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All Journal Jurnal Ilmu Kefarmasian Indonesia Jurnal Puan Indonesia Tedc International Journal of Health, Engineering and Technology
Rizqy Dimas Monica
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ANALISIS KUANTITATIF PENGISIAN REKAM MEDIS PASIEN POLI UMUM GUNA MENUNJANG MUTU REKAM MEDIS DI PUSKESMAS CIMAHI TENGAH Luqman Nul Haqim; Rizqy Dimas Monica
Jurnal TEDC Vol 15 No 2 (2021): JURNAL TEDC
Publisher : UPPM Politeknik TEDC Bandung

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Abstract

Berdasarkan hasil studi pendahuluan awal di Puskesmas Cimahi Tengah, dari 30 berkas rekam medis tedapat 25 berkas rekam medis yang tidak terisi dengan lengkap khusunya pada diagnosa, pemeriksaan fisik dan autentifikasi penulis seperti nama jelas dan tanda tangan. 5 berkas rekam medis yang lengkap terisi dari awal perjalanan klinis penyakit pasien dari awal masuk sampai pasien pulang. Tujuan penelitian ini untuk mengetahui pelaksanaan analisis pengisian rekam medis pasien poli umum guna menunjang mutu rekam medis di Puskesmas Cimahi Tengah. Metode yang digunakan dalam penelitian ini adalah penelitian deskriptif dengan pendekatan kuantitatif. Teknik pengumpulan data yaitu dengan observasi, wawancara dan studi pustaka. Hasil penelitian kelengkapan pengisian rekam medis di Puskesmas Cimahi Tengah dalam kenyataan nya masih terdapat rekam medis yang belum lengkap, angka pengisian kelengkapan tertinggi yaitu pada item Nomor Rekam Medis, nama pasien, tanggal berobat, dan anamnesa sebesar 100%, sedangkan angka pengisian ketidaklengkapan terendah yaitu pada item jenis kelamin sebesar 69%, pemeriksaan penunjang sebesar 96%, terapi sebesar 65%, rujukan sebesar 97%, keterangan sakit sebesar 98%, kontrol sebesar 100%, dan cap dokter sebesar 69%. Saran yang diberikan sebaiknya pengisian berkas rekam medis oleh petugas kesehatan harus dilakukan beriringan dengan setiap pelayanan kesehatan yang dilakukan, sehingga akan mengurangi jumlah ketidaklengkapan pengisian berkas rekam medis, petugas rekam medis bekerja sama dan berkoordinasi memberikan masukan kepada petugas kesehatan lain dan dokter tentang betapa pentingnya kelengkapan pengisian rekam medis sesuai aturan yang berlaku atau sesuai dengan waktu yang ditetapkan. Kata kunci: analisis kuantitatif, rekam medis, mutu rekam medis
TINJAUAN PENGGUNAAN BERKAS REKAM MEDIS DENGAN KONSEP FAMILY FOLDER GUNA MENUNJANG KUALITAS PELAYANAN DI PUSKESMAS CIBODAS Luqman Nul Hakim; Encep Hada; Ayu Hendrati Rahayu; Rizqy Dimas Monica
Jurnal TEDC Vol 13 No 3 (2019): JURNAL TEDC
Publisher : UPPM Politeknik TEDC Bandung

