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Rossalina Adi Wijayanti
Politeknik Negeri Jember
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Kajian Literatur Penyebab Keterlambatan Pengembalian Rekam Medis Rawat Inap di Rumah Sakit Sholikhatin Eka Prasetia; Maya Weka Santi; Rossalina Adi Wijayanti; Gamasiano Alfiansyah
Jurnal Penelitian Kesehatan SUARA FORIKES Vol 12 (2021): Nomor Khusus April 2021
Publisher : FORIKES

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33846/sf12nk233

Abstract

The timeliness of returning medical records can affect the speed of presenting medical record information. However, in practice, there are more than 50% delays in returning inpatient medical record files. It caused the medical record process in assembling, coding, filing, report, and services. The purpose of this research was to determine the factors that inflict the delay in returning hospitalized medical records. The method used in this research wss literature review using databases, namely Google Scholar, DOAJ, Crossref, and Garuda Portal. Based on the search results, it found 20 articles chosen that were selected based on inclusion and exclusion criteria. A total of 19 articles (95%) mentioned the first causative factor, the indiscipline of health workers in filling out and returning inpatient medical records. As many as 8 articles (40%) stated the socialization factor for standard operating procedures on returning inpatient medical records was another contributing factor that caused delays in returning hospitalized medical records. Efforts can be conducted to overcome delays based on these causal factors include regular monitoring and evaluation related implementation of returning inpatient medical records. Doing the routine socialization to medical and inpatient records officers regards Standard Operating Procedures using various media, so that all officers know the standard of returning inpatient medical records. Keywords: medical record; delay; returning ABSTRAK Ketepatan waktu pengembalian rekam medis dapat berpengaruh terhadap kecepatan penyajian informasi rekam medis. Namun dalam pelaksanaannya, masih ada keterlambatan pengembalian berkas rekam medis rawat inap lebih dari 50% sehingga menimbulkan dampak pada pengolahan rekam medis baik pada assembling, coding, penyimpanan, pelaporan dan pelayanan. Tujuan penelitian ini untuk mengetahui faktor penyebab keterlambatan pengembalian rekam medis rawat inap. Metode yang digunakan dalam penelitian ini adalah Literature Review menggunakan database yaitu Google Scholar, DOAJ, Crossref dan Portal Garuda. Berdasarkan hasil pencarian ditemukan 20 artikel terpilih yang diseleksi berdasarkan kriteria inklusi dan eksklusi. Sebanyak 19 artikel (95%) menyebutkan faktor penyebab pertama yaitu ketidakdisiplinan tenaga kesehatan dalam pengisian dan pengembalian rekam medis rawat inap. Sebanyak 8 artikel (40%) menyebutkan faktor sosialisasi Standar Prosedur Operasional (SPO) pengembalian rekam medis rawat inap merupakan faktor penyebab lain yang menyebabkan keterlambatan pengembalian rekam medis rawat inap. Upaya yang dapat dilakukan untuk mengatasi keterlambatan berdasarkan faktor penyebab tersebut diantaranya melakukan pengawasan serta evaluasi secara berkala terkait pelaksanaan pengembalian rekam medis rawat inap dan melakukan sosialisasi rutin kepada petugas rekam medis maupun rawat inap terkait Standar Prosedur Operasional (SPO) menggunakan berbagai media baik lisan maupun tertulis agar semua petugas mengetahui standar pengembalian rekam medis rawat inap. Kata kunci: rekam medis; keterlambatan; pengembalian
Faktor Penyebab Ketidaksesuaian Pelaksanaan Retensi Berkas Rekam Medis di Rumah Sakit Jember Klinik Rossalina Adi Wijayanti; Nur Aprilia Setyoyuni; Novita Nuraini
Jurnal Penelitian Kesehatan SUARA FORIKES Vol 13, No 1 (2022): Januari 2022
Publisher : FORIKES

