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All Journal Jurnal Kesehatan Masyarakat Jurnal Riset Kesehatan Jurnal Penelitian Kesehatan Suara Forikes Jurnal Wiyata : Penelitian Sains dan Kesehatan Jurnal Kesehatan Jurnal Manajemen Informasi Kesehatan Indonesia (JMIKI) Jurnal Pengabdian Masyarakat IPTEKS Jurnal Aisyah : Jurnal Ilmu Kesehatan Infokes : Jurnal Ilmiah Rekam Medis dan Informasi Kesehatan J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan

Novita Nuraini

Politeknik Negeri Jember

Author-ID : 2629202

Religion Humanities Computer Science & IT Health Professions Medicine & Pharmacology Nursing Public Health Social Sciences Veterinary Other

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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

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

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

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

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 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

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