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All Journal Jurnal Penelitian Kesehatan Suara Forikes Jurnal Wiyata : Penelitian Sains dan Kesehatan Jurnal Kesehatan Jurnal Manajemen Informasi Kesehatan Indonesia (JMIKI) Jurnal Pengabdian Masyarakat IPTEKS ARTERI : Jurnal Ilmu Kesehatan Jurnal Aisyah : Jurnal Ilmu Kesehatan J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Jurnal Rekam Medik & Manajemen Informasi Kesehatan (RAMMIK) JMMR (Jurnal Medicoeticolegal dan Manajemen Rumah Sakit)

Rossalina Adi Wijayanti

Politeknik Negeri Jember

Author-ID : 2629200

Religion Humanities Computer Science & IT Dentistry Economics, Econometrics & Finance Electrical & Electronics Engineering Health Professions Medicine & Pharmacology Nursing Public Health Social Sciences Veterinary Other

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Analisis Faktor Penyebab Ketidaklengkapan Informed Consent Bedah Rawat Inap Rumah Sakit Paru Jember Rossalina Adi Wijayanti; Rizky Putri Amalia
Jurnal Kesehatan Vol 11 No 1 (2023): April 2023
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-kes.v11i1.273

One of the indicators for medical record is 100% for Informed Consent completeness. Based on a preliminary study at Paru Hospital Jember, it was found that average number is at 40,20% of the 102 informed consent files are incomplete. The purpose of this research is analyzing factors brought incompletess filling in surgical informed consent. This research used a qualitative research method carried out at Paru Hospital Jember February to July 2021. The results showed that the high incompleteness of the informed consent was caused about there is no punishment was received by the officer if he did not fill in the informed consent. Doctors and nurses have never received training about medical records. The SOP does not include the number of completeness filling. The knowledge of doctors in completeness standarts of informed consent are less. The conclusion of this research is the incomplete number of informed consent filling caused the Minimum Service Standars of medical record in hospital cannot be fulfilled. It is because the performance has not been maximized

Incomplete Inpatient Medical Record Documents at Hospital Gamasiano Alfiansyah; Alvira Nafisah Eky Mulia; Rossalina Adi Wijayanti; Sabran Sabran
Jurnal Aisyah : Jurnal Ilmu Kesehatan Vol 7, No 4: December 2022
Publisher : Universitas Aisyah Pringsewu

The medical record contains the patient's identity, examination, treatment, actions and other services that have been provided to patients. There were incomplete integrated patient progress notes 61% and incomplete medical resumes 73%. The research intended to analyze the aspects that caused the incompleteness of inpatient medical record documents at the Besuki Hospital. This research used a qualitative method with data collection techniques interviews, observation dan documentation. The subjects in this study were 1 head of medical records and 5 medical record officers. The result showed that the factors causing the incompleteness of inpatient medical record documents from the motivational variable were that there was still no award and punishment for medical record officers. Opportunity variables were the absence of incomplete record cards, medical record officers who have never attended any training at all, SOPs for checking the completeness of medical records missing and having never been socialized. The ability variable was that there were medical record officers who did not have a minimum education of medical recorders, the knowledge of officers is still lacking and there were officers who had work experience of less than 2 years.Abstrak: Rekam medis berisi identitas pasien, pemeriksaan, pengobatan, tindakan dan pelayanan lain yang telah diberikan kepada pasien. Berdasarkan hasil observasi diketahui bahwa terdapat ketidaklengkapan CPPT sebesar 61% dan ketidaklengkapan resume medis sebesar 73%. Penelitian bertujuan untuk mengidentifikasi dan menganalisis penyebab ketidaklengkapan rekam medis rawat inap di RSUD Besuki. Jenis penelitian adalah kualitatif, pengumpulan data dilakukan dengan wawancara mendalam, dokumentasi, dan observasi. Subyek pada penelitian ini yaitu 1 ketua rekam medis dan 5 petugas rekam medis. Hasil penelitian menunjukkan faktor penyebab ketidaklengkapan dokumen rekam medis rawat inap dari variabel motivasi yaitu masih belum ada pemberian penghargaan dan hukuman untuk petugas rekam medis. Variabel kesempatan yaitu belum adanya kartu catatan ketidaklengkapan, petugas rekam medisbelum pernah mengikuti pelatihan sama sekali, SOP kegiatan pengecekan kelengkapan rekam medis hilang dan belum pernah disosialisasikan. Variabel kemampuan yaitu terdapat petugas rekam medis yang tidak memiliki pendidikan minimal D3 Rekam Medis, pengetahuan petugas rekam medis masih kurang dan ada petugas memiliki pengalaman kerja kurang dari 2 tahun.

