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Technology Acceptance Model to Implementation of Electronic Medical Record (EMR’s) at Clinic of Rumah Sehat Keluarga Jember Atma Deharja; Meiranda Normarisa Azis; Novita Nuraini; Angga Rahagiyanto; Maya Weka Santi; Muhammad Yunus
Jurnal Aisyah : Jurnal Ilmu Kesehatan Vol 7, No 4: December 2022
Publisher : Universitas Aisyah Pringsewu

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (860.343 KB) | DOI: 10.30604/jika.v7i4.1370

Abstract

The Rumah Sehat Keluarga Clinic is one of the clinics in Jember that has just implemented electronic medical records (RME) at the end of October 2020. Based on observations made on January 4, 2021, at the Rumah Sehat Keluarga Clinic, it is known that there are several obstacles in implementing the electronic medical record system. outpatient treatment indicating that analysis is necessary. This study aims to analyze the application of outpatient electronic medical records at the Rumah Sehat Keluarga Clinic. Identification of problems using the TAM (Technology Acceptance Model) method by reviewing aspects of external variables, aspects of perceived usefulness, aspects of perceived ease of use, and aspects of behavioral intention to use. This type of research is qualitative with data collection methods, namely interviews, observation, documentation and brainstorming. The subjects of this study are the head of the clinic and the medical record officer. The results showed that based on aspects of external variables, several constraining factors were obtained including the absence of guidelines for using RME for new or old users and there was a diagnosis menu that had not been integrated with the ICD 10 database. Aspects of perceived usefulness, namely the use of electronic medical records in the clinic made the work of the officers faster and more efficient. The perceived ease of use aspect showed that receiving electronic medical records is considered easy to understand, flexible enough with the work of officers and easy to use to help work. Based on the aspect of behavioral intention to use, even though there are several obstacles in its application, outpatients show interest in RME and they will use it in the future. Abstrak: Klinik Rumah Sehat Keluarga baru menerapkan Rekam Medis Elektronik (RME) pada akhir Oktober 2020. Berdasarkan pengamatan terdapat kendala dalam penerapannya yang menunjukkan perlu dilakukan analisis. Tujuan penelitian ini untuk menganalisis penerapan rekam medis elektronik rawat jalan Klinik Rumah Sehat Keluarga. Identifikasi permasalahan menggunakan metode TAM (Technology Acceptance Model) dengan meninjau dari aspek variable luar (external variable), aspek kebermanfaatan (perceived usefulness), aspek kemudahan (perceived ease of use), dan aspek minat (behavioral intention to use). Jenis penelitian ini kualitatif dengan metode pengumpulan data yaitu wawancara, observasi, dokumentasi dan brainstorming. Subjek penelitian ini adalah kepala klinik dan petugas rekam medis. Hasil penelitian menunjukkan bahwa berdasarkan aspek variabel luar (external variable) diperoleh faktor kendala diantaranya tidak adanya panduan penggunaan RME bagi pengguna baru atau lama dan terdapat menu diagnosis yang belum terintegrasi dengan database ICD 10. Aspek kebermanfaatan (perceived usefulness) yaitu penggunaan rekam medis elektronik di klinik membuat pekerjaan petugas menjadi lebih cepat dan efisien. Aspek kemudahan (perceived ease of use) menunjukkan dalam penerimaan rekam medis elektronik dinilai mudah dipahami, cukup fleksibel dengan pekerjaan petugas serta mudah digunakan untuk membantu pekerjaan. Berdasarkan aspek minat (behavioral intention to use) yaitu petugas rawat jalan menunjukkan minatnya terhadap RME serta berencana menggunakannya di masa yang akan datang.
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

Abstract

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.
Penyebab Terjadinya Duplikasi Nomor Rekam Medis di Puskesmas Pandanwangi Kota Malang Avivah Nur Aini; Gamasiano Alfiansyah; Novita Nuraini; Muhammad Yunus
Jurnal Penelitian Kesehatan SUARA FORIKES 2022
Publisher : FORIKES