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33846/sf.v13i1.1758

Abstract

Based on the results of a preliminary study conducted at the Jember Clinic Hospital, it was still found that the implementation of retention of medical record files was not in accordance with the SOPs and regulations of the minister of health, which resulted in the unavailability of a previous medical history when the patient came for treatment again, thus allowing for medical risks such as the danger of side effects. of the treatment given to the patient. This study aims to analyze and determine the priority causes of the problem of discrepancies in the implementation of retention of medical record files using the USG (Urgency, Seriousness, Growth) method. This type of research was qualitative with interview data collection, observation, documentation and brainstorming. The results of the study found that the priority causes of problems using the USG method were the number of active file storage racks was not sufficient and the in-active shelves were not available. Efforts to solve this problem are to propose an expansion of the filing space or the provision of other space for the addition of active file storage shelves and in-active shelves.Keywords: retention; medical records; storage shelf ABSTRAK Berdasarkan hasil studi pendahuluan yang dilakukan di Rumah Sakit Jember Klinik masih ditemukan kegiatan pelaksanaan retensi berkas rekam medis tidak sesuai dengan SOP dan peraturan menteri kesehatan, yang berdampak pada tidak tersedianya riwayat penyakit terdahulu saat pasien datang berobat kembali sehingga memungkinkan terjadinya resiko medis seperti bahaya efek samping dari pengobatan yang diberikan pada pasien. Penelitian ini bertujuan untuk menganalisis dan menentukan prioritas penyebab masalah terjadinya ketidaksesuaian pelaksanaan retensi berkas rekam medis menggunakan metode USG (Urgency, Seriousness, Growth). Jenis penelitian adalah kualitatif dengan pengumpulan data wawancara, observasi, dokumentasi dan brainstorming. Hasil penelitian yang didapatkan bahwa prioritas penyebab masalah dengan menggunakan metode USG yaitu jumlah rak penyimpanan berkas aktif belum mencukupi dan tidak tersedianya rak inaktif. Upaya penyelesaian masalah tersebut adalah mengajukan perluasan ruang filing atau penyediaan ruang lain untuk penambahan rak penyimpanan berkas aktif dan rak inaktif.Kata kunci: retensi; rekam medis; rak penyimpanan
ANALISIS FAKTOR YANG BERPENGARUH TERHADAP ANGKA KEMATIAN IBU (AKI) DI KABUPATEN JEMBER TAHUN 2018 Rossalina Adi Wijayanti; Dahlia Indah Amareta; Gamasiano Alfiansyah; Novita Nuraini; Atma Deharja; Maya Weka Santi
Jurnal Wiyata Penelitian Sains dan Kesehatan Vol 7, No 2 (2020)
Publisher : LP2M IIK (Lembaga Penelitian dan Pengabdian Masyarakat Institut Ilmu Kesehatan) Bhakti Wiy

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

Abstract

Latar belakang: Kabupaten Jember merupakan salah satu kabupaten yang terdapat di Propinsi Jawa Timur yang pada tahun 2016 menempati peringkat dua untuk Angka Kematian Ibu tertinggi. Jumlah kematian ibu di Kabupaten Jember dari tahun 2014 sampai dengan tahun 2017 mengalami peningkatan dimana pada tahun 2017 sebanyak 43 kematian. Puskesmas memiliki peranan utama dan sangat vital dalam upaya penurunan AKI di Indonesia. Program-program kesehatan di Puskesmas yang difokuskan pada kegiatan preventif dan promotif dalam program Kesehatan Ibu dan Anak masih belum berjalan dengan maksimal. Tujuan: menyusun upaya untuk menurunkan AKI melalui pelaksanaan manajemen program kesehatan ibu di Puskesmas yang meliputi planning, organizing, actuating dan controlling. Penelitian ini menggunakan metode observasional analitik dengan sampel berjumlah 34 Puskesmas. Hasil: Hasil penelitian menunjukkan planning dan organizing telah dilakukan namun dalam kategori cukup, actuating dan controlling dalam kategori baik. Terdapat pengaruh yang signifikan pada faktor organizing, actuating dan controlling terhadap AKI. Saran: Rekomendasi yang diberikan adalah mempertahankan kegiatan peningkatan cakupan ibu hamil dan ibu bersalin, melengkapai job description masing masing pekerjaan, meningkatkan keterlibatan lintas sektor pada kegiatan promosi, mempertahankan kegiatan controlling. Perlu keterlibatan seluruh pihak dalam menurunkan AKI.Kata kunci: manajemen, AKI, Jember
DETERMINAN KEAMANAN DAN KERAHASIAAN DOKUMEN REKAM MEDIS DI RUANG FILING RS X Gamasiano Alfiansyah; Rossalina Adi Wijayanti; Novita Nuraini; Selvia Juwita Swari; Siti Wafiroh
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 2 (2020): March
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v1i2.1961

