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Nofri Heltiani
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Perancangan dan Prosedur Penggunaan Out Guide pada Penyimpanan Berkas Rekam Medis di Rumah Sakit Rafflesia Bengkulu Nofri Heltiani
Jurnal Manajemen Informasi Kesehatan Indonesia (JMIKI) Vol 9, No 1 (2021)
Publisher : Asosiasi Perguruan Tinggi Rekam Medis dan Informasi Kesehatan Indonesia- APTIRMIKI

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33560/jmiki.v9i1.311

Abstract

Rumah Sakit Raflesia Bengkulu dalam melaksanakan kegiatan penyerahan maupun pengembalian loose sheet tidak langsung disatukan ke dalam folder rekam medis pasien yang bersangkutan, melainkan disimpan di dalam box khusus tanpa menggunakan map ataupun cover pelindung. Hal ini dikarenakan belum adanya out guide sebagai petunjuk keluar sekaligus tempat menyimpan loose sheet untuk sementara. Loose sheet yang tidak ditempatkan pada out guide berdampak pada hilangnya loose sheet rekam medis, kesalahan penempatan loose sheet rekam medis ke dalam folder yang keliru dan membutuhkan waktu yang lama untuk menelusuri lebih lanjut jika loose sheet rekam medis tidak didukung dengan identitas serta dapat mempengaruhi pada keabsahan penagihan dan perhitungan biaya perawatan. Penelitian ini bertujuan untuk Perancangan dan prosedur penggunaan out guide pada penyimpanan berkas rekam medis di Rumah Sakit Rafflesia Bengkulu. Jenis penelitian adalah deskriptif kualitatif dengan cara observasional. Teknik pengumpulan data dengan wawancara tentang berkas lepas (loose sheet) yang datang menyusul ke ruang filing. Tahapan penelitian ini adalah tahap anaisis, tahap perenacangan/desain out guide dan prosedur penggunaan out guide, tahap testing dan tahap pemeliharaan out guide. Hasil penelitian ini adalah rancangan out guide (petunjuk keluar) berkas rekam medis yaitu alternatif II. Bahan PVC (Pholy Vhynil Chloride) berbentuk persegi panjang dengan ukuran 25x33 cm dengan warna biru disertai kantong loose sheet mengunakan plastik transparan berukuran 23x33 cm dan memo yang terdapat nomor rekam medis, tanggal, ruangan/poli, loose sheet dan tanggal kembali serta Standar Operasional Prosedur (SOP) penggunaan out guide rekam medis. Rumah Sakit Raflesia diharapkan menggunakan out guide sebagai sarana petunjuk adanya loose sheet yang keluar untuk menghindari hilangnya loose sheet, kesalahan penempatan loose sheet serta pengaruhnya terhadap penagihan dan perhitungan biaya perawatan.
Analisa Bed Trun Over (BTO) Di Rumah Sakit Harapan dan Doa Kota Bengkulu Periode 2019 Nofri Heltiani
Jurnal Manajemen Informasi Kesehatan Indonesia (JMIKI) Vol 9, No 2 (2021)
Publisher : Asosiasi Perguruan Tinggi Rekam Medis dan Informasi Kesehatan Indonesia- APTIRMIKI

