyclinic, has gone well. Constraints from 5M Factor, namely Man, there are still registration officers who are incomplete or incorrect in filling in patient identity data, PPA (Professional Caring Provider) is incomplete in filling in patient diagnoses, Internet network material is sometimes slow, and the server is sometimes down, user complaints include display is less efficient, when filling. It is suggested to the Medical Record Unit, IT team and hospital management to evaluate the SOP, revise and socialize it in order to reduce the human error factor. Kembangan Hospital needs to improve the appearance of SIMRS Khanza to make it more attractive so as to increase the enthusiasm of the officers in inputting medical record data at SIMRS. Kembangan Hospital should improve network quality in the hospital environment to improve the performance of SIMRS.
Pengaruh Kompetensi PMIK Terhadap Kinerja Petugas Rekam Medis Di Rumah Sakit Angkatan Udara Dr. Esnawan Antariksa Armila Astiyana Triadi; Dina Sonia; Puteri Fannya; Noor Yulia
Vitamin : Jurnal ilmu Kesehatan Umum Vol. 2 No. 2 (2024): April : Jurnal ilmu Kesehatan Umum
Publisher : Asosiasi Riset Ilmu Kesehatan Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.61132/vitamin.v2i2.362

Abstract

This research was conducted with the aim of determining the influence of PMIK (Medical Recorder and Health Information) professional competence on the performance of medical record officers at the Dr. Air Force Hospital. Esnawan Antariksa. The research method used is quantitative with inferential analysis. The data collection techniques used were observation, interviews and questionnaires. The sampling technique used a total saturated sampling technique of 14 people. Obtained from 7 PMIK competency standard indicators (Noble Professionalism, Ethics and Legal, Introspection and Personal Development, Effective Communication, Health Data and Information Management, Clinical classification skills, Disease coding and other Health Problems as well as Clinical Procedures, Health Statistics Applications, Basic Epidemiology, and Biomedicine, Management of Medical Records Services and Health Information, there are still 2 indicators in the percentage that are not good, and in the 5 performance indicators of medical record officers (Quality of Work, Quantity of Work, Supervision, Attendance, Conservation) there are still 2 indicators in the percentage not good. It was found that 3 officers had a D-III RMIK education and 11 officers still had a high school education. Based on the results of the T test, it was found that the Sig. value was 275. It could be concluded that there was no influence of PMIK competency on the performance of medical records officers.
EVALUASI SISTEM INFORMASI MANAJEMEN OPERASIONAL (SIMOP) DENGAN METODE HOT-FIT DI RUMAH SAKIT PELABUHAN JAKARTA Nadia Sintia; Siswati, Siswati; Indawati, Laela; Yulia, Noor
Jurnal Kesehatan Tambusai Vol. 5 No. 4 (2024): DESEMBER 2024
Publisher : Universitas Pahlawan Tuanku Tambusai

