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All Journal Jurnal Kesehatan Komunitas Jurnal Kesehatan Indonesia Jurnal Maternitas Kebidanan Contagion: Scientific Periodical Journal of Public Health and Coastal Health Jurnal Ilmiah Keperawatan Imelda Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Indonesian Journal of Health Information Management Services (IJHIMS) Jurnal Ilmiah Pengabdian Kepada Masyarakat
Esraida Simanjuntak
Universitas Imelda Medan
Computer Science & IT Decision Sciences, Operations Research & Management Dentistry Economics, Econometrics & Finance Health Professions Medicine & Pharmacology Nursing Public Health Social Sciences

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Journal : Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI)

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Tinjauan Aspek Ergonomi Pada Ruang Penyimpanan Berdasarkan Standart Nasional Akreditasi Rumah Sakit (SNARS) Edisi 1 Di RSU Tere Margareth Medan Tahun 2020 Esraida Simanjuntak; Ermas Estiyana; Septi Anastasya
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Vol. 7 No. 1 (2022): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Februari
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v7i1.693

Abstract

In SNARS edition 1, it is known that medical record documents in paper or electronic form must be kept safe and confidential so they must be stored in a location that is protected from water, fire, heat, and other damage and protected from interference with access and unauthorized use. The purpose of this study was to determine the ergonomics aspect based on the National Standard for Hospital Accreditation (SNARS) Edition 1. The method used was observation and interviews with a descriptive type of research located at Tere Margareth General Hospital Medan in July 2020. The population in this study was the physical aspect. Ergonomics and medical records officers in the storage room as many as 2 people using the total sampling technique. is the storage room for medical record files at the Tere Margareth hospital that does not meet accreditation standards because there are still problems that occur related to room security which can be assessed based on the standard of ergonomic aspects. Ask the hospital to pay more attention to the state of the medical record storage room in order to meet the standard assessment elements of information management and medical records in SNARS Edition 1.
GAMBARAN STRESS KERJA PETUGAS REKAM MEDIS BAGIAN DISTRIBUSI DI RSUP H. ADAM MALIK MEDAN Esraida Simanjuntak
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Vol. 5 No. 1 (2020): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Februari
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v5i1.343

Abstract

ABSTRAK Stress kerja dapat dialami oleh semua orang tanpa terkecuali pekerja di rumah sakit dan merupakan konsekuensi dari peristiwa di tempat kerja yang menuntut keterlibatan fisik dan psikis karyawan secara berlebihan (Triatna, 2015). Stress kerja yang berlangsung secara terus menerus dapat menyebabkan perubahan emosional dan perilaku seperti mudah tersinggung dan sulit berkonsentrasi, sehingga dapat menurunkan motivasi kerja seseorang dan berakibat pada penurunan kualitas kerja. Tujuan Penelitian ini untuk mengetahui gambaran stress kerja petugas rekam medis bagian distribusi di RSUP H. Adam Malik Medan. Jenis penelitian yang dilakukan adalah deskriptif kualitatif. Sampel yang digunakan peneliti dengan mengambil seluruh petugas distribusi yang berjumlah 5 orang. Variabel penelitian adalah suatu atribut atau sifat orang yang mempunyai variasi tertentu yang ditetapkan oleh peneliti, instrumen penelitian berupa kuesioner yang diberikan kepada responden untuk melihat gambaran stress kerja petugas rekam medis bagian distribusi. Analisis data pada penelitian ini disajikan dalam bentuk tabel distribusi. Hasil penelitian yang dilakukan terhadap 5 responden bahwa mayoritas stress kerja dapat disimpulkan bahwa sebanyak 4 responden (80%) mengalami stress kerja, dan minoritas stress kerja sebanyak 1 responden (20%). Dari hasil penelitian diatas dapat disimpulkan bahwa gambaran stress kerja petugas rekam medis bagian distribusi di RSUP H. Adam Malik Medan mayoritas mengalami stress kerja. Saran peneliti kepada pihak rumah sakit agar memberikan fasilitas berupa alat pengangkut barang kepada petugas rekam medis dibagian distribusi untuk mempermudah pengiriman berkas rekam medis ke poliklinik dan hal ini dapat mengurangi beban kerja petugas rekam medis dalam mengangkat barang berat.
TINJAUAN PELAKSANAAN PEMELIHARAAN DOKUMEN REKAM MEDIS DI RUANGAN FILLING RUMAH SAKIT DR.PIRNGADI MEDAN TAHUN 2019 Esraida Simanjuntak; Rizka Mei Shella
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Vol. 5 No. 2 (2020): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Agustus
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v5i2.394