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33560/jmiki.v9i2.312

Abstract

Bed Turn Over (BTO) merupakan rerata jumlah pasien yang menggunakan setiap tempat tidur dalam periode tertentu. Nilai ideal BTO 40-50 kali/tahun. Indikator rawat inap terkait BTO sangat penting diperhatikan dalam upaya peningkatan mutu pelayanan. Tingginya BTO berpotensi mengganggu keseimbangan aspek klinis seperti infeksi nosocomial rumah sakit. Berdasarkan survey awal, nilai BTO tiga tahun terakhir di Rumah Sakit Harapan dan Doa Kota Bengkulu mengalami peningkatan yaitu tahun 2016 (58,23 kali/tahun), tahun 2017 (64-65 kali/tahun) dan tahun 2018 (65 kali/tahun). Hal ini menunjukkan bahwa pergantian tempat tidur pasien yang sangat cepat sehingga pemakaian tempat tidur melebihi ketentuan yaitu 40-50 kali/tahun artinya 1 tempat tidur digunakan lebih dari 50 pasien dalam setahun yang dapat menyebabkan terjadinya infeksi nosokomial. Tujuan penelitian ini adalah mengetahui nilai BTO di Rumah Sakit Harapan dan Doa Kota Bengkulu Periode 2019. Jenis penelitian yang digunakan pada penelitian ini adalah deskriptif kuantitatif dengan pendekatan cross sectional. Populasi dan sampel adalah 6.719 pasien rawat inap di Ruang Safa, Marwah dan Mina periode tahun 2019 dengan teknik pengambilan sampel adalah total populasi. Data yang digunakan adalah data sekunder yang diolah dengan cara collecting, editing, classification dan tabulating serta dianalisis dengan menggunakan rumus BTO. Hasil analisis data, jumlah pasien dirawat pada periode periode 2019 di Ruang Safa sebanyak 2.690 pasien, Ruang Mina 2.060 pasien dan Ruang Marwah 1.961 pasien. Jumlah pasien keluar (hidup maupun mati) pada periode 2019 di Ruang Safa sebanyak 2.654 pasien keluar hidup dan 31 pasien keluar mati, Ruang Mina sebanyak 2.045 pasien keluar hidup dan 15 pasien keluar mati serta Ruang Marwah sebanyak 1.938 pasien keluar hidup dan 23 pasien keluar mati sehingga nilai BTO di Ruang Safa 83,87 kali/tahun, Ruang Marwah 88,64 kali/tahun dan Ruang Mina 93,58 kali/tahun. Diharapkan pihak Rumah Sakit untuk melakukan penambahan tempat tidur di Ruang Safa, Marwah dan Mina untuk mencegah atau mengurangi terjadinya infeksi nosokomial.
Gambaran Kinerja dan Motivasi Petugas dalam Pelaksanaan Sensus Harian Pasien Rawat Inap di Rumah Sakit Rafflesia Bengkulu Tahun 2019 Nofri Heltiani
Jurnal Manajemen Informasi Kesehatan (Health Information Management) Vol. 4 No. 2 (2019): Health Information and Management
Publisher : Sekolah Tinggi Ilmu Kesehatan Sapta Bakti

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.51851/jmis.v4i2.167

Abstract

Sensus Harian Rawat Inap (SHRI) adalah kegiatan penghitungan pasien rawat inap yangdilakukan setiap hari pada setiap ruang rawat inap. SHRI berisi tentang mutasi keluar masukpasien selama 24 jam mulai dari pukul 00.00 s.d 24.00. Berdasarkan survei awal di RumahSakit Rafflesia Bengkulu setiap ruang rawat inap telah melaksanakan sensus harian rawatinap dan memiliki SOP akan tetapi dalam pelaksanaan tidak sesuai dengan SOP. Hal inidisebabkan karena pengiriman SHRI dari ruang perawatan ke ruang rekam medis dilakukanpada akhir bulan sehingga menyebabkan petugas rekam medis di bagian pelaporanmengalami kendala dalam pembuatan laporan rumah sakit setiap bulannya. Tujuan penelitianini adalah mengetahui gambaran kinerja dan motivasi petugas dalam pelaksanaan SHRI. Jenispenelitian yang digunakan pada penelitian ini adalah deskriptif dengan metode observasioaldan wawancara. Populasi dalam penelitian ini adalah petugas rekam medis dengan sampelsebanyak 9 orang petugas rekam medis dengan teknik pengambilan sampel total populasi.Menggunakan data primer yang diolah dengan cara editing, coding, cleaning dan posecingserta dianalisis secara univariat. Hasil penelitian ini adalah kinerja petugas rekam medismemiliki kriteria baik dalam menyelenggarakan statistik dan pelaporan 77,8%, cukup dalammenyediakan formulir dan uraian tugas 44,4% serta kurang dalam mengambil SHRI danmerekapitulasi SHRI 33,3%. Sedangkan motivasi petugas rekam medis sebagian besarmemiliki motivasi tinggi dalam hal kesesuaian harapan dalam melaksanakan pekerjaan100%, suasana tempat kerja sesuai dengan pembagian tugas 77,8%, adanya pedomanpembagian tugas 77,8% dan interaksi antar sesama petugas 88,9%, namun masih ada yangmemiliki motivasi sedang dalam hal rasa keterpanggilan dan tuntutan untuk melaksanakantugas 44,4%, kesempatan meningkatkan pelayanan pengelolaan data rekam medis 66,7%, danfaktor fisik dan lingkungan 44,4%, bahkan masih ada yang memiliki motivasi rendah karenatidak adanya insentif yang diperoleh petugas setelah melaksanakan pekerjaan 66,7%.Sehingga diharapkan kepala rekam medis untuk melakukan monitoring dalam hal mengambildan/atau menerima sensus harian rawat inap setiap hari pada jam 8 pagi serta memberikaninsentif sesuai dengan hasil pekerjaan yang dilakukan
Analisis Ketepatan Koding Jantung Iskemik Stemi di RSUD Dr. M.Yunus Bengkulu tahun 2018 Nofri Heltiani
Jurnal Manajemen Informasi Kesehatan (Health Information Management) Vol. 3 No. 2 (2018): Health Information and Management
Publisher : Sekolah Tinggi Ilmu Kesehatan Sapta Bakti

