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Rossalina Adi Wijayanti
Politeknik Negeri Jember
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Analisis Pelaksanaan Sensus Harian Rawat Inap di RSUD Dr. Saiful Anwar Malang Ferly Ferly; 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.v1i4.2163

Abstract

Abstract Information obtained from the daily inpatient census in the form of data that will be processed into information needed by the hospital, so that the daily inpatient census activities must be carried out correctly in accordance with procedures so that the data generated is accurate and can be used as a basis for decision making for management. This study aims to analyze the factors causing the inactivity of inpatient daily census activities correctly using a fishbone diagram. This research is a qualitative descriptive study conducted at Dr. Saiful Anwar Malang in February - March 2020. The subjects of this study were the daily census officer of the inpatient room, and the daily census officer of the medical record section. Data was taken by interview and observation methods. Data were analyzed using fishbone diagrams. The results of this study indicate that the factors that cause the inability of the inpatient daily census to be conducted correctly are Man (misperception of the inpatient census daily officer between the understanding day of care with the length of stay, educational background of the officer not from the medical record, and the officer has never attended training on the census), Money (there is no funding budget for training implementation, Materials (census information system on billing system is not implemented, census recapitulation is still manual using paper forms and Microsoft excel), Method (Daily SOP for inpatient census has not been revised), Machine (census application on billing system is not implemented) Fishbone diagrams where the in-patient census daily activities are carried out correctly are mostly caused by Man factors and Materials factors.
Analisis Faktor Penyebab Rendahnya Kinerja Petugas Pada Unit Filing di RSU Bhakti Husada Krikilan Nabilah Khoirun Nissa'; Rossalina Adi Wijayanti; Atma Deharja; Efri Tri Ardianto
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.v2i3.2187

Abstract

Berdasarkan survey pendahuluan di Rumah Sakit Umum Bhakti Husada Krikilan terdapat permasalahan terkait kinerja pada unit filing yaitu beberapa job description belum terlaksana dan belum dikerjakan maksimal, waktu penyediaan dokumen rekam medis lebih dari 10 menit, petugas filing berlatar belakang pendidikan sekolah menengah kejuruan dan sekolah menengah ekonomi atas. Penelitian ini bertujuan untuk melakukan analisis faktor penyebab rendahnya kinerja petugas rekam medis pada unit filing kemudian dilakukan analisis faktor penyebab kinerja rendah dari faktor individu, organisasi dan psikologi dengan metode Problem Tree Analysis. Jenis penelitian yang digunakan adalah penelitian kualitatif dan pengumpulan data dengan wawancara, observasi dan dokumentasi. Hasil penelitian ini menunjukkan bahwa pada penyebab utama faktor individu dan demografi, adanya latar belakang pendidikan petugas yang tidak sesuai sementara perekrutan tenaga baru belum dilaksanakan karena masih dalam proses perencanaan manajemen; pada faktor organisasi penyebab utama desain pekerjaan terdapat kurangnya koordinasi terkait job description dan SOP antar petugas dan atasan, terbatasnya jumlah tenaga, dan petugas kurang memahami pentingnya job description; pada faktor psikologi penyebab utama sikap yaitu adanya jam kerja yang cukup padat namun tenaga kerjanya terbatas sehingga penyediaan berkas terlambat dan pada faktor penyebab utama motivasi yaitu adanya motivasi dalam diri petugas (bukan pengakuan dari orang lain yang mendorong kerja petugas) serta  motivasi dari luar diri petugas (pihak luar kurang memahami pentingnya job description dan masih  dalam proses perencanaan manajemen).
Pendekatan Sistem Dalam Pengelolaan Rekam Medis di Rumah Sakit Mitra Sehat Situbondo Tias Agustin Ayuningrum; Rossalina Adi Wijayanti; Atma Deharja; Maya Weka Santi
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.v1i4.2199