Bahasa Inggris Aghasi Hana Faradila; Rossalina Adi Wijayanti; Novita Nuraini; Riskha Dora Candra Dewi
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 4 No 2 (2023): March
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v4i2.3831

The incomplete filling of medical records affects the quality of medical record services and has an impact on the discontinuity of health services provided to patient. Based on the result of observations at the Puskesmas Babadan , it is known that there was an incompleteness of outpatient medical records with a percentage of 27,3% with the number of medical records that are not completely filled as many as 44 from 161 outpatient medical records. This study aims to analyze the factors causing the incompleteness of outpatient medical records at the Puskesmas Babadan by priorotizing problems using the Urgency, Seriousness, Growth (USG) method and improvement efforts through brainstorming. The results found in this study are based on motivation variables namely the absence of rewards and punishments given to officers, based on the opportunity variables namely that there is no Standard Operating Procedures (SOP) that regulates the completeness of filling out medical records and officers involved in filling out outpatient medical records have never received training on the completeness of filling out medical records, based on the ability variables, namely the ability of education, experience and medical staff to assist in filling out outpatient medical records. The absence of Standard Operating Procedures (SOP) which is the cause of incomplete filling of outpatient medical records. The effort to fix the problem is by making clear Standard Operating Procedures (SOP) regarding the completeness of filling out medical records in accordance with applicable medical record service standars.

Impact of Work Environment and Work Stressing on The Job Satisfaction of Medical Record Officers Atma Deharja; Nonik Aisyah Rohman; Rossalina Adi Wijayanti
JMMR (Jurnal Medicoeticolegal dan Manajemen Rumah Sakit) Vol. 9 No. 2 (2020): August 2020
Publisher : Universitas Muhammadiyah Yogyakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.18196/jmmr.92123

Factors that influence the work satisfaction of medical record officer is the work environment and work stress. Uncomfortable work environment and work stressing with a lot of work demands make the staff will experience severe pressure. Based on the preliminary study on April 1st, 2018, it's found that seven officers who often absent (above 10%), small workspace, awkward movement, inadequate facilities, double jobs, and double shifts that made 10 out of 13 officers experience unenjoyable in their work. The purpose is to analyze the effect in the work environment and work stressing on the work satisfaction of medical record officers in the X Hospital. It is analytical with a cross-sectional approach using ordinal logistic regression and questionnaire as an instrument. The sample used is 13 medical record officers—the work environment and work stressing as independent variables and work satisfaction as dependent variables. The significance value of the work environment and work stress variable is 0.002. It has a significance value <α (P <0.05), proving that the work environment and work stressing have a significant effect on work satisfaction. This study's suggestions need to be the expansion of workspace, additional facilities, and officers to avoid double jobs and double shifts.

Faktor Penyebab Ketidaklengkapan Pengisian Dokumen Rekam Medis Rawat Inap Rumah Sakit Azis, Anisya; Alfiansyah, Gamasiano; Wijayanti, Rossalina Adi; Selviyanti, Erna
Jurnal Penelitian Kesehatan SUARA FORIKES 2022
Publisher : FORIKES