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31004/jkt.v5i4.35060

Abstract

Evaluasi rekam medis elektronik adalah suatu usaha untuk mengetahui kondisi terhadap penyelenggaraan RME. Sistem yang digunakan di Rumah Sakit Pelabuhan adalah Sistem Informasi Manajamen Operasional (SIMOP). faktor yang masih menjadi penghambat SIMOP di Rumah Sakit Pelabuhan Jakarta, yaitu dibagian SIMOP memiliki fitur-fitur yang banyak pilihan namun tampilannya terlalu kecil sehingga menjadi kendala petugas untuk menginputnya kemudian pada sistem SIMOP yang digunakan terkadang down. Dampak dari down yaitu Dokter Penanggung Jawab Pasien (DPJP) dan petugas melakukan pekerjaan dua kali atau mengisi secara manual. Tujuan penelitian ini untuk mendapatkan gambaran mengenai evaluasi sistem informasi manajemen operasional (SIMOP) di Rumah Sakit Pelabuhan Jakarta. Desain penelitian ini menggunakan metode HOT-FIT dengan pendekatan kuantitatif, dengan populasi sebanyak 179 orang, sampel pada penelitian ini sebanyak 64 orang, dengan menggunakan teknik random sampling, variabel penelitian menggunakan variabel dependen dan independen, pengumpulan data pada penelitian ini menggunakan angket, dan teknik analisis data penelitian ini Skala Likert. Hasil pada penelitian ini menunjukkan bahwa dari aspek human 44 responden (69%) menyatakan baik dan 20 responden (31%) menyatakan tidak baik. Dari aspek organization 38 responden (59%) menyatakan baik dan 26 responden (41%) menyatakan tidak baik. Dari aspek technology 33 responden (52%) menyatakan baik dan 31 responden (48%) menyatakan tidak baik. Dari aspek net-benefit 40 responden (62,5%) menyatakan baik dan 24 responden (37,5%) menyatakan tidak baik. Kesimpulan penelitian ini adalah bahwa SIMOP di Rumah Sakit Pelabuhan Jakarta secara umum telah memenuhi harapan pengguna dan dapat memberikan manfaat, meskipun masih ada hal yang masih perlu dilakukan perbaikan lebih lanjut terutama dalam aspek teknologi.
Keamanan Sistem Informasi Rekam Medis Elektronik Di Rumah Sakit Islam Jakarta Sukapura Endah Wardani; Happy Putra, Daniel; Sonia, Dina; Yulia, Noor
Jurnal Rekam Medik & Manajemen Informasi Kesehatan Vol. 3 No. 2 (2024): Oktober
Publisher : Indonesian Journal Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.47134/rmik.v3i2.1756

Abstract

The implementation of Electronic Medical Records (EMR) in all health service facilities is outlined in Minister of Health Regulation Number 24 of 2022, with a deadline of 31 December 2023. Ensuring the security of EMR is vital to protect patient data privacy, prevent unauthorized data access, and avoid breaches. This study evaluates the security practices of EMR systems at the Islamic Hospital Jakarta Sukapura using a descriptive qualitative research method with seven informants. The study focuses on six key aspects of EMR security: privacy, integrity, authentication, availability, access control, and non-repudiation. The results show that the hospital has established security procedures, such as using usernames and passwords, but there are significant areas for improvement. The study notes the need for automatic logout features to prevent unauthorized access when computer screens are left unattended and emphasizes the importance of regularly updating passwords to improve security, as well as hospitals using encryption and firewall technologies to protect data during transmission and storage. Apart from this, research shows that some staff members still use default passwords, posing a security risk. Overall, this study provides recommendations for strengthening RME security frameworks in hospitals.
Tinjauan Media Komunikasi Sebagai Media Penyampaian dan Penyebaran Informasi Kesehatan Kasus Covid19 di Indonesia (Literature Review) Pinkan, Lia; Yulia, Noor; Rumana, Nanda Aula; Indahwati, Laela
Jurnal Ilmiah Wahana Pendidikan Vol 10 No 20 (2024): Jurnal Ilmiah Wahana Pendidikan
Publisher : Peneliti.net

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.5281/zenodo.14310609

Abstract

kesehatan menyajikan tentang isu-isu kesehatan, masalah kesehatan, resiko kesehatan serta solusi kesehatan. Untuk memperoleh informasi kesehatan diperlukan media komunikasi yang dapat menyampaikan dan menyebarkan informasi kepada seluruh khalayak umum, agar informasi ini dapat digunakan dalam mencegah dan menanggulangi pandemi covid19 di Indonesia. Tujuan dari penelitian ini adalah untuk mengetahui media komunikasi, peran dan kendala media komunikasi dalam penyampaian dan penyebaran informasi kesehatan covid19. Metode Penelitian menggunakan metode literature review pada 12 jurnal. Hasil penelitian berdasarkan uraian tinjauan pustaka yang telah dilakukan pada 12 jurnal didapatkan hasil adalah pertama, media komunikasi yang di gunakan dalam penyampaian dan penyebaran infomasi covid19 adalah media sosial, media audiovisual dan media cetak. Kedua, media komunikasi berperan mengedukasi masyarakat pentingnya penerapan protokol kesehatan, penyajian data secara realtime dan media berperan sebagai tracking virus atau melacak penyebaran virus. Ketiga, faktor yang menyebabkan terkendalanya komunikasi kebanyakan diakibatkan faktor teknis disebabkan gangguan jaringan internet, ketidakpahaman pengunaan teknologi dan faktor semantik disebabkan struktur bahasa dan banyaknya jargon yang sulit dimengerti. Simpulan : untuk saat ini media sosial efektif sebagai media penyampaian dan penyebaran informasi kesehatan
Manfaat Komunikasi Kesehatan Dalam Penggunaan Aplikasi Instagram : Literature Review Syarif, Hilwa; Yulia, Noor; Sonia, Dina; Happy Putra, Daniel
Jurnal Manajemen Informasi dan Administrasi Kesehatan Vol. 7 No. 2 (2024): JMIAK
Publisher : Program Studi D3 Rekam Medis dan Informasi Kesehatan