Abstract

Pengelolaan rekam medis di Rumah Sakit Mitra Sehat Situbondo kurang optimal. Hal tersebut dibuktikan pada Juni 2019, terjadi ketidaklengkapan pengisian rekam medis di bagian assembling sebesar 66,67%. Selanjutnya, pada bagian coding terjadi pengembalian klaim BPJS pada triwulan 1 tahun 2018 sebanyak 131 berkas. Selain itu, pada bagian filling ditemukan bahwa ruang penyimpanan tidak cukup untuk menampung dokumen rekam medis, sehingga ada dokumen yang ditumpuk di lantai. Tujuan penelitian ini menganalisis pengelolaan rekam medis melalui pendekatan sistem. Jenis penelitian ini adalah kualitatif dengan teknik pengumpulan data wawancara, observasi, dan dokumentasi. Subjek penelitian yaitu kepala rekam medis, petugas assembling, petugas coding, dan petugas filling. Penelitian ini menggunakan metode USG untuk prioritas masalah. Hasil penelitian didapatkan bahwa jumlah petugas rekam medis masih kurang dan ada petugas yang tidak berkualifikasi pendidikan rekam medis, serta ada petugas yang belum mendapatkan pelatihan. Hasil penelitian juga didapatkan bahwa buku ekspedisi rawat inap dan komputer untuk pelaporan belum tersedia. Selain itu, ruang penyimpanan terasa panas dan jumlah rak penyimpanan masih kurang. Standar prosedur operasional rekam medis juga kurang disosialisasikan. Hasil penelitian pada proses assembling ditemukan terjadi ketidaklengkapan pengisian rekam medis. Selain itu, pada proses coding terjadi kekosongan pengisiandiagnosa dan tindakan serta tulisan dokter tidak terbaca. Hasil dari prioritas masalah dapat disimpulkan bahwa yang menjadi masalah utama dalam pengelolaan rekam medis adalah kurang optimalnya fasilitas filling, dimana ruang penyimpanan terasa panas dan rak penyimpanan masih kurang. Saran yang diberikan adalah melakukan pengadaan AC dan pencatatan grafik suhu ruangan secara rutin serta meningkatkan dukungan manajemen dalam penyediaan rak penyimpanan.
Analisis Faktor-Faktor Penyebab Kejadian Misfile di Puskesmas Kademangan Kabupaten Bondowoso Desi Syahbaniar; Rossalina Adi Wijayanti; Feby Erawantini; Efri Tri Ardianto
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 2 No 2 (2021): March
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v2i2.2201

Abstract

The observation results of the medical record filing unit in Kademangan Public Health Service Bondowosofound that, in a week, 51 of 366 outpatient medical records were on the wrong location or lost (misfile) Theimpact of misfiling is the delay of service patients in search of medical records, duplication of numbersrecord the medical, and the contents of medical records document become not sustainable. This studyaimed to analyze the factors that cause medical records misfile in Kademangan Public Health ServiceBondowoso. This study used qualitative methods and data obtained through an interview, observation, andUSG (Urgency, Seriousness, Growth) method. The results of the research showed that the priority problemof misfile’s causes was the less of leadership motivation such as reward and punishment. The alternativesolutions were giving punishment or reward to medical record officers, especially to the filling officer tocreate their discipline in doing their work. The discipline of the filing officers in conducting work makes themanagement of filing medical records run optimally
SISTEM INFORMASI PEMINJAMAN DAN PENGEMBALIAN DOKUMEN REKAM MEDIS MENGGUNAKAN METODE WATERFALL (STUDI KASUS PUSKESMAS BANJARSENGON) Nur Malika Jamil; Niyalatul Muna; Rossalina Adi Wijayanti; Andri Permana Wicaksono
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.v1i2.2241

