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All Journal Jurnal Informasi Kesehatan Indonesia (JIKI)
Rivaldi Indra Nugraha
Magister Sistem Informasi, Universitas Diponegoro
Health Professions Nursing Public Health

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Tinjauan Proses Pembuatan Laporan Internal Rekam Medis Di Rumah Sakit Umum Anna Medika Madura Angga Ferdianto; Nutfah Kamila; Rivaldi Indra Nugraha
Jurnal Informasi Kesehatan Indonesia (JIKI) Vol 7 No 2 (2021): Jurnal Informasi Kesehatan Indonesia (JIKI)
Publisher : Politeknik Kesehatan Kemenkes Malang (State Health Polytechnic of Malang)

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31290/jiki.v7i2.2994

Abstract

Background: Internal reports of medical records are reports that are made as input to formulate the basic design concept of a hospital management information system. The accuracy of filling in the internal reports of medical records at Anna Medika Madura's Hospital is 60% out of 100%. The purpose of study is to review the process of making internal reports on medical records at Anna Medika Madura General Hospital Subjects and Method: This research design used descriptive method with a qualitative approach. The subjects of study were reporting officers and medical record officers, while the object of study were the internal reports of medical record and the process of making internal reports of medical records. How to collect data observation and interviews. The technique used purposive sampling. Results: Inaccuracies of internal reports of medical records up to 40% in the operating room unit, 50% in the labor room unit, and 30% in the daily census, so that the inaccuracy of internal reports of medical record must be controlled. The inaccuracy factor was that there were still officers who are inconsistent (man), and there was no SOP (method), and has been fulfilled (machines), which had a negative impact on the process on internal reports of medical records. Conclusion: Supposed to make SOP related to the preparation, control, and accuracy of filling internal medical records, conducting evaluations and disseminating information to officers regarding the importance of accuracy in filling internal medical records. Keywords: Accuracy, Delay, Internal reports of medical record.
Tinjauan Proses Pembuatan Laporan Internal Rekam Medis Di Rumah Sakit Umum Anna Medika Madura Angga Ferdianto; Nutfah Kamila; Rivaldi Indra Nugraha
Jurnal Informasi Kesehatan Indonesia (JIKI) Vol 7 No 2 (2021): Jurnal Informasi Kesehatan Indonesia (JIKI)
Publisher : Politeknik Kesehatan Kemenkes Malang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31290/jiki.v7i2.2994

Abstract

Latar Belakang: Laporan internal rekam medis disusun untuk memenuhi rancangan dasar sistem informasi manajemen rumah sakit. Ketepatan pengisian laporan internal rekam medis di RSU Anna Medika Madura sebesar 60% dari 100%. Tujuan dari penelitian adalah Meninjau proses pembuatan laporan internal rekam medis di RSU Anna Medika Madura. Subjek dan Metode: Subjek penelitian adalah 1 petugas pelaporan dan 1 petugas rekam medis sedangkan objek penelitian adalah laporan internal rekam medis dan proses pembuatan laporan internal rekam medis. cara pengumpulan data observasi dan wawancara. Pengambilan sampel menggunakan teknik purposive. Desain penelitian menggunakan metode deskriptif dengan pendekatan kualitatif. Hasil: Ketidaktepatan laporan internal rekam medis mencapai 40% pada unit kamar operasi, 50% pada unit kamar bersalin, dan 30% pada sensus harian sehingga harus dilakukan pengendalian ketidaktepatan laporan internal rekam medis. faktor ketidaktepatan yaitu masih ada petugas yang tidak konsisten (man), belum adanya SOP (method), dan sudah terpenuhi (machine), hal tersebut berdampak terhadap proses laporan internal rekam medis menjadi terlambat. Kesimpulan: Ketidaktepatan pengsian laporan internal rekam medis dipengaruhi oleh beberapa faktor, yaitu faktor: man, money, method, materials dan machine
Co-Authors Angga Ferdianto Nutfah Kamila