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All Journal J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan
Dian Fadilah Ayu Lestari
Politeknik Negeri Jember
Health Professions Public Health

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Tinjauan Faktor Penyebab Ketidaktepatan Waktu Pengembalian Sensus Harian Rawat Inap di RSUP dr. Soeradji Tirtonegoro Tahun 2020 Dian Fadilah Ayu Lestari; Andri Permana Wicaksono; Atma Deharja
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.v1i3.2108

Abstract

Based on the results of preliminary studies conducted at the RSUP dr. Soeradji Tirtonegoro is known thehighest delay count is the Anggrek of 95% room and 4th Dahlia room of 80%. The delay has an impactwhich daily census returned is not timely, and be it can increase the work of officers for the next day andsending the recapitulation results to the reporting department is delayed. This study aims to observe theimplementation of the daily census and the factors causing the inaccuracy in returning the daily census ofhospitalization, the determination of the main causes of the problem are using a fishbone diagram. Thistype of research uses qualitative and are collected a data with observation, interview and documentation.The results of the main problem are Man (the work of the recapitulation officer is delayed and ineffective,the employee's indiscipline). Method (there is not written policies of Standard Operating Procedure, theofficer does not know the Standard Operating Procedure). Minutes (The deadline for retuning the dailycensus of hospitalization are not consistent). Machine (there are no features that support the daily censusof hospitalization in SINERGIS, daily inpatient census is manually). Money (there is no rewards).
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.
Co-Authors Andri Permana Wicaksono Atma Deharja Indah Muflihatin