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<![CDATA[Faktor Penyebab Ketidaklengkapan Rekam Medis Rawat Inap di RSUD dr. Saiful Anwar Malang ]]>
<![CDATA[Ana Nafidatul Khoiroh]]>;
<![CDATA[Novita Nuraini]]>;
<![CDATA[Maya Weka Santi]]>
<![CDATA[ J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 2 No 1 (2020): December ]]>
Publisher : <![CDATA[Politeknik Negeri Jember ]]>
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DOI: 10.25047/j-remi.v2i1.2080
<![CDATA[One of efforts to improve the quality of healthcare facilities is to improve the quality of medical record services including completeness, speed and accuracy in providing information for health care needs. A complete and accurate medical record can be used as a reference to health services, legal bases, supporting information to improve medical quality, medical research and be used as a basis to assess the performance of hospitals. The purpose of this research identifies the factors causing the incompleteness of the replenishment of inpatient medical record in the RSUD Dr. Saiful Anwar Malang. The type of research used is qualitative. Data collection techniques by way of document study, interviews and observation. Document studies are conducted on 100 inpatient medical record documents that have not been conducted assembling, while the interview is conducted to the IRNA 2 medical record officer to determine the factors causing the incompleteness of medical record documents. Observation is done to complete the interview data. The results of the analysis on 100 inpatient medical record files were obtained that the incomplete number of medical records was 79%, with the most incompleteness presentation on the responsibilities of the doctor which includes medical resumes, casemix sheets, and surgery reports. The interview and observation results show that the main causation factor for the filing of an inpatient medical record of a surgical ward is from the doctor's awareness and discipline in filling in the medical record documents. As a solution to improve the completeness of medical record filling is by spur motivation and increase the discipline of doctors in filling medical record documents by providing reward and punishment and to repair SOP filling medical record of hospitalizatio.]]>
<![CDATA[Analisis Penyebab Ketidaksesuaian SPO Pengisian General Consent di Rumah Sakit Universitas Airlangga ]]>
<![CDATA[Nuril Amalia]]>;
<![CDATA[Novita Nuraini]]>;
<![CDATA[Andri Permana Wicaksono]]>;
<![CDATA[Rosita Prananingtias]]>
<![CDATA[ J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 3 (2020): June ]]>
Publisher : <![CDATA[Politeknik Negeri Jember ]]>
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DOI: 10.25047/j-remi.v1i3.2090
<![CDATA[The incompatibility of SPO (Standart Operational Procedure) for General Consent completion was one ofmany problems that exist in the implementation of medical record activities at Airlangga UniversityHospital. SPO incompatibility in General Consent Completion could be seen from incorrect answer inGeneral Consent form for each indicator. From 21 samples of General Consent forms, there wasunsuitable answers in such as the identity of the person in charge (62%), the identity of the patient (71%),the approval for information release, privacy, personal values and patient confidence as well as thesignature and name of the witness (100%), the signature and the name of the patient person in charge(24%) and the date (43%). The purpose of this study was to analyze the cause of the SPO incompatibilityfor General Consent completion in Airlangga University Hospital. This type of research was qualitativeresearch and data collection obtained through interview. The subjects in this study were 5 registrationofficers at Airlangga University Hospital. The result of this study showed the causes of the GeneralConsent Completion SPO incompatibility were no specific training about medical records, the GeneralConsent Completion SPO did not explain the procedures to complete the form thoroughly, and there wasno socialization related to the General Consent Completion at Airlangga University Hospital. The solutionsfor this problem are, there should be an effort to improve the General Consent Completion SPO, providetraining for registration officers and conduct socialization on General Consent Completion.]]>
<![CDATA[Analisis Faktor Penyebab Kerusakan Berkas Rekam Medis di Rumah Sakit Universitas Airlangga ]]>
<![CDATA[Aulia Nurul Kholifah]]>;
<![CDATA[Novita Nuraini]]>;
<![CDATA[Andri Permana Wicaksono]]>
<![CDATA[ J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 3 (2020): June ]]>
Publisher : <![CDATA[Politeknik Negeri Jember ]]>
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DOI: 10.25047/j-remi.v1i3.2104
