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All Journal Jurnal Buana Informatika Jurnal Penelitian Kesehatan Suara Forikes Jurnal Kesehatan Jurnal Aisyah : Jurnal Ilmu Kesehatan J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Jurnal Rekam Medik & Manajemen Informasi Kesehatan (RAMMIK) JMMR (Jurnal Medicoeticolegal dan Manajemen Rumah Sakit)

Demiawan Rachmatta Putro Mudiono

Jurusan Kesehatan, Politeknik Negeri Jember

Author-ID : 2843418

Computer Science & IT Dentistry Economics, Econometrics & Finance Health Professions Medicine & Pharmacology Nursing Public Health Veterinary

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Analisis Penyebab tidak Ditemukannya Dokumen Rekam Medik Bagian Riset RSUPN dr. Cipto Mangunkusumo Jakarta Widiyanto Widiyanto; Gamasiano Alfiansyah; Demiawan Rachmatta Putro Mudiono
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 3 (2020): June
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v1i3.2046

Provision of medical record documents in the medical record research center Dr. Hospital CiptoMangunkusumo is still not in accordance with the number of requests needed, in October there were 4,836requests, 3,953 documents were available, in November there were 3,823 requests and 2,977 documentswere available, in December there were 4,151 requests and 3,143 documents were available. The purpose ofthis study was to analyze the absence of medical record documents in the research section. This type ofresearch is a qualitative study using interview, observation and documentation data collection techniquesinvolving 3 respondents. The results of the study showed that the cause of the absence of medical recorddocuments was that the officers' knowledge was still low, the attitude of the officers who were still lacking indiscipline, supporting facilities and infrastructure were lacking and there was no motivation. Improvementefforts to overcome these problems are providing training, disciplinary officers need to be improved, do systemdesign, provide awards and conduct monitoring and evaluation.

Analisis Faktor Penyebab Keterlambatan Pengembalian Berkas Rekam Medis Rawat Jalan di RSUPN Dr. Cipto Mangunkusumo Rizky Farah Dilla; Demiawan Rachmatta Putro Mudiono; Gamasiano Alfiansyah
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 4 (2020): September
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v1i4.2085

Keterlambatan pengembalian berkas rekam medis dapat mempengaruhi pelayanan rekam medis dan akan menghambat kegiatan selanjutnya, seperti kegiatan assembling, koding, analisis, indeks. Pengembalian berkas rekam medis rawat jalan di RSUPN Dr. Cipto Mangunkusumo masih mengalami keterlambatan. Pada bulan januari sampai dengan februari total berkas rekam medis rawat jalan yang terlambat sebanyak 282 berkas (0,016%) dari 17.616 berkas. Tujuan dari penelitian adalah menganalisis faktorÂ penyebab keterlambatan pengembalian berkas rekam medis rawat jalan di RSUPN Dr. Cipto Mangunkusumo. Jenis penelitian yang digunakan adalah kualitatif. Teknik pengumpulan data berupa wawancara dan observasi. Subjek penelitian ini adalah Kepala Rekam Medis, Petugas Penanggung Jawab Operasional Unit Rekam Medis, Petugas Filling, Petugas Pengembalian Berkas. Penelitian Â dilakukan pada bulan februari sampai bulan maret 2020. Hasil dari penelitian yang didapatkan yaitu pengetahuan dan sikap beberapa petugas masih belum paham dengan SOP pengembalian berkas rekam medis dan kepatuhan sikap petugas pengembalian masih kurang baik. Sarana dan prasarana sudah mendukung, hanya kurangnya ketelitian pada sumber daya petugas pengembalian. Sudah diberikan motivasi oleh koordinator pelayanan Unit Rekam Medis, dan sudah terdapat (SOP) pengembalian berkas rekam medis. Upaya yang dilakukan adalah memberi tahu perawat tentang batas waktu pengembalian berkas rekam medis rawat jalan, kepala rekam medis memberi teguran kepada perawat yang terlambat mengembalikan berkas rekam medis, memberikan motivasi kerja dan sering melakukan sosialisasi SOP terkait pengembalian berkas rekam medis rawat jalan.