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33846/sf.v13i0.2177

The standard for completing medical record documents is 100%, but in some hospitals it is still common to find incomplete filling of medical record documents. So a study is needed that aims to analyze the factors that cause incomplete filling of medical record documents for inpatients at the hospital by using the 5M management elements, namely Man, Materials, Method, Machine, and Money. This study is a literature review of 14 articles obtained from Google Scholar, Garuda, and Crossref. Of the 14 articles reviewed, the causes of incomplete filling in medical record documents for inpatients at the hospital are the lack of discipline of doctors in completing medical records, lack of facilities and infrastructure to support medical record filling, lack of socialization regarding filling out medical record documents, lack of reward and punishment, and limited funds.Keywords: incompleteness; medical records; inpatient; hospital ABSTRAK Standar kelengkapan pengisian dokumen rekam medis adalah 100%, namun pada di beberapa rumah sakit masih sering ditemukan ketidaklengkapan pengisian dokumen rekam medis. Maka diperlukan studi yang bertujuan untuk menganalisis faktor penyebab ketidaklengkapan pengisian dokumen rekam medis pasien rawat inap di rumah sakit dengan menggunakan unsur manajemen 5M, yaitu Man, Materials, Method, Machine, dan Money. Studi ini merupakan literature review terhadap 14 artikel yang didapatkan dari Google Scholar, Garuda, dan Crossref. Dari 14 artikel yang ditelaah, penyebab ketidaklengkapan pengisian dokumen rekam medis pasien rawat inap di rumah sakit adalah kurangnya kedisiplinan dokter dalam melengkapi rekam medis, kurangnya sarana dan prasarana pendukung pengisian rekam medis, kurangnya sosialisasi mengenai pengisian dokumen rekam medis, belum adanya reward dan punishment, dan terbatasnya dana.Kata kunci: ketidaklengkapan; rekam medis; rawat inap; rumah sakit

Keterikatan Faktor Pendidikan, Pengetahuan, Sikap, dan Sarana Prasarana Terhadap Kejadian Missfile di Puskesmas Tegalsari, Kabupaten Banyuwangi Rossalina Adi Wijayanti; Virda Hardiana; Ervina Rachmawati; Selvia Juwita Swari
Jurnal Penelitian Kesehatan SUARA FORIKES Vol 14, No 2 (2023): April 2023
Publisher : FORIKES

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33846/sf14229

The incidence of missfiles at the Tegalsari Health Center, Banyuwangi from January to March 2021 was 9.1%. The purpose of this study was to identify the attachment of education, knowledge, attitudes, and infrastructure to the occurrence of missfiles at the Tegalsari Health Center, Banyuwangi Regency. This study used a qualitative approach. Data collection techniques used were interviews, observation and documentation. The results of this study indicate that the predisposing factors that cause missfiles were: 1) none of the officers had a medical record educational background; 2) staff lack of knowledge about storage systems, missfiles, and file provisioning time; 3) the attitude of the officer who just made the file when he did not find the file he was looking for, the officer did not return the file directly to the storage rack, and the officer used a tracer. Enabling factors include: 1) storage space that was narrow and became one with the registration room; 2) lack of storage shelves; 3) the tracer was only in the form of buffalo paper and the lack of tracer availability; 3) the computer often experiences errors and slow connections. It was concluded that there are still many predisposing factors and enabling factors that cause missfiles to occur. Tegalsari Community Health Center is expected; 1) involving officers in training, 2) providing socialization about storage procedures, and 3) preparing a budget plan to support infrastructure.Keywords: missfile; storage; medical records ABSTRAK Kejadian missfile di Puskesmas Tegalsari, Banyuwangi pada bulan Januari sampai dengan Maret 2021 sebanyak 9,1%. Tujuan pada penelitian ini yaitu untuk mengidentifikasi keterikatan faktor pendidikan, pengetahuan, sikap, dan sarana prasarana terhadap kejadian missfile di Puskesmas Tegalsari, Kabupaten Banyuwangi. Penelitian ini menggunakan pendekatan kualitatif. Teknik pengumpulan data yang digunakan adalah wawancara, observasi dan dokumentasi. Hasil dari penelitian ini menunjukkan bahwa presdiposing factors penyebab missfile yaitu: 1) petugas tidak ada yang berlatar belakang pendidikan rekam medis; 2) kurangnya pengetahuan petugas tentang sistem penyimpanan, missfile, dan waktu penyediaan berkas; 3) sikap petugas yang baru membuatkan berkas saat tidak menemukan berkas yang dicari, petugas tidak mengembalian berkas secara langsung pada rak penyimpanan, dan petugas mengunakan tracer. Enabling factors meliputi: 1) ruang penyimpanan yang sempit dan menjadi satu dengan ruang pendaftaran; 2) kurangnya rak penyimpanan; 3) tracer hanya berupa kertas buffalo dan kurangnya ketersediaan tracer; 3) komputer sering mengalami error dan lambatnya koneksi. Disimpulkan bahwa bahwa masih banyak predisposing factors dan enabling factors yang menyebabkan terjadinya missfile. Puskesmas Tegalsari diharapkan; 1) mengikutsertakan petugas dalam pelatihan, 2) memberikan sosialisasi tentang prosedur penyimpanan, dan 3) menyusun rencana anggaran untuk menunjang sarana prasarana.Kata kunci: missfile; penyimpanan; rekam medis