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Abstract

Based on preliminary studies conducted from February 3, 2019 to February 8, 2019, with the use of the family folder medical record file, there is still a lack of service. There were 30 families who were treated in two poles together. Then a sample of 30 patients was taken with a presentation (100%). This results in other family members having to wait for other family members to be checked with an average of 40 minutes 02 seconds. Where patients should not be left waiting for a long time to get services because the services provided must be immediately carried out. The purpose of this study was to determine the use of family folder medical record file at the Cibodas Health Center. The research method used is descriptive method with quantitative and qualitative approaches. Data collection techniques are by observation, interview, questionnaire and literature study. The research instrument used a research table, interview guidelines, questionnaire, stopwatch, stationery and calculator. The results of the examination waiting time became longer because of the added examination time in the first poly with an average time of 32 minutes 10 seconds and not yet available SOPs for the service of two family members in an simultaneously using the family folder medical record file. Advice that can be given is to immediately make an SOP for examination of two patients together in one family, pay more attention to waiting time and use of the family folder medical record file for the future so that patient satisfaction is met as a whole and monitor also periodic evaluations for the better filing of medical records.
ANALISIS KEBUTUHAN SUMBER DAYA MANUSIA DI INSTALASI REKAM MEDIS BERDASARKAN TEORI WORKLOAD INDICATORS OF STAFF NEED (WISN) GUNA MENUNJANG EFEKTIVITAS KERJA DI RUMAH SAKIT TNI AU DR. M. SALAMUN BANDUNG Neni Rohaeni; Rizqy Dimas Monica; Encep Hada
Jurnal TEDC Vol 13 No 2 (2019): Jurnal TEDC
Publisher : UPPM Politeknik TEDC Bandung

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Abstract

Based on preliminary study results, previous interviews and observations made by the authors are 18 medical record officers, some parts of medical record activities there are officers who concurrently work as in the coding section, assembling and analysis into the registration form so that the work received by the officer experienced a buildup of 10 medical record files (0.1%). The research method used is a descriptive method of quantitative approach. The research instrument used in this unstructured interviews, observations and documentation studies. The results of human resource calculations based on WISN theory in the outpatient registration and hospitalization required as much as 8 people while the number of officers available only 2 people so that it is necessary to replenishment 6 people, for other parts such as outpatient and hospitalization mix requires 1 person has been fulfilled, assembling, analysis requires 1 person has been fulfilled, coding 1 person has been fulfilled, and the 6 person filling section has been fulfilled. Preferably in a service evaluation meeting conducted 1 time a month discussing about human resources so that there is no human resources that concurrently work and create a buildup of work and monitoring and conduct routine evaluation so that every problem that occurs can be anticipated and resolved properly.
TINJAUAN TATA RUANG ERGONOMI PELAYANAN RAWAT JALAN BERDASARKAN KONSEP ERGONOMI GUNA MENUNJANG EFEKTIVITAS KERJA DI PUSKESMAS PASIRLANGU Ayu Hendrati Rahayu; Rizqy Dimas Monica; Intan Pujilestari
Jurnal TEDC Vol 14 No 3 (2020): Jurnal TEDC
Publisher : UPPM Politeknik TEDC Bandung

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Abstract

Based on preliminary observations, in February 2020 the writer found the problems that were closely related to the outpatient services, especially at the Puskesmas Pasirlangu as follows; (1) Lack of ergonomics in each room there are still spaces that are still narrow resulting in a lack of effectiveness; (2) There are still leaks and humidity in the room, causing mold; (3) improper layout. The purpose of this study was to determine the layout of outpatient services based on the concept of ergonomics in order to support the effectiveness of work in the Pasirlangu Community Health Center. The method used is descriptive with a qualitative analysis approach. Data collection techniques used were observation and interviews. The research instrument used was stationery and interview guidelines. Spatial research results are still not in accordance with the concept of ergonomics because of each room there are shortcomings ranging from lighting, ventilation, room temperature, room humidity and layout that are not yet neat and the effectiveness of work there is not yet fully effective work effectiveness.
TINJAUAN KELENGKAPAN KODE DIAGNOSA KARAKTER KE-5 PADA KASUS INJURY GUNA MENUNJANG KUALITAS INFORMASI REKAM MEDIS RAWAT INAP DI RSUP DR HASAN SADIKIN BANDUNG Rizqy Dimas Monica; Fia Oktarica
Jurnal TEDC Vol 15 No 2 (2021): JURNAL TEDC
Publisher : UPPM Politeknik TEDC Bandung

