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Analisis Faktor Penyebab Ketidaklengkapan Rekam Medis Pasien Rawat Inap di Puskesmas Kotaanyar Dian Fadilah Ayu Lestari; Indah Muflihatin
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 2 No 1 (2020): December
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v2i1.2217

Abstract

Based on the results of a preliminary study conducted at the Kotaanyar Public Health Center, 30 medical records of inpatients in April and May 2019 are known, which were identified based on patient identification, important reports and their authentication, the average overall number of incompleteness was 720 (53.08%). The incompleteness of the medical record has an impact which results of administrative and clinical data are not accurate, This incompleteness also creates a loss in fulfilling the patient's right to the contents of their medical record, obstruction of reporting activities and submission of claims and cause the quality of health services are low. This study aims are to analyze the factors causing incomplete medical records of inpatients, determining priority causes of problems using USG (Urgency, Seriousness, Growth) and remedial efforts are using brainstorming. This type of research uses qualitative and data collection by observation, interviews, questionnaires and documentation. The results obtained that the priority cause of the incomplete medical records problem of inpatients are there is no SOP (Standard Operational Procedure). Efforts to fix the problem are making SOP, put the SOP in the inpatient unit where it can be reached, conduct socialization at any time and renew SOP according to the SOP renewal agreement.
ANALISIS FAKTOR KINERJA PENGISIAN DOKUMEN REKAM MEDIS RAWAT INAP KLINIK dr. M. SUHERMAN JEMBER Aditya Dwi Arimbi; Selvia Juwita Swari; Novita Nuraini; Indah Muflihatin; Gamasiano Alfiansyah
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.v1i2.2238

Abstract

Percentage of incompleteness of filling in the medical records of the Clinic Dr. M. Suherman shows thatthe Minimum Service Standards in the Hospital are not yet 100%. Incomplete data has shown that thecompleteness of filling medical record documents is still not in accordance with the specified standards.The incompleteness of filling out the medical record document may be caused by the performance factorof the officer in completing the inpatient medical record document. The purpose of this study is to analyzethe performance factors in filling out the record documents. The purpose of this study was to analyze theperformance factors in filling out medical records of inpatients at the Clinic dr. M. Suherman Jember. Thisstudy uses qualitative research that aims to identify and analyze performance factors in filling inpatientmedical record documents at the Clinic dr. M. Suherman Jember, who will be associated with performancetheory with personal factors, leadership factors, team factors, system factors, and situational factors, andusing the USG (Urgency, Seriousness, Growth) method to determine the main factors of the 5 factors thataffect performance as well as efforts to correct problems using brainstorming. The results of this studyobtained priority causes of the incompleteness of filling medical records documents for inpatients at theClinic dr. M. Suherman Jember is the lack of awareness of each individual related to filling medical recorddocuments, lack of evaluation and monitoring, lack of socialization, lack of understanding related to SOPfor filling medical record documents because there is no SOP for filling medical record documents, so theClinic, Dr. M. Suherman asked researchers to make SOPs for filling in the records of inpatients. As asuggestion, do a commitment to complete the completeness of filling medical record documents, conductsocialization, evaluation and routine monitoring, as well as making SOP for filling medical recorddocuments.
Analisis Kualitatif Sistem Pengendalian Berkas Rekam Medis di Puskesmas Mojoagung Kabupaten Jombang Anggun Citta Isvara Maharesi Putri; Rossalina Adi Wijayanti; Feby Erawantini; Indah Muflihatin
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 2 No 3 (2021): June
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v2i3.2271

