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Novita Nuraini
Politeknik Negeri Jember
Religion Humanities Computer Science & IT Health Professions Medicine & Pharmacology Nursing Public Health Social Sciences Veterinary Other

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Analisis Penyebab Keterlambatan Pengembalian Berkas Rekam Medis Rawat Jalan di Rumah Sakit Mitra Medika Bondowoso Adlien Rizqo Fadillah; Novita Nuraini; Feby Erawantini; Ervina Rachmawati
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.v2i1.2213

Abstract

The delay in returning medical record file can affect medical record service and will hampered further activities, such as assembling, coding, analysis, or index activities. The return of outpatient medical records in Mitra Medika Bondowoso Hospital is still experiencing delays. In the first quarter of 2019 the total number of late outpatient medical records was 871 out of 7404 files or 11.76%. The purpose of the study was to analyze the causes of the delay in returning the outpatient medical record file at Mitra Medika Hospital. This research using qualitative research. To gather all of the important data the researchers using various techniques such as interview, observation, and documentation. The subjects of this study were 1 head of medical record, 1 medical record officer, and 5 poly nurses. The results of this study that there was still lack of knowledge and attitude, inadequate infrastructure or facilities. There was no motivation given by the head of the medical record, and the SOPs about the returning of outpatient medical record files had never been socialized. Things that can be taken are making an efforts to socialize SOPs to increase knowledge of health professionals, giving a warning from the head of medical records to nurses who are late returning medical record files, redesigning outpatient expedition books, providing work motivation and updated SOPs related to returning medical record files outpatient.
ANALISIS FAKTOR KINERJA PENGISIAN DOKUMEN REKAM MEDIS RAWAT INAP KLINIK dr. M. SUHERMAN JEMBER Aditya Dwi Arimbi; Selvia Juwita Swari; Novita Nuraini; Indah Muflihatin; Gamasiano Alfiansyah
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.v1i2.2238

Abstract

Percentage of incompleteness of filling in the medical records of the Clinic Dr. M. Suherman shows thatthe Minimum Service Standards in the Hospital are not yet 100%. Incomplete data has shown that thecompleteness of filling medical record documents is still not in accordance with the specified standards.The incompleteness of filling out the medical record document may be caused by the performance factorof the officer in completing the inpatient medical record document. The purpose of this study is to analyzethe performance factors in filling out the record documents. The purpose of this study was to analyze theperformance factors in filling out medical records of inpatients at the Clinic dr. M. Suherman Jember. Thisstudy uses qualitative research that aims to identify and analyze performance factors in filling inpatientmedical record documents at the Clinic dr. M. Suherman Jember, who will be associated with performancetheory with personal factors, leadership factors, team factors, system factors, and situational factors, andusing the USG (Urgency, Seriousness, Growth) method to determine the main factors of the 5 factors thataffect performance as well as efforts to correct problems using brainstorming. The results of this studyobtained priority causes of the incompleteness of filling medical records documents for inpatients at theClinic dr. M. Suherman Jember is the lack of awareness of each individual related to filling medical recorddocuments, lack of evaluation and monitoring, lack of socialization, lack of understanding related to SOPfor filling medical record documents because there is no SOP for filling medical record documents, so theClinic, Dr. M. Suherman asked researchers to make SOPs for filling in the records of inpatients. As asuggestion, do a commitment to complete the completeness of filling medical record documents, conductsocialization, evaluation and routine monitoring, as well as making SOP for filling medical recorddocuments.
ANALISIS KUALITATIF DOKUMEN REKAM MEDIS RAWAT INAP PADA PASIEN TUBERKULOSIS PARU Novita Nuraini; Demiawan Rachmatta Putro Mudiono; Mitha Audia Rachma
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.v1i2.2240