Show Abstract | Download Original | Original Source | Check in Google Scholar

Abstract

Teknologi kesehatan adalah suatu bentuk alat, produk atau metode yang digunakan untuk mengedukasi, pencegahan, dan penanganan permasalahan kesehatan. Aplikasi instagram merupakan media sosial berbasis foto dan video, instagram termasuk salah satu aplikasiang populer dengan pengguna terbanyak di dunia. Pada aplikasi instagram terdapat banyak sekali fitur yang sangat berguna dan dapat diakses oleh siapa saja tanpa melihat usia. Dengan kemajuan teknologi saat ini masyarakat dapat melihat dan menerima informasi kesehatan melalui sosial media instagram. Tujuan penelitian ini dilakukan untuk melihat manfaat komunikasi kesehatan dalam penggunaan aplikasi instagram. Metode penelitian menggunakan systematic literature review dengan pendekatan metode PICO mengenai penyebaran informasi kesehatan melalui media sosial instagram dan manfaat dalam penggunaan aplikasi instagram. Hasil penelitian menggunakan 12 jurnal literature review didapatkan bahwa penyebaran informasi kesehatan melalui media sosial instagram dikatakan cukup efektif karena memudahkan masyarakat dalam menerima dan memahami isi dan pesan komunikasi yang telah disampaikan tersebut dengan adanya bantuan dari fitur share, tagging, dan komentar sehingga followers juga dapat menyebarkan informasi yang sudah disampaikan tersebut. Kesimpulan di era teknologi digital saat ini komunikasi kesehatan dalam penggunaan aplikasi instagram sangat memungkinkan bagi para professional kesehatan dalam menyampaikan informasi kesehatan secara lebih mudah, cepat, efektif serta memudahkan masyarakat dalam menerima informasi kesehatan dengan melalui teknologi digital yaitu aplikasi instagram.
Tinjauan Penerapan E-Puskesmas Pada Puskesmas Babelan I Kabupaten Bekasi Magdalena, Selvy; Yulia, Noor; Sonia, Dina; Fannya, Puteri
Indonesian of Health Information Management Journal (INOHIM) Vol 11, No 2 (2023): INOHIM
Publisher : Lembaga Penerbitan Universitas Esa Unggul