Analysis of Filling in the Inpatient Medical Record Files at Arjasa Health Center Jember Rossalina Adi Wijayanti; Hikmatus Surur; Novita Nuraini; Indah Muflihatin
Jurnal Aisyah : Jurnal Ilmu Kesehatan Vol 6, No 2: June 2021
Publisher : Universitas Aisyah Pringsewu

The Medical record form is an important means of communication because it records detailed data about all actions taken by medical officers. The activities of filling in medical records in Arjasa Health Center are applied less sufficiently. This can be seen from some incomplete filling of the medical record. It impacts the process of classification, and diseases coding, reporting, and claims submission. This study aims to analyze the filling of medical records files in the Arjasa Health Center, Jember Regency. This type of research is qualitative research. The data collections are interviews, observations, documentation, and questionnaires. There 5 subjects of the study which consist of medical record officer, nurse, midwife, nutrition officer, and doctor. The results show several factors that cause incomplete filling of the medical records are the absence of medical record training for officers, SOP, qualified officer, punishment and reward for officers’ performance. The efforts to solve these problems obtained by brainstorming include conducting medical record training, recruiting officers based on the qualifications, creating and socializing SOP, providing punishment or reward to officers with good performance in filling in the files completely and appropriately. Abstrak: Formulir rekam medis merupakan sarana komunikasi yang penting karena didalamnya tercatat data rinci mengenai semua tindakan yang dilakukan tenaga medis. Kegiatan pengisian berkas rekam medis di Puskesmas Arjasa masih belum optimal. Hal ini dapat dilihat dari beberapa berkas rekam medis yang masih belum terisi secara lengkap. Dampak dari pengisian berkas rekam medis yang tidak lengkap yaitu dapat menghambat proses pengklasifikasian dan kodefikasi penyakit, terhambatnya kegiatan pelaporan dan pengajuan klaim. Penelitian ini bertujuan untuk menganalisis pengisian berkas rekam medis di Puskesmas Arjasa Kabupaten Jember. Jenis penelitian adalah penelitian kualitatif. Pengumpulan data menggunakan wawancara, observasi, dokumentasi dan kuesioner. Subyek penelitian berjumlah 5 orang yang terdiri dari petugas rekam medis, perawat, bidan, petugas gizi serta Dokter. Hasil penelitian menunjukkan bahwa beberapa faktor yang dapat dapat menyebabkan ketidaklengkapan pengisian berkas rekam medis diantaranya belum pernah diadakannya suatu pelatihan terkait dengan pentingnya pengisian rekam medis secara lengkap, pendidikan petugas masih ada yang belum sesuai kualifikasi pendidikan RM, tidak ada SOP tentang pengisian berk;as rekam medis, tidak ada punishment dan reward bagi petugas sebagai bentuk motivasi dalam mengisi berkas rekam medis. Upaya penyelesaian masalah yang didapatkan dengan menggunakan brainstorming antara lain mengadakan pelatihan rekam medis, merekrut petugas sesuai kualifikasi Rekam Medis, membuat serta melakukan sosialisasi SOP tentang pengisian berkas rekam medis, memberikan punishment atau reward kepada petugas yang mengisikan berkas rekam medis secara lengkap dan tepat.

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

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