Abstract

Qualitative analysis is a review of filling medical records relating to the consistency of the contents of the medicalrecord. A good medical record must contain complete medical records. This study aims to analyze qualitativeinpatient Medical Record Documents (DRM) in pulmonary tuberculosis patients in Tongas Probolinggo RegionalHospital in the first quarter of 2017. This research type is descriptive with a qualitative approach with datacollection techniques of observation and interviews. The results of this study are that there are still documentson pulmonary tuberculosis medical records at Tongas Probolinggo Regional Hospital which are still incompleteand inaccurate. One of them is in the administrative qualitative analysis, which is the incomplete patient addresswriting100%, because nurses pay less attention and remind patients / guardians in filling out informed consentsheets. In addition, medical staff did not apply 100% of the writing of the tuberculosis standard abbreviationcontained in the SOP of the Tongas Hospital Standard Standard, because there was still a lack of socializationfrom the RM unit to medical personnel related to the use of the tuberculosis standard abbreviation. In aqualitative medical analysis, there were no X-ray examination results on patients who had X-ray examinationsas many as 19 documents, because in Tongas Regional Hospital did not have an examination result sheet, sothe results of the examination were not written in the DRM. So the quality of DRM in patients with pulmonarytuberculosis both administratively and medically is still not good. It is better if the accuracy and discipline ofmedical staff are needed in filling DRM
TINGKAT PENERIMAAN DAN PENGGUNAAN SISTEM INFORMASI MANAJEMEN PUSKESMAS KABUPATEN JEMBER Sedyo Pinerdi; Efri Tri Ardianto; Novita Nuraini; Ida Nurmawati
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.v1i2.2242

Abstract

The district health office of Jember conducted a trial of operating SIMPUS in 20 puskesmas, but only 16puskesmas operated the SIMPUS. The district health office of Jember will be announced at the end of 2019SIMPUS will be fully operated in 50 puskesmas throughout the Jember district. This study is aimed to describethe level of acceptance and use of the Puskesmas management information system using the Theory ofAcceptance and Use of Technology (UTAUT) method. This study discusses the variables of performanceexpectancy, effort expectancy, sosial influence, facilitating conditions, behavioral intention, and the usebehavioral of SIMPUS users that are spread across 16 public health platforms in the District Health Office ofJember. This type of research is observational descriptive. The data analysis technique used is descriptive.The results of this study were that the officers were quite confident that they would get ease while workingusing SIMPUS (55.9%), the work became easy when the officers used SIMPUS (69.5%), the head of thepuskesmas and health offices supported the use of SIMPUS (73,7%), the facilities and infrastructure providedcan support the use of SIMPUS (58.5%), officers wish to use SIMPUS in the near future (70.3%), and officersuse SIMPUS when working (65.3%). The district health office of Jember needs to operate SIMPUS again andincrease server capacity so that the acceptance and use of SIMPUS increases.
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.
PERANCANGAN DAN PEMBUATAN WEBSITE PUSKESMAS NOGOSARI DENGAN MENGGUNAKAN METODE WATERFALL Haris Hammaminata; Feby Erawantini; Novita Nuraini; Gamasiano Alfiansyah
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.v2i2.2260

Abstract

Submission of information at Nogosari Public Health Center was done by sticking announcements in the cornerof the wall and bulletin board. Nogosari Public Health Center’s queue registration system was still offline-based.People could only get this information and take the queue if they came to the public health center. This researchaimed to design and create Nogosari Public Health Center’s website using waterfall method. The approach ofthis research was Research and Development (R & D). Data collection techniques used interviews andobservations. The analysis unit of this research were the head of the Nogosari Public Health Center Jember, ahealth promotion officer, an environmental health officer, a surveillance officer, a KIA-KB-Nutrition serviceofficer, a medical record officer, and 2 patients in Nogosari Public Health Center Jember. The results showedNogosari Public Health Center’s website accompanied by additional features include online queuing features,suggestion box facilities, and question and answer pages. Suggestions from researchers are the system shouldbe developed into an integrated service system by adding customize features to existing services. NogosariPublic Health Center Jember need a domain host so that this website can be accessed by the internet.
Upaya Perbaikan Keterlambatan Pengajuan Klaim BPJS Kesehatan Pada Unit Rawat Inap di RSIA Srikandi IBI Jember Tahun 2019 Elsa Mayori; Atma Deharja; Novita Nuraini; Maya Weka Santi
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.v2i4.2301

