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All Journal J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan
Aditya Dwi Arimbi
Politeknik Negeri Jember
Health Professions Public Health

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ANALISIS KUANTITATIF KELENGKAPAN PENGISIAN FORMULIR INFORMED CONSENT RUMKITAL DR. RAMELAN SURABAYA Aditya Dwi Arimbi; Indah Muflihatin; Niyalatul Muna
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 2 No 2 (2021): March
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v2i2.2009

Abstract

Completeness informed consent form of RUMKITAL Dr. Ramelan Surabaya is still less than the MinimumHospital Service Standard of 100%, it is based on a preliminary study of researchers that the incompleteinformed consent form on the identity component is 60%, important reporting is 80%, authentication is40%, and the correct documentation is 0%. The purpose of this study was to conduct a quantitativeanalysis of the completeness of the informed consent form of RUMKITAL Dr. Ramelan Surabaya. Thisstudy uses descriptive research with a cross-sectional approach to identify the completeness of filling outinformed consent. Data collection used is observation and documentation on the informed consent form.The results show the identification component with the highest completeness by 90% and the highestincompleteness by 55%; The important reporting component with the highest completeness is 80% andthe highest incompleteness is 80%; The authentication component with the highest completeness is 90%and the highest incompleteness is 50%; The correct documentation component with the highestcompleteness is 85% and the highest incompleteness is 50. Some suggestion to fix the problem is bymaking the Statement of Commitment, the SOP of evaluating and monitoring the medical recorddocuments completion, improving the Informed Consent SOP and Medical Records Completion SOP byadding completeness standard of informed consent filling which is must be achieved by RUMKITAL Dr.Ramelan Surabaya.
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.
Co-Authors Gamasiano Alfiansyah Indah Muflihatin Niyalatul Muna Novita Nuraini Selvia Juwita Swari