Abstract

The information system is made based on problems in recording the implementation of loans, returningmedical records. This computerized information system where in the borrowing and returning of medicalrecords is no longer manual. The purpose of this information system is to facilitate officers in recording,borrowing, returning, controlling and controlling medical records. The borrowing and return of medical recordsmust be controlled properly to reduce duplication of medical record numbers and delays in medical recorddocuments. Qualitative research using documentation data collection methods and interviews at theBanjarsengon Health Center in Jember. The method used in this research is the 2011 somerviel waterfallmethod. The steps taken are requirements analysis, system design, program code writing, and programtesting. The design of this information system uses flowchart design, context diagrams, Data Flow Diagrams(DFD), and Entity Relationship Diagrams (ERD) then the design results are implemented into a visual basicprogramming language using Miscrosoft Visual Studio 2010. The results of this study are lending informationsystems. and return of medical record documents. This information system is equipped with a warning alert asa notification that medical record documents borrowed by POLI to be returned immediately, can help ease theworkload of filing officers by minimizing the number of delays in medical record documents and duplication ofmedical record documents.
TINJAUAN PENYEBAB KLAIM PENDING BADAN PENYELENGGARA JAMINAN SOSIAL (BPJS) KESEHATAN DI RSU HAJI SURABAYA Ariqpurna Bayu Triatmaja; Rossalina Adi Wijayanti; Novita Nuraini
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 3 No 2 (2022): March
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v3i2.2252

Abstract

Badan Pelaksana Jaminan Sosial (BPJS) Kesehehatan provide health services to the public by using a prospective payment system. Surabaya Hajj General Hospital is one of the type B educational hospitals that has been collaborating with the BPJS since 2014. Based on primary data at Surabaya Haji Hospital it was found that the claim file had pending claims. This is due to incomplete claim file, inaccurate diagnostic code due to differences in perception between the coders and verifiers. This study aims to analyze the pending claims factor of the Health Social Security Administration Agency (BPJS) at Haji Hospital Surabaya. Problem identification uses 5M management elements (man, material, methods, machine, money). This type of research is descriptive qualitative, narrating the results of the study. In the man element that causes the pending claim is the officer still feels difficulty in reading the diagnoses and actions of patients due to the writing of doctors who are difficult to read, and incorrect diagnosis codes and actions due to differences in perception between the coder and verifier of the BPJS. The material element that causes the pending claim is the incomplete claim file, such as the results of patient support examinations. In the Method element that causes pending claims, there is no SOP governing the filling of a specific diagnosis file claim. On the machine element that causes pending claims is the computer used in the claim submission process often experiences long loading times and often experiences network disruptions. In the element of money in this study does not cause pending claims, because casemix officers can not know the amount of loss caused by pending claims.
Analisis Kualitatif Sistem Pengendalian Berkas Rekam Medis di Puskesmas Mojoagung Kabupaten Jombang Anggun Citta Isvara Maharesi Putri; Rossalina Adi Wijayanti; Feby Erawantini; Indah Muflihatin
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.v2i3.2271

Abstract

Based on the results of a preliminary study at the Mojoagung’s Public Health Center (Puskesmas), there was matter such as the use of expedition books for the unrecorded files caused the control system for the incompatible medical record. This research aims to analyze the control system for medical record file in Puskesmas of Mojoagung, while it delivers a qualitative study by using the approach of POAC (Planning, Organizing, Actuating and Controlling). The result consists of: (a) Planning, an inappropriate control system caused by the use of unsuitable expedition books; (b) Organizing, any double jobs and unclear job description; (c) actuating, no reward and punishment for officers and no guidance on the use of expedition books; (d) controlling, no evaluation from the leadership. Therefore, there are some suggestions that researcher recommends for Puskesmas of Mojoagung as follows: applying the expedition book and evaluating routinely once three months, providing guidance to the officer to use the expedition book correctly, giving insight on the importance of using expedition books and always reminding for briefing in the morning and socialization routinely, any clear job descriptions, reward to the officer if finishing the job well and reprimand if unfinished it, briefing in each of meeting on managing medical records in particular of the control system for the medical record file, and regular meetings once a month to evaluate or assess the performance of the medical records’ officer to achieve the stated goals.
Analisis Kepuasan Pasien Rawat Jalan Puskesmas Dringu Kabupaten Probolinggo Ani Nuraini; Ida Nurmawati; Rossalina Adi Wijayanti; Ervina Rachmawati
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 2 No 4 (2021): September
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v2i4.2310