Abstract

Based on a preliminary study at RSIA Srikandi IBI Jember, there was a delay in submitting claim health BPJS to the inpatient unit over the next ten months. The delay in submitting claim health BPJS as many as 28 days with 353 inpatient files (57,5%) in January 2019, while February as 31 days with 249 inpatient files (78,3%) and March 29 days with 313 inpatient files (75,0%).It would harm hospital finances because of delays in the payment of health BPJS funds. This research aimed to improve the delay claim of health BPJS in inpatient units at RSIA Srikandi IBI Jember. This research used a qualitative method with interviews, observation, questionnaires, and brainstorming to collect data methods. This research showed that the cause of delay in submitting claims health BPJS by material factor was incomplete inpatient claim such as medical resume, the result of examinations. The Plan made SOP submit requests claims BPJS to the inpatient unit, the checklist of BPJS document, and SOP to verify the completeness and accuracy to the inpatient claim. The Do stage accepts the SOP to the hospital director. Stage of Check is to see the result of implementation claim health BPJS to the inpatient unit in February-April 2020, and that showed a decrease in the number of delays in submitting claims health BPJS at the hospital. Action steps were known that these efforts could help the BPJS health claims process.
Strategi Percepatan Waktu Distribusi Dokumen Rekam Medis di RSU dr. H. Koesnadi Bondowoso Isye Isyanti Dewi; Feby Erawantini; dr. Novita Nuraini; Gamasiano Alfiansyah
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.v2i4.2456

Abstract

Pendistribusian dokumen rekam medis adalah suatu kegiatan mendistribusikan dokumen rekam medis ke poliklinik setelah pasien registrasi. Keterlambatan pendistribusian dokumen rekam medis rawat jalan sering dijumpai pada kegiatan penyelenggaraan rekam medis. Batas waktu pendistribusian dokumen rekam medis rawat jalan di RSU dr. H. Koesnadi Bondowoso yaitu ≤ 10 menit setelah pasien mendaftar. Data keterlambatan yang dilakukan pada survey awal bulan November 2019 mencapai 53,5%. Tujuan dari penelitian ini adalah menyusun strategi untuk melakukan perbaikan keterlambatan pendistribusian dokumen rekam medis rawat jalan di RSU dr. H. Koesnadi Bondowoso. Penelitian ini merupakan penelitian kualitatif dengan metode Action Research. Teknik pengumpulan data menggunakan wawancara mendalam, observasi dan brainstorming. Hasil penelitian ini diketahui bahwa faktor penyebab keterlambatan pendistribusian dokumen rekam medis rawat jalan yaitu pengetahuan petugas tentang SOP kurang, kedisiplinan petugas yang masih kurang disiplin, tidak terdapat petugas khusus pendistribusian dokumen rekam medis, tidak terdapat tracer pada rak penyimpanan, petugas filing tidak pernah mendapatkan reward dari pimpinan dan belum pernah diadakan sosialisasi SOP. Berdasarkan hal tersebut upaya penyelesaian masalah yang peneliti sarankan pada pihak RSU dr. H. Koesnadi Bondowoso dengan merevisi SOP dan sosialisasi SOP secara berkala.
Analisis Faktor Penyebab Ketidaksesuaian Pencatatan Sensus Harian Rawat Inap dengan SIMRS di RSU dr. H. Koesnadi Bondowoso Isye Isyanti Devi; dr. Novita Nuraini; Feby Erawantini; Dony Setiawan Hendica P
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 3 No 1 (2021): Desember
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v3i1.2469