Abstract

Based on the results of a preliminary study at the Mojoagung’s Public Health Center (Puskesmas), there was matter such as the use of expedition books for the unrecorded files caused the control system for the incompatible medical record. This research aims to analyze the control system for medical record file in Puskesmas of Mojoagung, while it delivers a qualitative study by using the approach of POAC (Planning, Organizing, Actuating and Controlling). The result consists of: (a) Planning, an inappropriate control system caused by the use of unsuitable expedition books; (b) Organizing, any double jobs and unclear job description; (c) actuating, no reward and punishment for officers and no guidance on the use of expedition books; (d) controlling, no evaluation from the leadership. Therefore, there are some suggestions that researcher recommends for Puskesmas of Mojoagung as follows: applying the expedition book and evaluating routinely once three months, providing guidance to the officer to use the expedition book correctly, giving insight on the importance of using expedition books and always reminding for briefing in the morning and socialization routinely, any clear job descriptions, reward to the officer if finishing the job well and reprimand if unfinished it, briefing in each of meeting on managing medical records in particular of the control system for the medical record file, and regular meetings once a month to evaluate or assess the performance of the medical records’ officer to achieve the stated goals.
TINJAUAN KELENGKAPAN PENGISIAN SERTIFIKAT PENYEBAB KEMATIAN DI RUMAH SAKIT : LITERATURE REVIEW Fitriani Fitriani; Ervina Rachmawati; Novita Nuraini; Indah Muflihatin
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 3 No 3 (2022): June
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v3i3.2526

Abstract

The death cause's certificate is used to document the major cause of the death and to identify the mortality circumstance that used to inform about the health policy and to enhance the strategy of the death prevention and recording. The purpose of this study is to investigate the percentage of completeness towards the filling of the cause of death certificate and to know the factor causing the incompleteness towards the filling of the death cause's certificate. This type of study is the literature review with 11 selected journals according to the inclusion criteria. There are four components in the analysis of the completeness towards the filling of the death cause's certificate namely, patient identification, important report, author authentication, and good recording. In the result of the study, the lowest percentage component was found in the important report at 55.96% and the highest percentage component was found in the author's authentication at 93.72%. The most dominant factor in the incompleteness towards the filling of the death cause's certificate is due to the absence of SOP and the excessive number of components in the death cause's certificate. The suggestion for future researchers is they might redesign the death cause’s certificate by attaching the sections or columns as needed.
ANALISIS PENYEBAB KETIDAKLENGKAPAN PENGISIAN INFORMED CONSENT DI RSUD dr. ABDOER RAHEM SITUBONDO Irene Anjar Pratiwi; Efri Tri Ardianto; Atma Deharja; Indah Muflihatin
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 3 No 3 (2022): June
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v3i3.2601

Abstract

The incompleteness of informed consent in general surgery cases inpatients at dr. Abdoer Rahem Situbondo hospital has an increase every month in the first trimester of 2019. The highest increase occurred in March, which was 74% from the previous 64% in February. Based on the Minister of Health of the Republic of Indonesia No. 129 of 2008, the minimum standard for filling out informed consent is 100%. The purpose of this research was to analyze the factors causing the incomplete filling of informed consent in inpatient general surgery cases at Dr. Abdoer Rahem Situbondo using Simamora's performance theory. The type of this research is qualitative analysis. The research design used is action research. Data collection techniques used were interviews, questionnaires, documentation, CARL (Capability, Accessibility, Readiness, Leverage), and brainstorming. The preliminary study was carried out from January to February 2020. Data collected were an inpatient general surgical case informed consent form, which had been returned to the medical record unit. The results obtained from this research are that there has never been an evaluation of informed consent’s incompleteness. No award was given for the performance of completeness informed consent. There has never been any learning such as a seminar or training on filling out the informed consent.
Daya Terima dan Kandungan Gizi Modisco dengan Penambahan Tepung Daun Kelor (Moringa oleifera) Galih Purnasari; Indah Muflihatin
Jurnal Kesehatan Vol 8 No 3 (2020): Desember
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-kes.v8i3.157

Abstract

Jumlah balita gizi buruk di Indonesia pada tahun 2018 masih di atas target SDG, sekitar 17,7%. Modisco (Modified Dietetic Skim dan Cotton Sheet Oil) adalah makanan tambahan yang mengandung kalori tinggi untuk meningkatkan berat badan balita. Penelitian ini bertujuan untuk menganalisis pengaruh penambahan tepung daun kelor terhadap daya terima dan kandungan gizi modisco. Desain eksperimental yang digunakan dalam penelitian ini adalah rancangan acak lengkap dengan penambahan konsentrasi tepung daun kelor dalam empat taraf, yaiu 0%, 2,5%, 5%, dan 7,5%. Penentuan produk modisco dipilih berdasarkan  tingkat kesukaan/preferensi panelis pada uji hedonik. Secara keseluruhan, modisco dengan skor tertinggi adalah modisco dengan penambahan tepung daun kelor 2,5%. Hasil uji Kruskal Wallis menunjukkan bahwa ada perbedaan yang signifikan dalam atribut warna, aroma, dan rasa (p = 0,00), tetapi tidak dalam atribut kekentalan (p = 0,340). Modisco terpilih dengan  penambahan bubuk daun kelor 2,5% memiliki kandungan energi, protein, zat besi, dan kalsium secara berurutan 80 kkal, 14,51 g, 6,3 g, 249 mg dalam 100 ml produk.
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