Abstract

Rumah Sakit X menerapkan pengelolaan rekam medis sebagai penunjang medis. Dokumen rekam medis belum terjaga keamanan dan kerahasiaannya, dimana banyak petugas medis lain keluar masuk ruang filing, terdapat petugas makan dan minum diruang filing, penyimpanan masih di rak terbuka, dan petugas atau mahasiswa penelitian membocorkan isi rekam medis pasien.  Tujuan dari penelitian ini adalah mengetahui determinan keamanan dan kerahasiaan dokumen rekam medis di Rumah Sakit X. Jenis penelitian yang digunakan dalam penelitian ini adalah penelitian kualitatif menggunakan metode brainstorming dengan teknik wawancara, observasi dan dokumentasi. Hasil yang didapatkan dalam penelitian ini adalah faktor karakteristik petugas terdiri dari tingkat pendidikan terakhir petugas SMA, umur petugas 32-38 tahun, dan jenis kelamin laki-laki. Faktor psikologi meliputi attitude seperti petugas masih makan dan minum, petugas medis lain keluar masuk, membuka dokumen rekam medis tanpa izin dan terdapat pembocoran isi dokumen rekam medis. Faktor motivasi meliputi petugas merasa puas dan kompetitif dalam bekerja. Faktor organisasi meliputi penghargaan berupa pujian dan kepemimpinan belum dilakukan pemberian petunjuk pergantian dokumen rekam medis yang hilang. Hasil brainstorming yang menjadi penyebab utama yaitu tingkat pendidikan petugas yang masih rendah yaitu SMA. Saran yang diberikan meliputi pendidikan lanjutan atau pelatihan, memberi evaluasi secara rutin dan piagam kepada petugas. Kata kunci : keamanan, kerahasiaan, penyimpanan
Analisis Faktor Penyebab Ketidaktepatan Kode Diagnosis Penyakit Diabetes Mellitus di Rumah Sakit Umum Haji Surabaya Errica Rostia Loren; Rossalina Adi Wijayanti; Nikmatun Nikmatun
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 3 (2020): June
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v1i3.1974

Abstract

The accuracy of determining the disease diagnosis code is one of the important things that must beconsidered in carrying out the coding process of the patient's disease diagnosis made by the coder. Theaccuracy and inaccuracy of providing disease diagnosis codes will affect data and information in the healthservice process and reduce the quality of services in hospitals. Besides, in the era of National HealthInsurance (JKN), the accuracy of the diagnosis code was also very influential in financing at hospitals. Thisresearch was aimed to analyze the factors which cause the diagnosis code inaccuracy in Diabetes Mellitus inSurabaya Hajj General Hospital in 2019. This research used qualitative methods with data collectiontechniques such as interviews, observation, and literature studies. The number of samples used in the studywas 21 medical records of Diabetes Mellitus patients and 2 informants. The results of research on the medicalrecord documents of patients with Diabetes Mellitus found that the documents have an incorrect code of 13medical record documents (62%) and documents that have an exact code of 8 medical record documents(38%). The results of the analysis found were several factors that influence the inaccuracy of the code such ascoder's competency, coder's knowledge, as well as the experience of coder and medical record document,both the completeness of the filling and the documentation. The solution that can be proposed by theresearcher is to included the coder and medical personnel in training and outreach related to thedetermination of diagnosis code, especially Diabetes Mellitus.
Faktor Penyebab Ketidaklengkapan Pengisian Kode Diagnosa Rawat Jalan di RS Husada Utama Nabiilah Qurrota A'yun; Rossalina Adi Wijayanti; Gilang Nur Permana; Ida Nurmawati
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 2 No 1 (2020): December
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v2i1.2001