Abstract

Dringu Public Health Center, Probolinggo Region, has a vision to become a public health center with the optimal health services. It can be known from patient satisfaction assessment. So far, the patient satisfaction assessment has never been carried out in Dringu Public Health Center. The purpose of this study was to analyze the outpatient satisfaction of the Dringu Public Health Center, Probolinggo Region, through service quality method based on five (5) service quality dimensions of tangible, reliability, responsiveness, assurance and empathy. This type of research used a quantitative method. The populations consist of 23526 peoples and the samples were 100 respondents. The sampling technique used purposive sampling.  Data were collected by questionnaire. The results showed that the percentage of services in tangible dimension were 86.3% of patient satisfaction and 13.7% of patient dissatisfaction. The percentage of services in reliability dimension were 89.6% of patient satisfaction and 10.4% of patient dissatisfaction. The percentage of services in responsiveness dimension were 69.7% of patient satisfaction and 30.3% of patient dissatisfaction. The percentage of services in the assurance dimension were 68.2% of patient satisfaction and 31.8% of patient dissatisfaction. In the empathy dimension, the percentage of service were 74.1% of patient satisfaction and 25.9% of patient dissatisfaction. It is recommended to create a patient admission flow as well as create a service schedule poster for Dringu public health center.
Faktor Penyebab Ketidaklengkapan Pengisian Resume Medis Guna Penunjang Akreditasi di RS Bhayangkara Lumajang Melati Ayu Pratiwi; Rossalina Adi Wijayanti; Efri Tri Ardianto; Ervina Rachmawati
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 2 No 4 (2021): September
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v2i4.2328

Abstract

Completeness of medical record 24 hours after completion of service in accordance with the minimum standard of hospital service is 100%, including on the completeness of filling the medical resume form. Based on preliminary studies at Bhayangkara Lumajang Hospital, it was found that one of the unfulfilled standards of MIRM was MIRM 13.4 regarding the completeness of. The researcher checked the completeness of medical resume by taking 265 samples in the quarter I 2019 at Bhayangkara Hospital Lumajang obtained that the overall average medical resume form of completeness was 39%. Average for incompleteness of 54.3%. The purpose of this study is to determine the factors that cause the incompleteness of medical resume replenishment to support accreditation at Bhayangkara Hospital in Lumajang by identifying personnel behavior based on individual, organizational and psychological factors. This type of research is qualitative research. The data collection techniques used are interviews, questionnaires, checklists and documentation. Research results using NGT (Nominal Group Technique) technique obtained priority cause main problem is the limitation of time of the officer in filling the completeness of medical resume from the problem is obtained solution from the result of NGT (Nominal Group Technique) that it needs, monitoring of follow up (specialized areas evaluate completeness).
ANALISIS FAKTOR YANG BERHUBUNGAN DENGAN KELENGKAPAN RESUME MEDIS – LITERATURE REVIEW Nafa Maharani; Atma Deharja; Rossalina Adi Wijayanti; Dony Setiawan Hendyca Putra
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 3 No 2 (2022): March
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v3i2.2667

Abstract

A Medical resume is a summary of the whole medical patient's treatment. The incomplete medical resume can cause the patient's medical history to not continue with the patient's previous data. The various factors cause an incomplete medical resume. The research aimed to analyze the aspects related to the completeness of a medical resume. The study is a literature review with database from Google Scholar and Garuda. This research's keywords are factors related AND completeness OR complete AND medical resume OR medical resume OR discharge summary OR discharge summary. The manpower elements are 21,4 percent of good knowledge, 28,5 percent of long working tenure, 21,4 percent of civil servant employment status, 7,1 percent of good attitude, and 7,1 percent of higher education. The motivation elements are 14,2 percent of adequate supervision (monitoring and evaluation), 7,1 percent of good leadership, and 7,1 percent of reward and punishment. Media elements are 7,1 percent of how to pay for BPJS patients and 7,1 percent of directly related work conditions (unique table and chair to fill medical records) and other work environments (lighting and noise room to fill medical resumes). The main factor related to medical resume's completeness is tenure, and other high factors are knowledge and employment status. The writer suggests that health facilities should facilitate patient data completeness, especially for doctors with a new term, bad experience, and non civil servant employment status.
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