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.47007/inohim.v11i2.524

Abstract

AbstractHealth Centers take advantage of advances in information technology to meet the demands for fast and accurate health services. The ePuskesmas application manifests technology and communication, significantly enhancing excellent patient service. The objective is to review the implementation of ePuskesmas at the Babelan I Health Center in Bekasi Regency. Descriptive Research Methods with a qualitative approach to analysis. Data collection techniques through observation and interviews with six research informants using interview guide instruments. Research Results: The contents of the SPO of ePuskesmas administration do not follow the ePuskesmas ManualBook. At the Puskesmas, units still have not implemented ePuskesmas (Medical Record Unit, HIV Poly, Leprosy Poly, Pharmacy Unit). In practice, not all officers can use ePuskesmas optimally. The main obstacle factor is that the Man (Human Resources) is still lacking in terms of quality and quantity, the ePuskesmas filling method is not under the Manual Book, the data input material to ePuskesmas is not complete, sometimes the system is not integrated, Machine The availability of facilities and infrastructure is still lacking. The conclusion is that implementing ePuskesmas in the Babelan I Health Center Outpatient Unit is not optimal because not all units use ePuskesmas according to the Manual Book. Suggestion: The SOP for the procedures for implementing ePuskesmas is revised and disseminated to all units.Keywords: ePuskesmas, SPO, Constraint factor AbstrakPuskesmas memanfaatkan kemajuan informasi teknologi dalam memenuhi tuntutan pelayanan kesehatan yang cepat dan akurat. Aplikasi ePuskesmas merupakan wujud penerapan teknologi dan komunikasi yang memberikan kontribusi besar dalam meningkatkan pelayanan prima kepada pasien. Tujuan Penelitian: meninjau Penerapan ePuskesmas pada Puskesmas Babelan I Kabupaten Bekasi. Metode Penelitian Deskriptif dengan analisa pendekatan secara kualitatif. Teknik pengumpulan data melalui observasi dan wawancara kepada 6 orang informan penelitian dengan menggunakan instrumen pedoman wawancara. Hasil Penelitian: Isi dari SPO tata laksana ePuskesmas belum sesuai dengan ManualBook ePuskesmas, di Puskesmas masih ada unit yang belum menerapkan ePuskesmas (Unit Rekam Medis, Poli HIV, Poli Kusta, Unit Farmasi), dalam pelaksanaannya belum semua petugas dapat menggunakan ePuskesmas secara optimal, Faktor kendala utama adalah Man (Sumber Daya Manusia) masih kurang dari segi kualitas dan kuantitas, Method (Metode) pengisian ePuskesmas belum sesuai ManualBook, Material (Bahan) data yang di input ke ePuskesmas belum lengkap, kadang sistem tidak terintegrasi, Machine (Mesin) Ketersediaan sarana dan prasarana masih kurang. Kesimpulan: Penerapan ePuskesmas di Unit Rawat Jalan Puskesmas Babelan I belum optimal karena belum semua Unit menggunakan ePuskesmas sesuai dengan ManualBook. Saran: SPO tata cara penerapan ePuskesmas direvisi dan disosialisasikan untuk semua unit.Kata Kunci: ePuskesmas, SPO, Faktor kendala 
Tinjauan Ketepatan Kode Penyakit Gastroenteritis di Rumah Sakit (Literature Review) Anisa Dewi Wahyuni; Noor Yulia; Nanda Aula Rumana; Laela Indawati
Sehat Rakyat: Jurnal Kesehatan Masyarakat Vol. 4 No. 1 (2025): Februari 2025
Publisher : Yayasan Pendidikan Penelitian Pengabdian Algero

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.54259/sehatrakyat.v4i1.3774

Abstract

Factors of completeness of medical record documents, medical personnel, coding infrastructure, coders, and policies affect the coding of gastroenteritis diagnoses where inaccuracy due to this can cause a decrease in service quality, inaccurate report data, and errors in billing for services that have been provided by the hospital. This study aims to identify the accuracy of coding gastroenteritis disease and the factors that cause inaccuracy in coding gastroenteritis disease based on the 5M elements. The research method uses the literature review method with the PICO framework, P = Medical records of gastroenteritis patients, I = Gastroenteritis, O = Accuracy of coding of gastroenteritis disease. The inclusion criteria in this study are journals that discuss the accuracy and accuracy as well as the factors of inaccuracy and inaccuracy of gastroenteritis disease codes. The results of the 10 journals analyzed showed that the lowest code accuracy was 0% in 2 journals, while the highest percentage reached 91.5% in 1 journal. The most common factor in the inaccuracy of gastroenteritis codes is found in the man factor, namely the diagnosis provided by doctors is often incomplete or not written at all, and coding is often not based on other supporting information. Coders also lack mastery in analyzing medical record documents and errors in disease coding are related to coder knowledge. In addition, communication between coders and doctors was not effective. Increased training and provision of adequate resources to improve the accuracy of disease coding are needed.
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.