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33846/sf13nk447

Abstract

Duplication of medical record numbers has an impact on writing errors in the patient's medical history, especially in the patient's referral letter, so it takes time to correct it, while the patient has to wait a long time. This study aims to analyze the factors that cause duplication of medical record numbers at the Pandanwangi Health Center based on Gibson's performance theory. This type of research was qualitative with interview techniques, observation and documentation. The results of the study were based on individual factors, not all officers knew about the numbering system, the educational qualifications of the officers had not met the standards, the officers had been working for more than two years. Based on organizational factors, facilities and infrastructure had not been used optimally, there was no evaluation from superiors, there was no standard operating procedure for numbering, there was already an organizational structure. Based on psychological factors, rewards or punishments in the form of praise or reprimand, the officer's attitude was less than optimal.Keywords: unit numbering system; duplication; public health center ABSTRAK Duplikasi nomor rekam medis berdampak pada kesalahan penulisan riwayat penyakit pasien terutama pada surat rujukan pasien, sehingga membutuhkan waktu untuk membetulkan, sedangkan pasien harus menunggu lama. Penelitian ini bertujuan untuk menganalisis faktor penyebab terjadinya duplikasi nomor rekam medis di Puskesmas Pandanwangi berdasarkan teori kinerja Gibson. Jenis penelitian ini adalah kualitatif dengan teknik wawancara, observasi dan dokumentasi. Hasil penelitian berdasarkan faktor individu, tidak semua petugas mengetahui tentang sistem penomoran, kualifikasi pendidikan petugas belum memenuhi standar, lama kerja petugas sudah lebih dari dua tahun. Berdasarkan faktor organisasi, sarana dan prasarana belum maksimal penggunaannya, tidak ada evaluasi dari atasan, tidak ada standar prosedur operasional penomoran, sudah terdapat struktur organisasi. Berdasarkan faktor psikologis, penghargaan atau hukuman berupa pujian atau teguran, sikap petugas kurang maksimal.Kata kunci: sistem penomoran unit; duplikasi; puskesmas
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

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (1347.033 KB) | DOI: 10.30604/jika.v6i2.484

Abstract

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.
Analisis Faktor Risiko Gagal Ginjal Kronis Berdasarkan Rekam Medis Pasien Rawat Inap di RSUD Blambangan Banyuwangi Ervina Rachmawati; Anisah Mahshunah; Novita Nuraini; Indah Muflihatin
ARTERI : Jurnal Ilmu Kesehatan Vol 7 No 2 (2026): Februari
Publisher : Puslitbang Sinergis Asa Professional

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37148/arteri.v7i2.657

Abstract

Chronic kidney disease is a condition in which the structure or function of the kidneys slowly declines over several months to years, this has the potential to cause permanent kidney damage. Cases of chronic kidney disease at the Blambangan Regional General Hospital, cases of chronic kidney disease morbidity always rank in the top 10 diseases and mortality cases always increase in 2021-2023. This study aims to analyze risk factors for chronic kidney disease between age, gender, family history, history of diabetes mellitus, history of hypertension, history of obesity, and history of smoking habits. Data collection uses observation of medical records. The research sample consisted of 94 case samples and 94 control samples using simple random sampling technique. Data analysis used univariate and bivariate with chi square test with α 0.05. The results showed that the age variable (p value = 0.036), family history (p value= 0.001), history of diabetes mellitus (p value = 0.020), history of hypertension (p value = 0.003), history of obesity (p value= 0.005), and a history of smoking habits (p value = 0.016) was associated with the incidence of CKD. While the gender variable (p value = 0.883) was not associated with the incidence of CKD. This study concludes that those aged ≥ 50 years with, a family history, history of diabetes mellitus, history of hypertension, history of obesity, and history of smoking habits are at risk of developing CKD. Health workers need to provide education to the community, especially at-risk populations such as people aged ≥ 50 years and have a family history of CKD who are advised to control blood sugar, blood pressure, and body weight, and avoid smoking habits
Analisis Penyebab Keterlambatan Retensi dan Pemusnahan Rekam Medis Rumah Sakit Citra Husada Digna Hastika Nandita; Gamasiano Alfiansyah; Novita Nuraini; Selvia Juwita Swari
Health & Medical Sciences Vol. 1 No. 1 (2023): November
Publisher : Indonesian Journal Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.47134/phms.v1i1.661