Abstract

At present hospitals and paramedics prone to demands that demands the quality of service , lawsuits from a patient and the competitors in the same because of that required to improve the quality and keep the quality of health services at the hospital .One parameter to determine the quality of health services at the hospital is data or information from medical record good and complete , both the contents , accurate , timely and working persayaratan legal aspects .Based on working practices roomy implemented in february to march obtained hasill that incomplete filling out of code diagnose on medical record outpatient husada surabaya hospital main reach 100 % it is not in line with permenkes 269 year 2008 stating that document completeness medical record must be fully 100 %. A journal aims to understand the factors causing the incomplete filling out of the diagnosis code .Incompleteness this researched use the undirected behavior lawrence green with a variable presdiposing factors , enabling options factors , reinforcing factors .Incomplete filling out of the diagnosis code was conducted by interviews is not structured and observation activities directly when performing my roomy .The result of the report is affecting behavior because of the incomplete on charging the diagnosis code outpatient medical record husada hospital as much as the main the hospitals are required to carry out socialization of standard operating procedures aimed at the paramedics to be the remembrance of the content and doing the work of in accordance with the sop.
Analisis Faktor Penyebab Terjadinya Duplikasi Nomor Rekam Medis Rawat Jalan di Puskesmas Kencong Kabupaten Jember Esa Amanda Setiawan; Rossalina Adi Wijayanti; Atma Deharja; Selvia Juwita Swari
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 3 (2020): June
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v1i3.2005

Abstract

Duplication that occurred in the Kencong Public Health Center was 46 files on February 2019, this could beextremely powerful on legality aspect of medical record file interrupted if it happens the legal case. The aimof this research was to analyze and decide the priority causes of the happening duplication by using USG.The variety of this research is qualitative one by using the collection of interviewing data, observation,documentation and brainstorming. The result of this research stated that the case causing priority is by usingUSG method namely, the education of officer whose education qualification is Diploma D3 degree of MedicalRecord had been appropriated. The trial solving that trouble is recruiting the officers whose educationDiploma D3 degree of Medical Record and they need to have the recommendation about more educationespecially for the officers who still have the minimal education or knowledge about medical record side.
Analisis Penyebab Lama Penyediaan Berkas Rekam Medis Rawat Jalan di Puskesmas Mangaran Lutfiatun Nadibah Herman; Rossalina Adi Wijayanti; Atma Deharja; Mochammad Choirur Roziqin
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 2 No 1 (2020): December
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v2i1.2031

Abstract

The provision of long-term patient outpatient medical record files in Mangaran Public Health Center is one type of service provided to patients. Based on pre-research survey, it known that the time for providing the medical record files that exceed the established standards is 17.70%. This researched aim is to analyze the caused factors of the long duration for supplying medical file records of long-term patient based on individual and situational factors which will the priority causes of the main problems using the Reinke method. This research is qualitative research. The results showed that long waited for supplying medical record files of long-term patient is the searching process of the medical file records that takes a long time due to the attitude of the officer while handling misfile is not optimal, there is no training related to the medical records, less detailed SOP registration does not contain the standard time to provide the medical file records and the absence of SOP to return the medical records, and also the computers that often error and unavailability of tracers in the storage room. In response to those factors, it is necessary to make an improvement and socialization about the registration SOP’s, requesting propose of the medical record file map/folders and the use of tracers, and also held a training specifically about the medical file records at least 2 or 3 times a year and also doing the computer maintenance at least once a month.
Evaluasi Sistem Informasi Admisi Terpadu Dengan Metode EUCS di RSUD Dr. Saiful Anwar Malang Liza Amalia Putri; Maya Weka Santi; Rossalina Adi Wijayanti
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 3 (2020): June
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v1i3.2052

Abstract

Integrated Admision Information System (SISMIDU) is a system that serves to conduct bed managementdata in RSUD Dr. Saiful Anwar Malang. This system is a supporting facility to know the availability of bedinformation so that it can provide fast service in patients. The implementation of SISMIDU still has someobstacles that the system often encountered error in conducting patient data search, it takes a long time tosave data and system that is less update related to information availability of room in the inpatient area soas to cause inpatient buildup in the hospitalization of admission patient. The Purpose of this research is toevaluate the SISIMIDU based on user satisfaction. This type of research is qualitative research with datacollection through questionnaires. Method used is the End User Computing Satisfaction the methodconsisting aspects of content,aspects of accuracy, aspects of the format, aspects of timeliness and aspectof ease of use. Result of the research of the five aspects, among others, the aspect of content 67%respondents expressed satisfaction, aspect of accuracy 100% respondents expressed dissatisfied, aspectsof format 67% of respondents expressed dissatisfied, the aspect of timeliness 100% of respondentsexpressed dissatisfied and aspect of ease of use 100% expressed dissatisfied. It is hoped that hospitals canmake improvements and development against SISMIDU in order for SISMIDU to provide information thatsuits the needs of the user.
Analisis Faktor Penyebab Rendahnya Bed Occupancy Rate (BOR) di Rumah Sakit Mitra Medika Kabupaten Bondowoso Widiyanto Widiyanto; Rossalina Adi Wijayanti
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 4 (2020): September
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v1i4.2060