<![CDATA[Medical records are files that contain records and documents regarding patient identity, examination results,treatment, actions and other services that have been provided to patients. Management of medical records is oneof medical support services. Based on the results of a preliminary study conducted at Airlangga UniversityHospital Surabaya it is known that in February 2020 amount 104 files were damaged so that the forms containedin them could be torn. This research was aimed to analyze the factors that cause damage to medical record filesat Airlangga University Hospital Surabaya. This type of research uses qualitative and data collection withinterviews and observations by using the analysis of 5M management elements is Man, Machine, Method,Material, Money. The population in this study is the medical records officer filing room section of 5 officers. Theresults obtained are that there are still many medical records officers who have a background not DIII medicalrecords, the lack of socialization of SOPs related to the maintenance of medical record files, limited number ofrack filing, and the less used folder material. So the suggestion made by the researchers is to redesign themedical record file folder by using a color code, and calculate the rack filing needs.]]>
<![CDATA[Analisis Kegiatan Penyediaan Berkas Rekam Medis Rawat Inap di RSU Haji Surabaya ]]>
<![CDATA[Novita Yuken Nur Aulia]]>;
<![CDATA[Novita Nuraini]]>;
<![CDATA[Rossalina Adi Wijayanti]]>
<![CDATA[ J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 4 (2020): September ]]>
Publisher : <![CDATA[Politeknik Negeri Jember ]]>
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DOI: 10.25047/j-remi.v1i4.2107
<![CDATA[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.]]>
<![CDATA[Studi Literatur : Faktor Penyebab Ketidakpuasan Pasien di Pelayanan Pendaftaran Rawat Jalan RSU Haji Surabaya 2020 ]]>
<![CDATA[Agni Candramawa Sholikha]]>;
<![CDATA[Rossalina Adi Wijayanti]]>;
<![CDATA[Novita Nuraini]]>
<![CDATA[ J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 2 No 1 (2020): December ]]>
Publisher : <![CDATA[Politeknik Negeri Jember ]]>
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DOI: 10.25047/j-remi.v2i1.2112
<![CDATA[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.]]>
<![CDATA[Desain Rak Penyimpanan Berkas Rekam Medis di Rumah Sakit Universitas Airlangga Surabaya ]]>
<![CDATA[Day Rahmania]]>;
<![CDATA[Andri Permana Wicaksono]]>;
<![CDATA[Novita Nuraini]]>
<![CDATA[ J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 2 No 1 (2020): December ]]>
Publisher : <![CDATA[Politeknik Negeri Jember ]]>
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DOI: 10.25047/j-remi.v2i1.2113
<![CDATA[Filling room has an important role in maintaining medical records, especially in terms of storage and protection of medical records. The creation of officers ease in taking and storing medical records in supported by the existence of an ergonomic storage space that is adapted to the anthropometric aspects. The design of the storage rack in accordance with the anthropometric data of the officer can facilitate the work of the officers. Storage racks at Airlangga University Hospital are not in accordance with the anthropometry of the officers, resulting in work discomfort and fatigue. The purpose of this study was to analyze the ergonomics aspects of the storage rack based on the anthropometry of the filling officer. This type of research is descriptive and data collection is done by observation. The population of this study was 5 filing officers. The results of this study indicate that the condition of the storage rack in the filling room of the Airlangga University Hospital is not in accordance of the filling officer. The anthropometry of the filling officer used in designing the rack, namely the reach of the hand up to 202 cm, is used to measure the height of the medical record file storage rack, data fathom length 162 cm is used to reference the length of the medical records file storage rack and shoulder width data used to reference the distance between medical record file storage rack.]]>
<![CDATA[Evaluasi Implementasi Aplikasi Primary Care (P-Care) dengan Menggunakan Metode Task Technology Fit di Puskesmas Patrang Kabupaten Jember Tahun 2019 ]]>
<![CDATA[Inggil De Crystal]]>;
<![CDATA[Sustin Farlinda]]>;
<![CDATA[Novita Nuraini]]>;
<![CDATA[Andri Permana Wicaksono]]>
<![CDATA[ J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 4 (2020): September ]]>
Publisher : <![CDATA[Politeknik Negeri Jember ]]>
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DOI: 10.25047/j-remi.v1i4.2127
<![CDATA[Puskesmas Patrang merupakan salah satu puskesmas yang sudah menggunakan aplikasi Primary Care (P-Care). Aplikasi ini digunakan untuk mengentrikan data sosial, data pemeriksaan pasien dan pembuatan surat rujukan untuk pasien BPJS. Dalam pelaksanaannya masih ditemui berbagai kendala yang dialami oleh pengguna,yaitu seperti aplikasi p-care yang mengalami error,  pembuatan surat rujukan hanya dilakukan oleh 1 petugas serta pengguna harus melakukan double entry data guna untuk kebutuhan laporan yang dibutuhkan oleh puskesmas. Tujuan dari penelitian ini adalah mengevaluasi implementasi aplikasi Primary  Care dengan  menggunakan   metode  TTF  (Tasks Technology Fit) . Jenis penelitian ini adalah penelitian kualitatif dengan pendekatan deskriptif. Hasil evaluasi implementasi aplikasi Primary care  di Puskesmas Patrang menunjukkan bahwa dari 5 responden menyatakan karakteristik tugas sudah sangat baik, semua tugas yang dilakukan sudah terfasilitasi disetiap menu aplikasi. Kriteria karakteristik dalam penerapan teknologi yang digunakan sudah baik, meskipun ketersediaannya belum merata. Kriteria kesesuaian tugas yang dirasakan oleh pengguna sudah sesuai dengan teknologi yang digunakan. Kriteria kebermanfaatan diperoleh bahwa pengguna merasakan butuh dengan aplikasi ini. Serta kriteria dampak kinerja dalam penerapan aplikasi ini yaitu ini sudah dirasakan dengan baik. Upaya penambahan kebutuhan pendukung seperti komputer dan scanner, penggunaan SIMPUS serta pembuatan SOP perlu diterapkan agar implementasi aplikasi primary care bisa berjalan dengan baik.]]>