Abstract

Rumah Sakit Citra Husada terlambat dalam pelaksanaan retensi dan pemusnahan rekam medis. Berdasarkan studi pendahuluan pada 20 Juli 2022 di Rumah Sakit Citra Husada, bahwa retensi rekam medis belum optimal dan pemusnahan rekam medis tahun 2012 sampai sekarang belum dilaksanakan. Penelitian ini bertujuan untuk menganalisis faktor-faktor penyebab keterlambatan retensi dan pemusnahan rekam medis di Rumah Sakit Citra Husada. Penelitian ini merupakan jenis penelitian kualitatif, pengumpulan data melalui wawancara, observasi, dan USG. Variabel dalam penelitian ini yaitu personal factors, leadership factors, team factors, system factors, dan situational factors. Hasil penelitian ini, keterlambatan retensi dan pemusnahan rekam medis disebabkan kurangnya pengetahuan petugas, petugas masih ada yang berlatar belakang pendidikan bukan RMIK, staf rekam medis belum pernah mengikuti pelatihan, kapasitas ruang dan rak penyimpanan rekam medis inaktif penuh, kurangnya alat scanner, petugas kesusahan membaca diagnosa dalam mengisi daftar pertelaan, tidak terdapat alat pemusnah rekam medis inaktif, dan petugas melakukan double job. Hasil USG prioritas masalah yaitu petugas melakukan double job.
Perancangan Aplikasi Pelayanan Kesehatan (SIP-KES) di Nutrition Care Center Berbasis Android Sonia Putri Haris Fadilah; Novita Nuraini; Niyalatul Muna; Muhammad Yunus
Health & Medical Sciences Vol. 1 No. 1 (2023): November
Publisher : Indonesian Journal Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.47134/phms.v1i1.676

Abstract

Berdasarkan hasil studi pendahuluan yang dilakukan di Nutrition Care Center ditemukan permasalahan yaitu pendaftaran dan pencatatan rekam medis dilakukan secara manual karena belum adanya sistem secara terkomputerisasi. Belum adanya sistem informasi di Nutrition Care Center dikarenakan keterbatasan personal computer dibagian pendaftaran, diruang asesmen gizi, dan di ruang konselor gizi. Permasalahan lainnya yaitu hasil pemeriksaan yang diberikan kepada pasien dalam bentuk kertas. Penelitian ini bertujuan untuk merancang dan membuat aplikasi pelayanan kesehatan (SIP-Kes) di Nutrition Care Center berbasis android. Kelebihan SIP-Kes dapat melakukan upload lembar InBody, pemilihan jenis lembar leafleat, dan dapat melakukan registrasi online. Metode yang digunakan adalah metode prototype dengan tahapan identifikasi kebutuhan user, membuat dan penyesuain prototype, membuat sistem, melakukan testing, menyesuaikan sistem, dan menggunakan sistem. Pembuatan SIP-Kes menggunakan bahasa pemrograman dart dengan framework flutter dan database Mysql. Didukung dengan penghitungan kepuasan pengguna terhadap SIP-Kes menggunakan metode skala likert dengan hasil range nilai tingkat kepuasan 4.2 – 5 termasuk dalam kategori sangat puas. Hasil penelitian ini dengan adanya SIP-Kes dapat mempermudah petugas dalam pelaksanaan pelayanan gizi di Nutrition Care Center.
Analisis Faktor Penyebab Ketidakakuratan Kode Diagnosis Utama Injury dan External causes pada Rekam Medis Rawat Inap di RSD dr. Soebandi Jember Novita Nuraini; Dyah Palupi Budiningsih; Maya Weka Santi; Dony Setiawan; Hendyca Putra
Manajemen Pelayanan Kesehatan Vol. 1 No. 4 (2024): October
Publisher : Indonesian Journal Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.47134/mpk.v1i4.6024

