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Analisis Pelaksanaan Layanan Perawatan Dukungan dan Pengobatan (PDP) HIV–AIDS di Rumah Sakit Daerah Balung Rintan Illahi Wahyu; Faiqatul Hikmah; Rossalina Adi Wijayanti; Niyalatul Muna
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.v1i4.2070

Abstract

The implementation of HIV - AIDS Support and Treatment (PDP) Care Services at Balung Regional General Hospital is not yet in line with the target. This is evidenced by the number of PLHIV fulfilling the requirements to start treatment, not all of them are taking ARV treatment, so an analysis of these services is needed. The purpose of this study was to analyze the implementation of HIV - AIDS support and treatment (PDP) care services at Balung Regional Hospital. This type of research is qualitative, using interview, observation and documentation data collection methods. Informants in this study were 1 doctor, 1 counselor and 1 nurse and 8 ODHA This type of research is qualitative, the result of this study is an analysis of the implementation of HIV-AIDS support and treatment care services using 4M indicators (man, method, material and mechine). The results of the study were obtained that the analysis of PDP services based on the aspects of man, namely the availability of resources in the service is lacking and knowledge of HIV – AIDS  related to HIV - AIDS is still low, aspects of the method that there are SOP but there is no clear jobdesc, material aspects there is a medical record used for know the development of ODHA, but the officers in filling it are still incomplete, aspects of the mechine are available tools that are used to assist the process of conducting maintenance services such as general inspection tools and SIHA. Efforts to resolve the problem above so that the Balung Regional General Hospital for submitting letters to the Health Office regarding job analysis, the role of the medical recorder for checking the filing of ODHA medical record files and for problems of low knowledge of HIV – AIDS can be done by counseling in privacy.
Analisis Kerahasiaan Rekam Medis Berdasarkan Hak Akses Ruang Filing Rawat Jalan di RSUD Dr.Saiful Anwar Malang Eva Tri Wicahyanti; Maya Weka Santi; Rossalina Adi Wijayanti
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.v2i1.2073

Abstract

Confidentiality of medical records at RSUD Dr. Saiful Anwar Malang still had several obstacles in implementation, where there were non-medical record officers who enter and exit the outpatient filing room although there was finger prints and written warnings stating that "other than medical record officers are prohibited from entering" in the outpatient filing section. The purpose of this report is to analyze the confidentiality of medical records based on the right of access to outpatient filing rooms at RSUD Dr. Saiful Anwar Malang. This report used qualitative methods, and the analysis method used is 5M management aspects (man, money, material, method, and machine) to identify the problems and look for priority causes use USG (Urgency, Seriousness, Growth) techniques. The results of this report indicate that the management aspects of man, method, material, and machine are the factors causing the lack of secrecy of the medical record based on the right of access to outpatient filing rooms at RSUD Dr. Saiful Anwar Malang. The priority cause of the problem in this report is the ignorance of officers in relation to the existing SOP / Medical Record Services Book. The priority results of the cause of the problem produce a solution, it are necessary to conduct socialization about SOP for storing medical records and Medical Record Services Book relating to the secrecy of medical records to all medical records officers, especially filing officers before being placed in their work units and evaluating every three months by monitoring the implementation of SOP /Medical Record Services Book by an outpatient filing coordinator.
Analisis Ketidaksesuaian Kode Diagnosis pada SIMRS dengan Berkas Klaim BPJS Klinik Obgyn Ika Rahmadhani; Rossalina Adi Wijayanti; Novita Nuraini
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.v1i4.2075

Abstract

Ketidaksesuaian kode Diagnosis utama pada SIMRS dan pada berkas Kalaim BPJS sangat penting karena jika tingkat ketidakakuratan tinggi maka berdampak pada ketidakakuratan data morbiditas penyakit yang akan mempengaruhi data pelaporan 10 besar penyakit. Berdasarkan data hasil observasi di RSUD DR Saifur Anwar Malang terhadap ketidaksesuain kode diagnosis utama pada SIMRS dengan kode berkas Klaim BPJS menunjukkan bahwa sebesar 25.8% kode diagnosis utama pada SIMRS tidak diisi atau tidak lengkap, dan sebesar 48.3% kode diagnosis utama yang tertera pada SIMRS tidak sesuai atau tidak sama dengan kode yang tertera pada berkas klaim (casemix), serta sebesar 25.8% kode yang tertera pada SIMRS sesuai dengan kode yang tertera pada berkas klaim (casemix). Tujuan Penelitian ini yaitu Menganalisis Ketidaksesuaian Kode Diagnosis Utama Pada SIMRS Dengan Berkas Klaim BPJS Klinik Obgyn Di RSUD Dr. Saiful Anwar Malang berdasarkan metode Motivation, Opputunity dan Ability. Jenis penelitian yang digunakan yaitu penelitian kualitatif dengan metode pengumpulan data wawancara dan observasi. Hasil yang didapatkan pada saat observasi sebanyak 146 berkas klaim BPJS klinik Obgyn pada tanggal 26-28 Februari dan 3 Maret 2020 angka ketidaksesuain kode diagnosis sebesar 72.6%. Dari hasil analisis didapatkan bahwa ketidaksesuain tersebut terjadi karena kurangnya kedisiplinan petugas Koding di poliklinik dalam menginputkan kode di SIMRS, tidak adanya pelatihan terkait tata cara kodefikasi diagnosis yang benar, petugas entri data di poliklinik bukan lulusan rekam medik serta tidak adanyan job description spesifik yang mengatur tentang pelaksanaan kodefikasi diagnosis untuk kasus rawat jalan.
DESAIN ERGONOMI RUANG FILING REKAM MEDIS RAWAT INAP DI RSUD DR. SAIFUL ANWAR MALANG Haris Hammaminata; Maya Weka Santi; Rossalina Adi Wijayanti
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 2 No 3 (2021): June
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v2i3.2078