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (373.561 KB) | DOI: 10.47134/rmik.v1i2.21

Abstract

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
Peranan Penggunaan Early Detection of Stunting Terhadap Sikap Ibu dalam Melakukan Pemantauan Tinggi Badan Anak di Desa Kemuning Lor Indah Muflihatin; Andri Permana Wicaksono; Demiawan Rachmatta Putro Mudono
Jurnal Penelitian Kesehatan SUARA FORIKES Vol 14, No 1 (2023): Januari 2023
Publisher : FORIKES

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33846/sf14108

Abstract

Nutritional status in early childhood is very important, with one of the problems that is still high, namely stunting. One effort to overcome nutritional problems is by carrying out early detection, namely the EDOS (Early Detection of Stunting) application. So research is needed that aims to analyze the role of using EDOS in monitoring children's height. This quasy experimental study involved 40 mothers with toddlers, who were selected by total sampling technique. The measurement instrument is a child growth monitoring observation sheet. Based on the results of the logistic regression test, the p-value = 0.027 was obtained, which means that the EDOS application affects the awareness of mothers in monitoring children's height. It was concluded that EDOS is very useful in early detection and prevention of stunting.Keywords: stunting; application; attitude; toddler mother ABSTRAK Status gizi pada anak usia dini merupakan hal yang sangat penting, dengan salah satu masalah yang masih tinggi yaitu stunting. Salah satu upaya untuk mengatasi masalah gizi yaitu dengan melakukan deteksi dini yaitu dengan aplikasi EDOS (Early Detection of Stunting). Maka diperlukan penelitian yang bertujuan untuk menganalisis peranan penggunaan EDOS terhadap pemantauan tinggi badan anak. Penelitian ini quasy experimental ini melibatkan 40 ibu yang mempunyai balita, yang dipilih dengan teknik total sampling. Instrumen pengukuran adalah lembar observasi pemantauan pertumbuhan anak. Berdasarkan hasil uji regresi logistik didapatkan nilai p = 0,027 yang berarti bahwa aplikasi EDOS berpengaruh terhadap kesadaran ibu dalam memantau tinggi badan anak. Disimpulkan bahwa EDOS sangat bermanfaat dalam deteksi dini pencegahan stunting.Keywords: stunting; aplikasi; sikap; ibu balita
Analisis Faktor Penyebab Rendahnya Bed Occupancy Rate (BOR) di Balai Besar Kesehatan Paru Masyarakat Makassar Agus Salim; Ervina Rachmawati; Maya Weka Santi; Indah Muflihatin
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 4 No 4 (2023): September
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v4i4.3322

Abstract

The Bed Occupancy Rate (BOR) at the Makassar Community Lung Health Center in the last 3 years has decreased in 2018 by 64%, in 2019 by 62% and in 2020 by 52%. BOR is an indicator of health services that can be used to determine the level of quality, level of utilization of facilities and efficiency of health services. The impact of the decrease in BOR causes a decrease in economic income for the Hospital. The purpose of this study was to analyze the factors causing the low BOR at the Makassar Community Lung Health Center with (human resources), (facilities and infrastructure), (discipline of health care providers) and (problem improvement efforts. This study used qualitative research methods, with the intention of digging deeper into the factors causing the low BOR by using interview, observation, documentation and brainstorming techniques involving 3 informants including HRD, head of facilities and infrastructure and head of nursing.The results of this study indicate that the factor causing low BOR is the lack of resources. human nurses, facilities and infrastructure are not adequate, the discipline of health service providers is not consistent. The solution is that human resources need to be added to facilities and infrastructure that are immediately improved and complete the facilities and infrastructure that are not yet available.
Strategi Pencegahan Keterlambatan Pengembalian Dokumen Rekam Medis Rawat Jalan Poli KIA di Puskesmas Siliragung Kabupaten Banyuwangi Novita Nuraini; Dewi Candra Agustin; Dony Setiawan Hendyca Putra; Indah Muflihatin
Jurnal Penelitian Kesehatan SUARA FORIKES 2022
Publisher : FORIKES