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

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

Perancangan dan Pembuatan Sistem Informasi Apotek di Puskesmas Banjarsengon Mahardika Nugraha; Niyatul Muna; Andri Permana Wicaksono; Demiawan Rachmatta Putro Mudiono
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.v2i4.2447

Banjarsengon public health center is one of the health agencies that deal with patient care and treatment. The pharmacy section of the Banjarsengon Health Center in carrying out registration, recording medical records, drug data collection and managing reports is still done manually. In addition, data collection errors are often encountered which can lead to inaccurate reporting data. The purpose of this research is to solve problems in drug data collection by designing a pharmacy information system at the Banjarsengon health center. The making of pharmacy information system application was using Microsoft Visual Studio 2019. System development was using waterfall method. Data collections consist of observation, interviews and documentation. The result of black box testing showed that this pharmacy information system can operate properly. The advantages are the pharmacy information system been integrated with the operation of pharmacists and management that can reduce the possibility of errors that affect the service to patients, improve the efficiency of the drug recording system quickly and accurately, facilitate pharmacists in recording, reduce and add drug stock automatically and also print reports in pdf form.

Evaluasi Penerapan SIMRS Ditinjau Dari Aspek Kualitas Informasi, Penggunaan Sistem dan Organisasi di RSU Dr. H. Koesnadi Bondowoso Demiawan Rachmatta Putro Mudiono; Moch. Choirur Roziqin
Jurnal Kesehatan Vol 7 No 3 (2019): Desember
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-kes.v7i3.94

Sistem Informasi Manajemen Rumah Sakit (SIMRS) adalah bagian dari sistem informasi kesehatan yang menyediakan sumber informasi yang relevan dan akurat di setiap unit rumah sakit. Berdasarkan hasil survey pada instansi rawat inap dan pendaftaran, hasil yang didapat yaitu permasalahan pada aspek manusia. Pengguna SIMRS sering mengalami kesalahan informasi pada aplikasi SIMRS mengenai tersedianya kamar yang diperoleh dari unit rawat inap. Permasalahan tersebut sesuai dengan temuan dilapangan bahwa komponen manusia yaitu perilaku pengguna SIMRS masih kurang baik. Permasalahan yang ada pada organisasi adalah pihak manajemen telah memberikan pelatihan terhadap pengguna sistem, akan tetapi pelatihan yang diberikan oleh pihak manajemen dirasa masih kurang. Berdasarkan masalah diatas, evaluasi penerapan SIMRS dengan aspek kualitas informasi, penggunaan sistem dan organisasi di Dr RSU. H. Koesnadi Bondowoso diperlukan. Tujuan Penelitian ini adalah untuk mengevaluasi penerapan SIMRS dengan aspek kualitas informasi, organisai dan penggunaan sistem. Jenis penelitian menggunakan penelitian explanatory dengan desain penelitian crossectional. Teknik sampling menggunakan disproportionate stratified random sampling. Analsis data menggunakan SEM dengan program PLS. Hasil penelitian ini terdapat pengaruh langsung antara variabel kualitas informasi dengan variabel penggunaan sistem; tidak ada pengaruh langsung antara variabel kualitas informasi dengan variabel organisasi dan tidak ada pengaruh tidak langsung antara variabel kualitas informasi dengan variabel penggunaan sistem melalui variabel organisasi. Saran untuk penelitian lebih lanjut yaitu terdapat penambahan variabel yang mendukung keberhasilan SIMRS dan penentuan model goodness of fit. Saran untuk rumah sakit yaitu perlu pelatihan secara berkala dan merata serta perlu penetapan SOP pengoperasian SIMRS disetiap unit.

Sistem Pakar Diagnosis Typoid Fever dan Dengue Fever Berbasis Web Andri Permana Wicaksono; Demiawan Rachmatta Putro Mudiono
Jurnal Kesehatan Vol 7 No 3 (2019): Desember
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-kes.v7i3.126