Abstract

BOR (Bed Occupancy Rate) di Rumah Sakit Mitra Medika Bondowoso masih rendah dimana pada bulan Oktober sebesar 59%, November sebesar 55% dan Desember sebesar 57%. Kondisi tersebut kemungkinan disebabkan oleh jumlah sumber daya manusia yang kurang, fasilitas atau prasarana yang masih belum lengkap, faktor lingkungan baik itu lingkungan internal dan eksternal maupun sikap petugas dalam memberikan pelayanan kepada pasien. Tujuan dri penelitian ini adalah untuk menganalisis faktor penyebab rendahnya persentase BOR di Rumah Sakit Mitra Medika Bondowoso. Jenis penelitian ini adalah penelitian kualitiatif dengan menggunakan teknik pengumpulan data wawancara, observasi dan dokumentasi yang melibatkan 5 responden meliputi kepala rekam medik, HRD, perawat, petugas rekam medik dan petugas administrasi atau pendaftaran. Penentuan prioritas utama penyebab masalah menggunakan metode USG (Urgency, Seriousnes, Growth) yang dilaksanakan dengan melakukan skoring. Selanjutnya menentukan alternatif solusi melalui diskusi bersama dengan responden. Hasil penelitian menunjukan bahwa penyebab utama rendahnya persentase BOR di Rumah Sakit Mitra Medika Bondowoso adalah fasilitas atau sarana dan pasarana yang masih belum lengkap. Alternatif solusi yang disarankan untuk mengatasi masalah tersebut dengan cara penyediaan fasilitas atau sarana dan prasarana yang masih belum lengkap. Sebagai saran, Rumah Sakit Mitra Medika Bondowoso harus segera berbenah dan melengkapi fasilitas atau sarana dan prasarana yang masih belum tersedia.
Co-Authors Aghasi Hana Faradila Agni Candramawa Sholikha Alfiansyah, Gamasiano Alvira Nafisah Eky Mulia Andri Permana Wicaksono Anggun Citta Isvara Maharesi Putri Ani Nuraini Ariqpurna Bayu Triatmaja Arisanty Nursetia Restuti Astrid Kartika Dewi Aprilia Atma Deharja Atma Deharja Ayu Imelda Rosita Azis, Anisya Dahlia Indah Amareta, Dahlia Indah Demiawan Rachmatta Putro Mudiono Desnia Sindi Damayani dony setiawan hendyca putra Dwi Winda Agustin Efri Tri Ardianto Errica Rostia Loren Esa Amanda Setiawan Eva Tri Wicahyanti Feby Erawantini Ferly Ferly Fikhy Rizky H Fikhy Rizky Hapsari Gamasiano Alfiansyah Gamasiano Alfiansyah Gamasiano Alfiansyah Gilang Nur Permana Gilang Nur Permana Gilang Nur Permana Haris Hammaminata Hikmah, Faiqatul Hikmatus Surur Ika Rahmadhani Indah Muflihatin Jamil, Nur Malika Lidya Nur Fatimatuz Zuhro Listiyawati Sahir Liza Amalia Putri Lutfiatun Nadibah Herman Maya Weka Santi Maya Weka Santi Maya Weka Santi Melati Ayu Pratiwi Mochammad Choirur Roziqin Muhammad Yunus Nabiilah Qurrota A'yun Nabilah Khoirun Nissa' Nafa Maharani Nashrul Kholiqir Rohman Nikmatun Nikmatun Niyalatul Muna Nonik Aisyah Rohman Novita Nuraini Novita Nuraini Novita Yuken Nur Aulia Nur Aprilia Setyoyuni nurmawati, ida Nurul Kamilia Rachmawati, Ervina Rintan Illahi Wahyu Riskha Dora Candra Dewi Rizky Putri Amalia Rowinda Dwi Kurniawati Sabran Sabran Selvia Juwita Swari Selvia Juwita Swari Selviyanti, Erna Sholikhatin Eka Prasetia Siti Alifa Lufianti Siti Wafiroh Sustin Farlinda Syahbaniar, Desi Tias Agustin Ayuningrum Virda Hardiana Widiyanto Widiyanto Yulianti, Adhiningsih