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.51851/jmis.v3i2.183

Abstract

Penyakit Jantung Iskemik STEMI merupakan suatu kondisi yang dapat berakibat kematiansel miosit jantung dan diderita semua usia dengan gejala tidak semua penderita mengalaminyeri dada dan memiliki kode I21.3. Berdasarkan data instalasi rekam medis RSUD Dr. MYunus Bengkulu penyakit jantung iskemik STEMI merupakan angka morbiditas danmengalami peningkatan setiap tahunnya. Pada tahun 2017 penyakit jantung iskemik STEMImenduduki peringkat pertama dari 10 penyakit tertinggi. Akan tetapi masih terdapatketidaktepatan dalam koding jantung iskemik STEMI. Hal ini disebabkan terdapat coretandiagnosis yang ditulis dokter tanpa diparaf pada salah satu berkas rekam medis, belum pernahdilakukannya audit coding dan kurang jelasnya informasi tentang coding yang disampaikanmelalui Standar Operasional Prosedur (SOP). Tujuan penelitian ini untuk mengetahuiketepatan koding jantung iskemik STEMI di RSUD Dr. M.Yunus Bengkulu Tahun 2018.Jenis penelitian ini adalah deskriptif dengan pendekatan cross sectional. Populasi padapenelitian ini adalah berkas rekam medis pasien jantung iskemik STEMI sebanyak 202berkas dan sampel sebanyak 134 berkas dengan teknik pengambilan sampel randomsampling, menggunakan data primer dan sekunder yang diolah secara univariat. Hasilpenelitian ini adalah Pelaksanaan pengkodean di RSUD Dr. M. Yunus Bengkulu belummenggunakan ICD-10 Volume 2. Ketepatan koding penyakit jantung iskemik STEMIsebanyak 98 berkas (73%) dan tidak tepat sebanyak 36 berkas (27%). Faktor-faktor penyebabketidaktepatan koding penyakit jantung iskemik STEMI adalah: Man; petugas koding belummengikuti workshop/pelatihan kaidah koding, Material; terdapat 2 berkas rekam medis yangtidak diagnosa dan 1 berkas rekam medis yang tidak di koding, Method; SOP hanya berisikegiatan pengkodingan diagnosis secara manual (menggunakan ICD-10).
Evaluation of the Hospital Management Information System (SIMRS) at Rafflesia Hospital Bengkulu Ismail Arifin; Nofri Heltiani; Iin Desmiany Duri
Jurnal Manajemen Informasi Kesehatan (Health Information Management) Vol. 8 No. 2 (2023): Health Information and Management
Publisher : Sekolah Tinggi Ilmu Kesehatan Sapta Bakti