Negara Indonesia salah satu negara tropis. Curah hujan yang tinggi dengan kepadatan penduduk di wilayah Indonesia menghasilkan berbagai banyak penyakit. Salah satu penyakit yang sering muncul adalah penyakit yang diakibatkan oleh infeksi dan parasit tropis. Penyakit yang tergolong dengan infeksi dan parasit yang sering di negara Indonesia yaitu Thypoid fever dan Dengue fever. Sistem pakar adalah inovasi terbaru dalam mendeteksi kondisi awal. Sistem pakar dapat diimplementasikan di sektor kesehatan, salah satunya adalah sistem diagnosis ahli yang berguna untuk mendiagnosis penyakit dengan gejala demam pada manusia dengan melihat karakteristik dan gejala yang dialami pasien. Penelitian ini bertujuan untuk mendiagnosis demam tifoid dan Dengue Fever yang disebabkan oleh gejala demam pada pasien. Metode penelitian ini adalah metode penelitian pengembangan dengan menggunakan metode sanders yang meliputi definisi masalah, analisis sistem, perancangan sistem, dan implementasi sistem. Hasil penelitian ini, menggunakan metode dempster shafer untuk menentukan penilaian terhadapat penyakit Typoid fever dan dengue Fever sehingga dari hasil tersebut mendapatkan nilai kekauratan dengan persentase penyakit typoid fever mencapai 93% dan dengue fever mencapai 94% dapat digunakan sebagai referensi untuk keakuratan diagnosis untuk mencegah penyakit Typoid Fever dan Dengue Fever.

Determinan Ketepatan Kode Diagnosis Utama di RS Pusat Pertamina Jakarta Selatan Nada Savira Nurjannah; Demiawan Rachmatta Putro Mudiono; Sustin Farlinda; Djasmanto Djasmanto
Jurnal Rekam Medik & Manajemen Informasi Kesehatan Vol. 1 No. 1 (2022): April
Publisher : Indonesian Journal Publisher

The inaccuracy of the main diagnosis code will have an impact on the hospital in terms of financing and the quality of the information produced. This can also be influenced by the accuracy of writing the main diagnosis. The purpose of this study was to determinants of the accuracy of the main diagnosis code in the discharged summary of inpatient in February 2022 at Pertamina Central Hospital by paying attention to several components, namely the clarity of writing the main diagnosis and the accuracy of the main diagnosis code. The method used is descriptive qualitative. The total sample is 130 of inpatient discharged summary sheets from a total of 463 medical record files in February 2022. The results showed that 42% discharge summary sheets were not clear in writing the main diagnosis and 86% the main diagnosis code did not correct. It is suggested that the hospital can improve the evaluation of the accuracy of filling in the code and writing the main diagnosis in the summary of discharge, holding training and seminars related to doctor's compliance with the ICD-10 code, and socializing how to enforce the code and write a diagnosis according to the ICD-10 rules.

Analisis Singkatan Dan Simbol Terhadap Formulir Discharge Summary Rawat Inap Untuk Penilaian Akreditasi Snars Mirm (12) Periode Februari Di Rumah Sakit Pusat Pertamina Jakarta Selatan Livia Nuri Syafitri; Demiawan Rachmatta Putro Mudiono; Sustin Farlinda; Djasmanto Djasmanto
Jurnal Rekam Medik & Manajemen Informasi Kesehatan Vol. 1 No. 1 (2022): April
Publisher : Indonesian Journal Publisher

Recording in SNARS Edition 1 is included in the Hospital Management Standards group on Information and Record Management (MIRM), one of the medical standards in MIRM, namely the standardization of diagnosis codes, procedure/action codes, symbols, abbreviations, and their meanings contained in the MIRM 12 standard. Where in the assessment element, the hospital must have regulations on standardizing diagnosis codes, procedure/action codes, definitions, symbols used and which should not be used, abbreviations used and which should not be used, and monitored their implementation. Pertamina Central Hospital is a referral hospital and accredited B. Where this hospital becomes the Presidential Hospital. Medical Records used in the form of Electronic and Manual Medical Records. On the Medical Record Form in the application there are abbreviations and symbols. In the use of abbreviations and symbols, socialization has been carried out which contains a guideline entitled "The RSPP abbreviation list book" but in its implementation no evaluation has been carried out. And also there are SOPs that state the existence of abbreviations, symbols, actions and diagnostic codes. In the period of February, there were 463 hospitalized patients. And researchers took samples of medical record number 132 medical records from 30% of the number of inpatients using the formula of slovin. This is a qualitative research using direct observation and documentation methods. The results of observation and study documentation show that the abbreviations that are not appropriate are 45%, 67% for symbols and 55% appropriate for summary form releases, The book of abbreviations and symbols belonging to Pertamina Central Hospital has not yet been legalized and socialized legally. And there is no SOP in accordance with SNARS MIRM 12 for abbreviations and symbols at Pertamina Central Hospital. There is also no evaluation in the implementation of the use of abbreviations and symbols as well as the books used, there are still not several symbols and abbreviations listed in the abbreviation and symbol guidelines in the Rspp.