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33846/sf13nk444

Abstract

According to the hospital's minimum service standards, the target for delays in returning medical record documents must reach 0% with 100% completeness of contents. The purpose of this study is to devise and implement strategies to prevent delays in returning medical record documents outpatient MCH poly. This type of research was qualitative using the PDCA method. The research subjects were medical record coordinators, medical record officers, MCH poly officers, DPJP, midwives, and heads of health center. Data were collected through interviews, observation, documentation studies, NGT and brainstorming. The validity test of the data was carried out by triangulating sources, time and techniques. The results of the research at the Plan stage were the identification of factors causing delays in DRM returns based on 5M, the man element, namely education that was still not in accordance with medical record qualifications, lack of knowledge of officers regarding DRM returns, lack of work experience due to a relatively new working period. The element of money was the insufficient budget for medical record facilities. The material element was that there are still incomplete DRM fillings. The machine element was that there were still problems with errors/slowness when inputting patient data on a computer/laptop, there was no telephone in the filing room, the use of expedition books was not optimal. The element of the method was that there was no SOP related to DRM returns and was also a priority problem with the proposed plan, namely making SOPs related to returning DRM and changing items in the expedition book. The do stage was carried out in April-May where before and after implementation there was a decrease. The Check stage had met the target so that the proposed planning activities could be continued in the action stage. The Action stage was validation and socialization regarding the SOP for returning DRM every month and optimizing the filling out of expedition books. It is recommended to optimize the filling out of expedition books, socialize SOPs every month, and evaluate the performance of officers.Keywords: PDCA; outpatient; medical records; public health center ABSTRAK Menurut standar pelayanan minimal rumah sakit, target keterlambatan pengembalian dokumen rekam medik harus mencapai 0% dengan kelengkapan isi 100%. Tujuan penelitian ini yaitu untuk menyusun dan melaksanakan strategi pencegahan keterlambatan pengembalian dokumen rekam medik rawat jalan poli KIA. Jenis penelitian yaitu kualitatif dengan menggunakan metode PDCA. Subjek penelitian yaitu koordinator rekam medis, petugas rekam medis, petugas poli KIA, DPJP, bidan, dan kepala puskesmas. Data dikumpulkan melalui wawancara, observasi, studi dokumentasi, NGT dan brainstorming. Uji keabsahan data dilakukan dengan triangulasi sumber, waktu dan teknik. Hasil penelitian pada tahap Plan adalah identifikasi faktor penyebab keterlambatan pengembalian DRM berdasarkan 5M, unsur man yaitu pendidikan yang masih belum sesuai dengan kualifikasi rekam medis, kurangnya pengetahuan petugas terkait pengembalian DRM, kurangnya pengalaman kerja akibat masa kerja yang terbilang baru. Unsur money yaitu anggaran dana yang kurang memenuhi untuk fasilitas rekam medis. Unsur material yaitu masih terdapat ketidaklengkapan pengisian DRM. Unsur machine yaitu masih terjadi kendala error/lemot saat input data pasien dalam komputer/laptop, tidak adanya telepon dalam ruang filing, kurang optimalnya penggunaan buku ekspedisi. Unsur method yaitu tidak adanya SOP terkait pengembalian DRM dan juga menjadi prioritas masalah dengan rencana usulan yaitu pembuatan SOP terkait pengembalian DRM dan perubahan item dalam buku ekspedisi. Tahap do dilakukan pada bulan April-Mei dimana sebelum dan sesudah pelaksanaan mengalami penurunan. Tahap Check telah memenuhi target sehingga usulan kegiatan perencanaan dapat dilanjutkan dalam tahap action. Tahap Action yaitu pengesahan dan sosialisasi terkait SOP pengembalian DRM setiap bulan serta pengoptimalan pengisian buku ekspedisi. Disarankan pengoptimalan pengisian buku ekspedisi, sosialisasi SOP setiap bulan, dan evaluasi kinerja petugas.Kata kunci: PDCA; rawat jalan; rekam medis; puskesmas