Abstract

Jarak antar rak di RSUD Dr. Saiful Anwar adalah 70 cm. Ruang filing tidak terdapat AC dan kondisi blower mati. Tinggi rak penyimpanan melebihi petugas menjadi suatu kendala dalam mengambil dan menyimpan berkas rekam medis rawat inap. Tujuan penyusunan laporan ini adalah mendesain secara ergonomi ruang filing berkas rekam medis rawat inap di RSUD Dr. Saiful Anwar Malang. Jenis penelitian menggunakan kualitatif. Subjek penelitian ini adalah petugas filing rawat inap di RSUD Dr. Saiful Anwar berjumlah 2 orang. Metode pengumpulan data menggunakan wawancara dan observasi. Hasil laporan didapatkan bahwa desain rak penyimpanan, meja, dan kursi di ruang filing rawat inap di RSUD dr. Saiful Anwar belum ergonomis. Luas ruang filing rawat inap di RSUD dr. Saiful Anwar saat ini masih belum ergonomis. Kebutuhan luas ruang filing rawat inap kedepannya berdasarkan kebutuhan rak baru adalah sebesar 922,58 m2. Kebutuhan sarana dan prasarana diruang filing sudah cukup memadai, hanya saja perlu penambahan rak baru dan AC. Kondisi linkungan fisik di ruang filing rawat inap belum sesuai standar rumah sakit. Upaya yang perlu dilakukan yaitu perlu modifikasi rak dan penambahan pengaman sesuai antropometri petugas, meja dan kursi sesuai antropometri petugas, tata ruang sesuai antropometri petugas, perubahan daya watt lampu dan jenis lampu, penambahan alat hygrometer untuk memberikan informasi temperatur, penambahan ventilasi mekanik berupa kipas angin dan teralis besi, serta penambahan APAR. Kata Kunci : rumah sakit, filing, ergonomi
Analisis Kegiatan Penyediaan Berkas Rekam Medis Rawat Inap di RSU Haji Surabaya Novita Yuken Nur Aulia; Novita Nuraini; 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.v1i4.2107

Abstract

One indicator in measuring the quality of medical records is the punctuality. The punctuality means managing the medical record file from the patient registering until the medical record file with the time limit specified in the standard operating procedure. At Haji Hospital Surabaya, the delay in providing the  inpatient medical records is still a problem. It can cause obstruction of the patient care process so that it will also affect service satisfaction. This research was aimed to analyze the activities of providing inpatient medical records at the Hajj General Hospital in Surabaya with the type of qualitative research. Data collection techniques used are observation, interviews, and documentation based on the variables Ability, Motivation, and Opportunities. The results of this study indicate that there are no SOPs related to the time the provision of inpatient medical records is the main factor being addressed. The Efforts can be made by rearranging SPOs related to providing inpatient medical record time.
Studi Literatur : Faktor Penyebab Ketidakpuasan Pasien di Pelayanan Pendaftaran Rawat Jalan RSU Haji Surabaya 2020 Agni Candramawa Sholikha; Rossalina Adi Wijayanti; Novita Nuraini
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.v2i1.2112

Abstract

Patient satisfaction is the result of the patient's assessment of the service received based on truth and reality that is then compared to his expectations. The results of observations made by researchers at Surabaya Haji Hospital based on medical record data on the number of outpatients visiting Surabaya Haji Hospital in January to March 2020 there is a decrease in the number of outpatient visits each month. The purpose of this study was to determine the level of patient satisfaction in the outpatient registration at RSU Haji Surabaya. This study uses a literature review method of 10 journals using measurement techniques of 5 dimensions of health service quality, namely tangibles, reliability, responsiveness, assurance, and empathy. The results of the literature review indicate that the satisfaction of the quality dimension is considered the most satisfied is the dimension of assurance and reliability, while the highest dimension of dissatisfaction is the dimension of tangibles and empathy.
Identifikasi Penyebab Keterlambatan Penyediaan Dokumen Rekam Medis Rawat Jalan di Rumah Sakit Husada Utama Surabaya Tahun 2020 Astrid Kartika Dewi Aprilia; Ida Nurmawati; 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.v1i4.2130