Abstract

Maintenance of medical record documents is a combination of various activities undertaken to maintain documents and production facilities including other production equipment or to repair them to a condition that is well accepted. Physical danger is damage to documents caused by sunlight, rain, flood, heat and humidity. Chemical hazard is document damage caused by food, beverages, and chemicals. Biological hazard is document damage caused by rats, cockroaches, and termites. The purpose of this study is to describe the implementation of maintenance of medical record documents in the room Dr. hospital filling Pirngadi Medan in 2019. This type of research is a description of the interview and observation methods. The place of research was conducted at Dr. Pirngadi Medan due to the inability of maintaining medical record documents. When the study was conducted in March-April 2019. Population and samples used were all medical record storage officers, amounting to 3 people. Based on the results of the study, there were still racks that used wood and did not use rool o'pack cabinets, there are damaged medical record documents that have not been replaced with new ones due to lack of cover inventory. The temperature and humidity of the room in the storage room are less controlled. The conclusion of this study is that the maintenance of medical record documents has not been carried out because the shelves are still made from wood and the lack of storage rack facilities make medical records documents partially placed under the floor. The suggestion from this research is that it is better to use a rool o'pack cupboard and keep the air conditioner on for 24 hours according to the theory.
Tinjauan Pelaksanaan Review Berkas Rekam Medis Sesuai Standar Manajemen Informasi Dan Rekam Medik (MIRM 13.4) Di Rumah Sakit Imelda Pekerja Indonesia Tahun 2020 Esraida Simanjuntak; Mustamil Alwi Dasopang
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Vol. 6 No. 1 (2021): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Februari
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v6i1.476

Abstract

One of the parameters for determining the quality of health services in the hospital is data or information from good and complete medical records. Medical records are an important part of helping the implementation of service delivery to patients at the hospital. Standards relating to medical records in SNARS Edition 1 are in the group of hospital management standards, namely Medical Record Information Management (MIRM) regarding medical record document processing including provision, filling of medical records and reviewing medical records. This research method is descriptive with the method of observation. When this research was conducted in July 2020 at the Imelda Hospital Worker Indonesia Medan. The population taken was 705 medical record documents while the sample in this study was 87 medical record documents. Based on the results of the study, in the review the accuracy of returning medical record documents was 57.4% and 42.5% were incorrect. Readability review of ER assessment as much as 63.2%, assessment of Inpatient as much as 56.3%, CPPT as much as 60.9%, approval for action as much as 77%, reports of anesthesia as much as 68.9%. 3 forms of completeness review are complete, namely Education Assessment, rejection and education form (100%). Suggestions in this study are that review officers must be more assertive to remind every doctor or other medical personnel to pay attention to the accuracy of the restoration, the legibility of medical record files and the completeness of medical record documents. As well as regularly socializing the elements of the MIRM 13.4 assessment.
Tinjauan Sistem Penyelenggaraan Rekam Medis Menurut Standart Akreditasi Puskesmas di Puskesmas Pangakalan Berandan Tahun 2020 Esraida Simanjuntak; Fajar Insani
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Vol. 6 No. 2 (2021): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Agustus
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v6i2.587