Analisis Berkas Rekam Medis Rawat Inap Pada Kasus Operasi Di Rumah Sakit Pusat Pertamina Jakarta Selatan Nungki Annisa Pratiwi; Demiawan Rachmatta Putro Mudiono; Djasmanto Djasmanto
Jurnal Rekam Medik & Manajemen Informasi Kesehatan Vol. 1 No. 1 (2022): April
Publisher : Indonesian Journal Publisher

Based on the results of observations made at Pertamina Central Hospital, it was found that several inpatient medical record file forms, especially in cases of surgery, were related to filling out forms that were not 100% complete and there was no evaluation of the completeness of inpatient medical record files in surgical cases. The purpose of this study was to analyze the completeness of inpatient medical record files, especially cases of surgery at Pertamina Central Hospital in February 2022. This research method used qualitative descriptive. Sampling using the Slovin formula with a population of 200 and the sample results obtained 67 samples. The results of this study obtained that the completeness of filling out the medical record file operation form in the complete category was 43 medical record files (64%) and 24 medical record files were incomplete (36%). The conclusion of this study is that the completeness of inpatient medical record files in surgical cases, especially related to filling out forms at Pertamina Central Hospital is categorized as incomplete because filling out forms is not 100% complete.

Analisis Faktor Penyebab Ketidaklengkapan Resume Medis Rawat Inap di Puskesmas Cermee Bondowoso Siti Alifa Lufianti; Rossalina Adi Wijayanti; Demiawan Rachmatta Putro Mudiono; Indah Muflihatin
Jurnal Rekam Medik & Manajemen Informasi Kesehatan Vol. 1 No. 2 (2022): Oktober
Publisher : Indonesian Journal Publisher

The patient's medical resume form is a summary of the entire period of patient care and treatment as has been attempted by health workers and related parties. Based on a preliminary study in March 2021, researchers obtained data information on incomplete medical resume forms, the highest incompleteness was found in the identification component, which was 86.7%, the next incompleteness was in the Authentication component, which was 80%, the next incompleteness was in the Authentication component. important reports that is equal to 56.7%. The purpose of this study was to analyze the factors causing the incomplete filling of the patient's medical resume form. This type of research uses qualitative research, the subject of this research consists of 1 head of puskesmas, 3 inpatient doctors, and 1 medical record officer, the object of this research is to use an inpatient medical resume form to determine the factors that cause incomplete medical resume forms. inpatient. The results found in this study are that the first priority is that there is no SOP (Standard Operational Procedure) regarding filling out medical resumes, so it is determined efforts to make SOPs for filling out medical resumes in accordance with medical record service standards

Co-Authors alifia tirta ramadhanti Andri Permana Wicaksono Atma Deharja Bakhtiyar Hadi Prakoso Cindy Kurnia Ressa Fransiska Djasmanto Djasmanto Erna Selviyanti Erna Selviyanti Erna Selviyanti Fajria Nur Rahmah Feby Erawantini Gamasiano Alfiansyah Gamasiano Alfiansyah Gandu Eko Julianto Suyoso Indah Muflihatin Insani Dzakirah Livia Nuri Syafitri Mahardika Nugraha Maya Weka Santi Maya Weka Santi Maya Weka Santi Mitha Audia Rachma Moch. Choirur Roziqin Nada Savira Nurjannah Niyatul Muna Novita Nuraini Nungki Annisa Pratiwi Rachmawati, Ervina Rizky Farah Dilla Rossalina Adi Wijayanti Selvia Juwita Swari Selvia Juwita Swari Siti Alifa Lufianti Sustin Farlinda Tamami Alifia Annisa Veronika Vestine Widha Alamanda Widiyanto Widiyanto

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