Abstract

The inaccurate coding of primary injury and external causes diagnoses is a classification issue in the ICD-10, posing risks of financial loss for hospitals and compromising the validity of statistical data. Between 2020 and 2022, the coding accuracy for inpatient injury diagnoses at RSD Dr. Soebandi Jember was 70%, while external100% inaccuracy because were not coded at all. This research aimed to analyze the factors causing inaccuracies in coding these diagnoses based on the Robbin performance theory and propose improvement strategies through brainstorming. In this qualitative study, data was collected through in-depth interviews, observations, and document analysis. Findings revealed ablity factor cause by the lack of Emergency Room physicians knowledge’s in completing injury case histories and discrepancies in medical terminology selection by attending physicians. Motivation factors were identified suboptimal reward and punishment systems, and the absence of feedback in evaluating medical record quality. The opportunity factor encompassed unclear task boundaries between coders and internal verifiers, and the coding process deviated from standard operating procedures (SOP). Suggestion to address these issues, re-socialization of SOPs related to coding procedures, advocating for appropriate reward and punishment, and organizing internal training on injury and external causes diagnosis coding.
Perancangan dan Pembuatan Sistem Penebusan Obat Berbasis Website di Instalasi Farmasi RSIA Muhammadiyah Kota Probolinggo Arga Kanya Dhanastra; Mochammad Choirur Roziqin; Novita Nuraini; Angga Rahagiyanto
Manajemen Pelayanan Kesehatan Vol. 1 No. 4 (2024): October
Publisher : Indonesian Journal Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.47134/mpk.v1i4.6025

Abstract

The long waiting time is due to the large number of prescriptions that must be served by the staff, the writing of the prescription is unclear and incomplete (for example: dose, amount, and patient name) so that the pharmacy staff must confirm it first with the doctor who wrote the prescription, this is because Doctors' knowledge of the availability of medicines is not well confirmed and doctors write prescriptions for medicines that are difficult for staff and patients to understand if they want to redeem medicines again. To overcome this problem, a drug redemption information system is needed. Research and development with data collection through interviews, observation, and documentation was used as the research method. The development method used is waterfall by pressman which consists of the stages of system requirements analysis, system design, coding and testing. This research produces a website-based drug redemption information system at the RSIA Muhammadiyah pharmacy installation in Probolinggo City which has advantages including redeeming medication electronically using a prescription given by a doctor, medication redemption can be done anywhere and then you can choose to pick it up at the hospital or have it delivered. Home, chat with pharmacists in real time which aims to make it easier for patients to ask questions about medicines, and electronic prescriptions to reduce prescriptions that are difficult to read.
Analisis Penyebab Ketidakamanan dan Ketidakrahasiaan Rekam Medis di RS Perkebunan Jember Klinik Velynsa Diana Putri; Novita Nuraini; Maya Weka Santi; Sabran
Manajemen Pelayanan Kesehatan Vol. 2 No. 1 (2025): January
Publisher : Indonesian Journal Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.47134/mpk.v2i1.6087