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.51851/jmis.v8i2.441

Abstract

Hospital Management Information System (SIMRS) is a communication information technology system that processes hospital services. Rafflesia Bengkulu Hospital has been implementing SIMRS since 2021. Currently there has not been an evaluation of the features contained in SIMRS so that this will result in not achieving service improvements, not achieving efficiency and slowing down service to patients. The aim of this research is to describe the implementation of the hospital management information system (SIMRS) at Rafflesia Hospital Bengkulu. The research used is a descriptive method, namely a method that aims to describe the description of the implementation of the hospital management information system (SIMRS). The subjects of this research were 10 respondents. It is known from the evaluation results of the system performance aspect that research results show that the system performance is good by 80% and the system performance is not good by 20%. 90% of the information produced is good, 10% of the information produced is not good. data security is good as much as 60% and not good as much as 40%. It is necessary to develop the SIMRS menu display so that it can support all services, and also to develop the system so that it does not experience frequent errors (errors). And notifications/warnings need to be given if SIMRS is accessed by unauthorized parties, so that the system can be controlled properly and is not misused by unauthorized parties.
Hospital Electronic Medical Record Storage Plan Nofri Heltiani; Khairunnisyah; Ismail Arifin
Jurnal Manajemen Informasi Kesehatan (Health Information Management) Vol. 9 No. 1 (2024): Health Information and Management
Publisher : Sekolah Tinggi Ilmu Kesehatan Sapta Bakti

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.51851/jmis.v9i1.507

Abstract

The Electronic Medical Record Storage System aims to increase efficiency at Bhayangkara Bengkulu Hospital. However, based on the initial survey conducted, it was discovered that the medical record storage system was still carried out manually. Borrowed medical records are recorded in the expedition book before being borrowed and distributed by officers so that it takes time to get to the unit concerned. Officers store medical records not according to the shelves based on the patient's medical record number and many medical records are damaged/recorded. This research aims to design an electronic medical record storage system at Bhayangkara Hospital, Bengkulu. This type of research is descriptive qualitative with the waterfall method. The subjects of this research were medical records and IT officers. The research data used is primary data obtained by observation using a checklist sheet, then the data is processed and analyzed univariately. The result of this research is a design for an electronic medical record storage system that is ready to be implemented. Through this implementation, it is hoped that efficiency and accuracy in medical record management can be improved. The suggestions put forward are to make changes to the medical record file storage shelves to make them more orderly, provide training to officers in using the new system, and carry out impact evaluations to measure efficiency and patient satisfaction due to system changes.
Accuracy of Dengue Hemorrhagic Fever (DHF) Diagnosis Codes in Terms of Completeness and Accuracy of Medical Information Dwi Widyawati; Nofri Heltiani; Nova Oktavia
Jurnal Manajemen Informasi Kesehatan (Health Information Management) Vol. 9 No. 2 (2024): Health Information and Management
Publisher : Sekolah Tinggi Ilmu Kesehatan Sapta Bakti

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.51851/jmis.v9i2.599

Abstract

The completeness of the physical examination and the accuracy of laboratory results are crucial in supporting the accuracy of diagnostic codes. A preliminary survey of 10 Dengue Hemorrhagic Fever (DHF) medical records revealed that 4 (40%) were accurate and 6 (60%) were inaccurate. This was due to incomplete and inaccurate physical examination and laboratory results, which affected diagnosis and coding. This resulted in decreased data, information, and reporting quality, as well as the accuracy of INA-CBG rates, which could negatively impact the quality of hospital services. This study aimed to determine the accuracy of DHF diagnostic codes in terms of the completeness of medical information. This study used an observational, quantitative descriptive design, with 86 DHF medical records as the population and sample. The data used were secondary data obtained through observation using a checklist. The data were then processed and analyzed univariately using a frequency distribution. The results of this study are that from 86 DHF medical record files, 33 (38%) were found to have complete physical examinations, 12 (10%) were accurate laboratory test results, 8 (9%) were accurate diagnoses, and 8 (9%) were accurate diagnosis codes. It is expected that medical record officers, especially in the assembling section, will conduct medical record audits through qualitative analysis and improve coder skills through coding classification training.
Waterfall Method Design for Implementing Medical Record Retention at Rafflesia Hospital, Bengkulu Khairunnisyah -; Nofri Heltiani; Ismail Arifin; Elisa Ayu
Jurnal Manajemen Informasi Kesehatan (Health Information Management) Vol. 9 No. 2 (2024): Health Information and Management
Publisher : Sekolah Tinggi Ilmu Kesehatan Sapta Bakti