Abstract

Puskesmas are required to maintain medical records containing data and information on patient care. Implementation according to accreditation standards, namely criteria 3.2 Registration Process and 3.8 Administration of medical records which are divided into 3.8.1 Coding, 3.8.2 Medical Record Access Rights 3.8.3 Clinical Information Filling and 3.8.4 Storage. The purpose of the study was to find out the implementation of the medical record management system according to the Puskesmas accreditation standards at the Pangkalan Berandan Health Center in 2020. This type of research was qualitative with a Phenomenology approach. The place of research was conducted at the Pangkalan Berandan Health Center. Time of study in July 2020. Research population is all medical record officers at the Pangkalan Berandan Health Center. The research sample is 5 officers. The research instrument was interview guide and check list sheet for observation. The results of the study revealed that the outpatient registration process had been carried out according to criteria 3.2 but there was no inpatient numbering of medical records. Coding was not carried out according to criteria 3.8.1, namely the absence of coding SOPs carried out by doctors using ICD 10, Medical Record Access Rights were carried out according to criteria 3.8. 2 but the implementation is not fully carried out in accordance with the SOP, the lending process is not recorded in the expedition book, Assembling is in accordance with criteria 3.8.3 but recording corrections are carried out using stip-ex and the storage process has been carried out according to criteria 3.8.4 but retention is not carried out according to the guidelines legislation. It is recommended for registration to give medical record numbers to inpatients, coding to make SOPs and given coding training, access rights to medical records to record loans in expedition books, assembling to be given socialization in terms of correcting recording of medical record files and storing tracers as well as in the retention process. given socialization about the implementation of retention.
Review Rekam Medis Pasien Ruang Isolasi Covid-19 RSU Imelda Pekerja Indonesia Tahun 2020 Mei Sryendang Sitorus; Esraida Simanjuntak; Valentina Valentina
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Vol. 7 No. 2 (2022): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Agustus
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v7i2.988

Abstract

Quantitative Analysis is a review of certain parts of the contents of medical records to find deficiencies, especially those related to the documenting of medical records. Coronavirus Disease 2019 (Covid-19) is an infectious disease caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARSCoV-2). The purpose of this study is to find out the implementation of the Covid-19 Isolation Room Patient Medical Record Document Review at RSU Imelda Pekerja Indonesia in 2020. The population is all patients treated in the Covid-19 Isolation Room in 2020 as many as 182 people, the study sample is all patients treated in the Covid-19 Isolation Room in October as many as 48 people. The DRM review was conducted on four variables. From the results of the study obtained that the Review of Timeliness of appropriate DRM Returns as much as 35.41%; Review of the Accuracy of Filling out DRM for the exact Opname Warrant Form (SPO) 31.25%, the appropriate IGD Assessment Form 52.08%, the right Medical Resume Form 100%, and the proper Observation Form 66.67%; DRM Readability Review for Opname Warrant Form (SPO) which reads 100%, IGD Assessment Form that reads 77.08%, Medical Resume Form that reads 100%, and Observation Form that reads 72.92%; Drm Completeness Review for Screening Form found in 68.75% of documents, Triage Form found in 77.08% documents, Internal Transfer Form found on 89.58% of documents, Discharge Planning Form found on 81.25% of documents.For General Consent Forms, Inpatient Assessments, CPPT Forms, Observation Forms, and Information and Education Forms are found in all documents that are 100%. It is recommended that the existing SPO socialization prioritizes the accuracy of filling out medical records qualitatively, not limited to the completeness of the form only.
Co-Authors Ani Soraya Azizah Putri Syafa Harahap Erlindai Ermas Estiyana Fajar Insani Hesti Despita Siregar Johanna Christy Linfia Isti Zenika Hulu Mei Sryendang Mei Sryendang Sitorus Mustamil Alwi Dasopang Rizka Mei Shella Septi Anastasya Siti Permata Sari Lubis Siti Permata Sari Lubis Valentina Valentina Valentina valentina valentina Zulham Andi Ritonga