<![CDATA[Analisis Beban Kerja Petugas Filling Rekam Medis Rawat Jalan dengan Metode WISN di RSU Haji Surabaya Tahun 2020 ]]>
<![CDATA[Nur Hasanah Ayu Purnamawati]]>;
<![CDATA[Novita Nuraini]]>;
<![CDATA[Yuni Astuti]]>
<![CDATA[ J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 2 No 1 (2020): December ]]>
Publisher : <![CDATA[Politeknik Negeri Jember ]]>
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DOI: 10.25047/j-remi.v2i1.2139
<![CDATA[Surabaya Haij General Hospital is one of the type B educational hospitals that has stored medical record files in the filling room. Surabaya Hajj General Hospital has 37 Outpatient Clinics with the number of visits in 2020 is 93,232 patients with an average number of old patient visits per day is 890.14 patients and the average number of new patient visits per day is 42.18 patients (Haji Hospital Surabaya, 2018) with 95.48% of old patients to the total number of outpatient visits. Outpatient filling is obtained that there are still a lot of outpatient medical records file that have been scattered or not yet entered on the filling rack. The purpose of this study is to analyze the workload of outpatient filling staff with the Work Load Indicator Staff Need (WISN) method at RSU Haji Surabaya in 2020. This research uses descriptive research type, with the method of observation and interview of 6 outpatient medical records filling officers. The object of this study is the workload of medical records filling officers. The results showed that the calculation of available working time for outpatient filling staff was 113,100 minutes / year, the main activities of outpatient filling staff at RSU Haji Surabaya were 44 minutes, Standard workload for outpatient filling officers at RSU Haji Suarabaya was 49,952 files / year, Standard allowance for outpatient filling staff at Surabaya Haji Hospital is 0.195 hours / year, with the results of the WISN calculation is 8 officers and a WISN ratio of 19.6.]]>
<![CDATA[Analisis Pelaksanaan Sensus Harian Rawat Inap di RSUD Dr. Saiful Anwar Malang ]]>
<![CDATA[Ferly Ferly]]>;
<![CDATA[Rossalina Adi Wijayanti]]>;
<![CDATA[Novita Nuraini]]>
<![CDATA[ J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 4 (2020): September ]]>
Publisher : <![CDATA[Politeknik Negeri Jember ]]>
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DOI: 10.25047/j-remi.v1i4.2163
<![CDATA[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.]]>
<![CDATA[Analisis Prioritas Penyebab Belum Terlaksananya Retensi dan Pemusnahan Dokumen Rekam Medis Rawat Inap di RS Mitra Medika Bondowoso Tahun 2019 ]]>
<![CDATA[Futari Ayu Istikomah]]>;
<![CDATA[Novita Nuraini]]>;
<![CDATA[Feby Erawantini]]>;
<![CDATA[Efri Tri Ardianto]]>
<![CDATA[ J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 4 (2020): September ]]>
Publisher : <![CDATA[Politeknik Negeri Jember ]]>
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DOI: 10.25047/j-remi.v1i4.2212
<![CDATA[Regulation of health ministry 2018 number 269 on Medical Record stated that the records of medical patient care inpatient in hospital must be kept at least five (5) years on a period since the date of the last patient treated or discharged. Since the Mitra Medika Bondowoso Hospital was found in 2011 the implementation of retention and destruction of medical record documents has never been carried out. This research was aimed to analyze and know the priority cause unimplementation retention and destruction of documents recording the medical -patient hospitalization by USG (Urgency, Seriousness, and Growth) and brainstorming in Mitra Medika Bondowoso Hospital. Type of this research is that qualitative and the technique collection of data by interviews, observation, documentation, and brainstorming. The results were obtained that the priority of the cause unimplementation of retention and destruction of documents medical record that is the double job of the medical record employees, Retention archive schedule in SOPs, and a lack of understanding of the medical record employees with SOP retention and extermination. The improvement efforts for the problems are to add more medical record employees and to build more teamwork between the employees. Another solutions are to make new SOP recently with the addition of the retention archive schedule as well as involving the employees in the preparation of SOPs.]]>