Abstract

Pencatatan sensus harian rawat inap adalah kegiatan pencatatan atau perhitungan pasien yang dilakukan setiap hari pada instalasi rawat inap. Informasi dari sensus harian rawat inap dibutuhkan oleh rumah sakit sebagai dasar pengambilan keputusan bagi pihak manajemen sehingga kegiatan sensus harian rawat inap harus dilaksanakan dengan benar agar data yang dihasilkan akurat dan dapat digunakan. Diketahui RSU dr. H. Koesnadi Bondowoso ditemukan permasalahan ketidaksesuaian pencatatan sensus harian rawat inap dengan SIMRS. Data tertinggi ketidaksesuaian pencatatan sensus harian rawat inap dengan SIMRS terjadi pada ruang Teratai bulan Juni yaitu 37%. Tujuan dari penelitian ini adalah menganalisis faktor penyebab serta melakukan upaya perbaikan masalah ketidaksesuaian pencatatan sensus harian rawat inap dengan SIMRS di RSU dr. H. Koesnadi Bondowoso. Jenis penelitian ini menggunakan kualitatif dengan teori kinerja Robbins (Motivation, Opportunity, Ability). Teknik pengumpulan data menggunakan wawancara mendalam, observasi, dokumentasi, dan brainstorming. Hasil penelitian ini diketahui bahwa faktor penyebab ketidaksesuaian pencatatan sensus harian rawat inap dengan SIMRS yaitu dari faktor Motivation pemberian reward dan punishment kurang maksimal, faktor Opportunity yaitu pengetahuan admin tentang SOP kurang, tidak ada pelatihan pencatatan sensus harian rawat inap, dan faktor Ability terkait pengetahuan admin memiliki perbedaan persepsi dalam mencatat sensus harian rawat inap dan kedisiplinan admin masih kurang teliti dan tertib dalam mencatat. Berdasarkan hal tersebut upaya penyelesaian masalah yang peneliti sarankan pada pihak RSU dr. H. Koesnadi Bondowoso dengan merevisi SOP dan dilakukan sosialisasi, serta pelatihan terkait pencatatan sensus harian rawat inap.
TINJAUAN KELENGKAPAN PENGISIAN SERTIFIKAT PENYEBAB KEMATIAN DI RUMAH SAKIT : LITERATURE REVIEW Fitriani Fitriani; Ervina Rachmawati; Novita Nuraini; Indah Muflihatin
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 3 No 3 (2022): June
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v3i3.2526

Abstract

The death cause's certificate is used to document the major cause of the death and to identify the mortality circumstance that used to inform about the health policy and to enhance the strategy of the death prevention and recording. The purpose of this study is to investigate the percentage of completeness towards the filling of the cause of death certificate and to know the factor causing the incompleteness towards the filling of the death cause's certificate. This type of study is the literature review with 11 selected journals according to the inclusion criteria. There are four components in the analysis of the completeness towards the filling of the death cause's certificate namely, patient identification, important report, author authentication, and good recording. In the result of the study, the lowest percentage component was found in the important report at 55.96% and the highest percentage component was found in the author's authentication at 93.72%. The most dominant factor in the incompleteness towards the filling of the death cause's certificate is due to the absence of SOP and the excessive number of components in the death cause's certificate. The suggestion for future researchers is they might redesign the death cause’s certificate by attaching the sections or columns as needed.
Co-Authors Aditya Dwi Arimbi Adlien Rizqo Fadillah Afrizal Noor Abidin Aghasi Hana Faradila Agni Candramawa Sholikha Ahmad Shofi Nur Kholili Ana Nafidatul Khoiroh Andri Permana Wicaksono Angga Rahagiyanto Angga Rahagiyanto Ariqpurna Bayu Triatmaja Arisanty Nur Setia Restuti Atika Mima Amalin Atma Deharja Atma Deharja Aulia Nurul Kholifah Avivah Nur Aini Dahlia Indah Amareta, Dahlia Indah Day Rahmania Demiawan Rachmatta Putro Mudiono Desnia Sindi Damayani Dewi Soviatus Zahro Dinda Darmawati Donny Adhasari Hasan Dony Setiawan Hendica P Efri Tri Ardianto Ellena Berliani Elsa Mayori Feby Erawantini Ferly Ferly Fitriani Fitriani Futari Ayu Istikomah Gamasiano Alfiansyah Gamasiano Alfiansyah Haris Hammaminata Hikmah, Faiqatul Hikmatus Surur Ika Rahmadhani Indah Muflihatin Inggil De Crystal Isye Isyanti Devi Isye Isyanti Dewi Maya Weka Santi Meiranda Normarisa Azis Mitha Amelia Rahmawati Mitha Audia Rachma Muhammad Yunus Najla Kamil Nashrul Kholiqir Rohman Nazilla Ade Nurlia Novita Yuken Nur Aulia Nur Aprilia Setyoyuni Nur Hasanah Ayu Purnamawati Nuril Amalia nurmawati, ida Puput Puji Lestari Rachmawati, Ervina Riskha Dora Candra Dewi Rosita Prananingtias Rosita Prananingtias Rossalina Adi Wijayanti Sari, Estu Pratika Sedyo Pinerdi Selvia Juwita Swari Septiya Atik Cahyani Siti Wafiroh Sustin Farlinda Yulianti, Adhiningsih Yuni Astuti