Abstract

Rumah Sakit Perkebunan Jember Klinik memiliki masalah seperti rekam medis rawat inap menumpuk di lantai ruang filing, rata-rata persentase kerusakan map dalam satu subrak 16,86%, rata-rata persentase rekam medis rawat jalan tidak ditemukan setiap minggu pertama bulan Januari-Maret 2023 yaitu 0,29%, dan tenaga kesehatan selain perekam medis keluar masuk ruang filing. Tujuan penelitian ini untuk menganalisis penyebab ketidakamanan dan ketidakrahasiaan rekam medis di Rumah Sakit Perkebunan Jember Klinik berdasarkan faktor predisposisi, pemungkin, dan penguat menggunakan wawancara mendalam, observasi, dokumentasi, CARL, dan brainstorming. Hasil penelitian yaitu petugas filing sudah mengetahui keamanan, kerahasiaan, dan ruang penyimpanan rekam medis, tetapi belum menyeluruh. Selain itu, petugas filing belum membatasi akses makan dan minum di ruang filing, pendidikan formal terakhir petugas filing bukan pendidikan rekam medis, masalah sarana (alat pengukur suhu dan kelembapan, APAR, AC, alat pendeteksi api atau asap, dan pintu ruang filing), masalah prasarana (suhu ruang filing dan pengukuran suhu kelembapan), serta ketersediaan dan kondisi fasilitas belum memadai. Saran yang diberikan yaitu kepala rekam medis diharapkan membatasi akses makan dan minum di ruang filing, menata ruangan, memperbaiki AC, membeli alat pengukur suhu dan kelembapan, dan mengikutsertakan petugas filing dalam pelatihan
Co-Authors Aditya Dwi Arimbi Adlien Rizqo Fadillah Afrizal Noor Abidin Aghasi Hana Faradila Agni Candramawa Sholikha Ahmad Shofi Nur Kholili Akulina Wilanti Alfina Farah Damayanti Ana Nafidatul Khoiroh Andri Permana Wicaksono Angga Rahagiyanto Angga Rahagiyanto Anisah Mahshunah Arga Kanya Dhanastra Ariqpurna Bayu Triatmaja Atika Mima Amalin Atma Deharja Atma Deharja Aulia Nurul Kholifah Avivah Nur Aini Azmia Hanna Zahda Bakhtiyar Hadi Prakoso Dahlia Indah Amareta, Dahlia Indah Day Rahmania Demiawan Rachmatta Putro Mudiono Desnia Sindi Damayani Dewi Risdayanti Dewi Soviatus Zahro Digna Hastika Nandita Dinda Darmawati Donny Adhasari Hasan Dony Setiawan Dony Setiawan Hendica P dony setiawan hendyca putra Dwi Nur Setyowati Dyah Palupi Budiningsih Efri Tri Ardianto Ellena Berliani Elsa Mayori Erna Selviyanti Feby Erawantini Ferly Ferly Fitriani Fitriani Futari Ayu Istikomah Gamasiano Alfiansyah Gamasiano Alfiansyah Gandu Eko Julianto Suyoso Haris Hammaminata Hendyca Putra Hikmah, Faiqatul Hikmatus Surur Ika Rahmadhani Ikhda Latifatun Indah Feby Kusuma Wardani Indah Muflihatin Inggil De Crystal Isye Isyanti Devi Isye Isyanti Dewi Kuni Adilata Maya Weka Santi Meiranda Normarisa Azis Mitha Amelia Rahmawati Mitha Audia Rachma Mochammad Choirur Roziqin Mudafiq Riyan Pratama Muhammad Yunus Najla Kamil Nashrul Kholiqir Rohman Nazilla Ade Nurlia Nelly Yanti Nindasari Okta Imelda Niyalatul Muna Novita Indriyani Novita Yuken Nur Aulia Nur Aprilia Setyoyuni Nur Hasanah Ayu Purnamawati Nuril Amalia Nuril Firdausiah nurmawati, ida Puput Puji Lestari Rachmawati, Ervina Restuti, Arisanty Nur Setia Rika Furi Retnoningrum Riskha Dora Candra Dewi Rita Maulana Rosita Prananingtias Rosita Prananingtias Rossalina Adi Wijayanti Rossalina Wijayanti Roudhotul Falah Sabran Sabran Sandi Nur Azizah Sanuri Istiqamah Sari, Estu Pratika Savira Puteri Wulandari Sedyo Pinerdi Selvia Juwita Swari Septiya Atik Cahyani Sherin Laila Khaza Siti Wafiroh Sonia Putri Haris Fadilah Sustin Farlinda Tyas Errica Dewi Maharani Velynsa Diana Putri Veronika Vestine Vivi Sumarliyanti Ekowati Sugiyanto Yulianti, Adhiningsih Yuni Astuti