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.51851/jmis.v9i2.611

Abstract

e-Retention is beneficial in supporting the efficient retention of medical record files. Retention is carried out by filing staff by selecting medical record numbers on the shelves by looking at the date/month/year of the patient's last visit and whether they have not returned for treatment for more than 5 years. A common problem in hospitals is that retained medical record data is not recorded or archived in the retention book. Consequently, when the patient returns for treatment, filing staff require considerable time to trace the medical record files to ensure they receive medical care. This impacts patient satisfaction with medical record services. This study aims to design a waterfall method for implementing medical record retention. Primary data were obtained through observation using a qualitative descriptive study using the waterfall method, with four staff members as subjects. The data used in this study were checklists, which were then processed and analyzed univariately. The result of this research is a design for an e-retention system for medical record files that is ready for implementation. This implementation is expected to improve the efficiency and accuracy of e-retention. Suggestions include making changes to the implementation of medical record file retention to make it more effective by using e-retention, providing training to staff on its use, and conducting an impact evaluation to measure efficiency and patient satisfaction resulting from the system changes.
Physical Examination Results and Medical Supporting Evidence Affect the Accuracy of Pneumonia Diagnosis Codes in Hospitals Nofri Heltiani; Ismail Arifin; Khairunnisyah
Jurnal Manajemen Informasi Kesehatan (Health Information Management) Vol. 10 No. 1 (2025): Health Information and Management
Publisher : Sekolah Tinggi Ilmu Kesehatan Sapta Bakti

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.51851/jmis.v10i1.743

Abstract

The Ministry of Health of the Republic of Indonesia, Decree No. HK.02.02/Menkes/514/2015, states that pneumonia is one of the diseases frequently leading to medical disputes, resulting in losses for hospitals. Based on an initial survey of 10 pneumonia medical records, five files contained missing supporting examination results (chest x-ray), two files contained incomplete physical examinations, and three files contained complete records (chest x-ray, physical examination), leading to doubts about the pneumonia diagnosis codes written in the medical records. This study aimed to determine the accuracy of pneumonia diagnosis codes by examining the results of physical examinations and medical support at Hospital X in 2024. This study was a quantitative descriptive study with a population and sample of 96 medical records of pneumonia cases. The data used in this study were primary and secondary data, using interview guidelines and observation sheets. The data were then processed and analyzed univariately using frequency distribution. The results of the study revealed that the completeness of the physical examination results and medical support was 38 (39%), the accuracy of the physical examination results and medical support was 35 (36%), and the accuracy of the pneumonia diagnosis code was 47 (49%). It is hoped that the Head of Medical Records will conduct a medical record audit through qualitative analysis to minimize the occurrence of medical disputes.
Tracing Diabetes Mellitus Readmission Incidence Through Medical Records at Bhayangkara Hospital, Bengkulu Anggia Budiarti; Nofri Heltiani
Jurnal Manajemen Informasi Kesehatan (Health Information Management) Vol. 10 No. 1 (2025): Health Information and Management
Publisher : Sekolah Tinggi Ilmu Kesehatan Sapta Bakti

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.51851/jmis.v10i1.744

Abstract

Readmission can occur for all diseases, including diabetes mellitus. A preliminary survey showed an increase in readmission rates over the past three years. If readmissions occur more than once within a 30-day period, and within a short period of time, the hospital cannot claim funding. The BPJS (Social Security Agency) claims payment system for healthcare services is based on a per-case payment within a predetermined timeframe of ≤30 days. If the time limit is exceeded, the hospital bears the costs. The purpose of this study was to determine the incidence of diabetes mellitus readmissions at Bhayangkara Hospital, Bengkulu. This study was a descriptive quantitative study, with 25 medical records of inpatient diabetes mellitus readmissions collected from January to December 2023 as the population and sample. The data used in this study were secondary data using observation sheets. The data were then processed and analyzed univariately using frequency distribution. The results of the study showed that the incidence of readmission of diabetes mellitus was 100% with the majority being 48% in the 56 - ≥65 years age group, 64% female gender and 52% family history of the disease.
Co-Authors Anggia Budiarti Dwi widyawati Elisa Ayu frisya anggita IIN DESMIANY DURI Ismail Arifin ismail arifin Khairunnisyah Khairunnisyah - Nova Oktavia RACHMI Triyulia Citra