Abstract

Fast and precise services are the desire of consumers. The speed of document provision of medical records to the PDS can be an indicator in measuring satisfaction. Based on the SPM of the hospital when providing outpatient medical records is ≤ 10 minutes. Husada Utama Surabaya Hospital has implemented medical records management, but there are problems in the implementation, in the provision of medical record documents less than the maximum and delayed. The aim of this research is to determine the factors causing delays in the provision of patient medical record documents in outpatient services based on 7M (man, money, method, material, machine, motivation, and media). This type of research is qualitative. Data collection used observation sheets and interview guidelines to 4 respondents. The results showed that the education, knowledge, and training of employee about the science of medical records is still lacking, the budget was managed by the financial management and there were no details for the needs of the medical record unit, there is no SOP about the provision of outpatient medical record documents, the medical record file is only a thin sheet of HVS paper, the folder used is easily damaged, outpatient medical records employee never get a reward from the leadership, room and rack filling cannot store medical records medical records properly. In conclusion, the factors that caused the delay in providing medical record documents are man, money, method, material, motivation, and media. The results of this study can be an evaluation material for Husada Utama Hospital to improve the service provision of medical records for outpatients.
Perancangan Sistem Informasi Peminjaman dan Pengembalian BRM Rawat Jalan di Rumah Sakit Husada Utama Lidya Nur Fatimatuz Zuhro; Ida Nurmawati; Rossalina Adi Wijayanti; Gilang Nur Permana
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.v1i4.2136

Abstract

Borrow and return outpatient medical records at the Husada Utama Hospital in Surabaya still uses manuals by referring to the date of discharge from the hospital to search for files that have not been returned or for file tracking so that it can cause difficulties for officers in tracking outpatient medical records. Data of delay in the return of outpatient medical records in February-March 2020 counted for 117 (14.88%) of the total files late from the 786 total outgoing files. SOP (Standard Operational Procedure) that applies at Husada Utama Hospital regarding hospital service standards is explained by the medical records of Specialist Practices which are returned within 1X24 hours on the same day. While the medical record file in the inpatient room is submitted no later than 2X24 hours after the date the patient is discharged from the hospital. This research  was aimed to design a web-based outpatient medical records and loan information system at the Husada Utama Hospital in Surabaya. The type of research is qualitative research with data collection methods of observation and interviews. The subjects of this research were the head of the medical record and the outpatient medical record officer. The method used by researchers is the waterfall method. The results of this research can be seen that the design of information systems for borrowing and returning outpatient medical record files are made according to the needs of users, making the system starts from the needs analysis so it produce a system design that suits your needs.
Identifikasi Faktor Penyebab Ketidaksesuaian Pelaksanaan Retensi Dokumen Rekam Medik Inaktif di RS Husada Utama Kota Surabaya Dwi Winda Agustin; Rossalina Adi Wijayanti; Gilang Nur Permana
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.v2i1.2156

Abstract

Hospitals as a health service facility are required to make medical records Retention is the transfer of inactive DRM to inactive filing to reduce the amount of DRM that is on an active filing rack. The number of visits in the Husada Utama Hospital in Surabaya each year has increased that is not proportional to the large capacity of storage space, causing an incompatibility of the implementation of medical record document retention SOP. The purpose of this study was to identify problems using five elements of management namely man, money, method, material, machine. This research is a type of qualitative research. The results of this study are the identification of problems that occur and the causes of the problem are knowledge, education, training, operational costs, inactive storage space, medical record shelves, scanning equipment, computers and SOP. As a result of these problems will result in a buildup of medical record files which causes narrowing in the storage room that affects the hospital's accreditation standards. The alternative solutions to problems are the existence of SOP socialization, attending training, the existence of a budget for procurement of equipment, the expansion of storage space and the addition of medical record file shelves, the provision of scanning tools and computers as well as SOP evaluation.
Identifikasi Faktor Penyebab Penumpukan Berkas Rekam Medis Aktif di RS Husada Utama Nurul Kamilia; Rossalina Adi Wijayanti; Ida Nurmawati
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.v1i4.2160

Abstract

Based on the results of a preliminary study conducted at the Husada Utama Hospital it is known that in 2018 there was an accumulation of active medical record files which were 310 files. The impact of the accumulation of medical record files is the provision of medical record files will take longer so that patients often complain, officers become fatigued quickly in doing their work so that it will also have an impact on the depreciation process that should be done every day, and officers also feel uncomfortable and disturbed because the accumulation of medical record files also interferes with access to filing officers when retrieving and returning medical record files. This study aims to identify the factors causing the accumulation of active medical record files in Husada Utama Hospital. This type of research uses qualitative and data collection by interview, observation, and documentation. The results obtained that the results showed that the cause of the accumulation of medical record files that affect from the Man side is that the officer has never attended medical records training, from the Money side that is still not getting a budget for storage shelves, from the Material side there is a medical record file that is not using a map, in terms of Machine that is the number of storage racks not according to needs and in terms of Method which is the implementation of a storage system, alignment, and retention that is not in accordance with the Standard Operating Procedure (SOP).
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