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Abstract

Berdasarkan hasil studi penelitian yang dilakukan oleh penulis di RSUP Dr. Hasan Sadikin Bandung pada tanggal 03 Februari – 27 Februari 2020 penulis menemukan angka kelengkapan kode diagnosa karakter ke-5 pada kasus injury yang dilihat dari 10 besar kasus injury terbanyak dengan jumlah kasus 376 dengan presentasi 70,2% dan angka ketidaktepatan dengan jumlah kasus 159 dengan presentasi 29,8%. Tujuan penelitian ini untuk mengetahui Kelengkapan Kode Diagnosa Karakter Ke-5 Pada Kasus Injury ICD-10 Rawat Inap di RSUP Dr. Hasan Sadikin Bandung.Metode penelitian yang digunakan adalah metode penelitian kuantitatif dengan pendekatan deskriptf. Teknik pengumpulan data yang digunakan yaitu observasi, wa wancara dan studi kepustakaan. Populasi dalam penelitian adalah berkas rekam medis pasien kasus injury rawat inap periode januari 2019 sampai dengan desember 2019, dengan pengambilan sampel sebanyak 105 berkas rekam medis.Hasil penelitian penulis dari 105 sampel yang diteliti, kelengkapan pengisian diagnosa karakter ke-5 pada kasus injury memiliki rata-rata sebesar 58,4% dengan rata-rata kelengkapan 57,1%, keakuratan 100% dan spesifik 18%.Penulis menyarankan sebaiknya rumah sakit segera melengkapi SPO coding klaim rawat jalan yang belum ditandatangani oleh Direktur Utama dan segera memperbarui SPO up date data(pemutakhiran data) yang sudah expired, sosialisasi secara berkala dan rutin kepada seluruh pihak terkait tentang pentingnya penulisan kode diagnosa secara lengkap. Kata kunci: kelengkapan, kode diagnosa, karakter ke-5, kasus injury
ANALISIS KELENGKAPAN LEMBAR RINGKASAN MASUK DAN KELUAR PASIEN RAWAT INAP COVID-19 GUNA MENUNJANG MUTU REKAM MEDIS DI RUMAH SAKIT BHAYANGKARA TK-II SARTIKA ASIH BANDUNG Intan Pujilestari; Rizqy Dimas Monica; Fury Try Lestary
Jurnal TEDC Vol 16 No 3 (2022): JURNAL TEDC
Publisher : UPPM Politeknik TEDC Bandung

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Abstract

Formulir ringkasan masuk dan keluar merupakan formulir rekam medis yang digunakan untuk mencatatat ringkasan perjalanan penyakit sejak pasien masuk saampai keluar Rumah Sakit. Berdasarkan hasil studi pendahuluan di RS. Bhayangkara TK-II Sarika Asih Bandung ditemukan kelengkapan pengisian ringkasan masuk dan keluar sebesar 63,33% dari 30 ringkasan masuk dan keluar yang diambil secara acak. Tujuan penelitian ini untuk mengetahui gambaran kelengkapan pengisian lembar ringfkasan masuk dan keluar rawat inap Covid-19 guna menunjang mutu berkas rekam medis di RS. Bhayangkara TK-II Sartika asih Bandung. Metode yang digunakan adalah metode deskriptif dengan pendekatan kuantitatif. Dalam penelitian ini menggunakan Teknik sampling simple random sampling. Populasi yang diambil sebanyak 320 berkas dan Sampel diambil sebanyak 178 berkas rekam medis. Teknik pengumpulan data yang digunakan adalah observasi, wawancara dan studi kepustakaan. Hasil penelitian ini menunjukkan adanya standar prosedur operasional pengisian ringkasan masuk dan keluar namun dalam pelaksanaanya belum optimal dikarenakan masih ditemukan pengisian yang belum lengkap. ketidak lengkapan pencatatannya sebesar 75,8% dengan item tertinggi ketidaklengkapan pada Kode ICD diagnosa tambahan sebesar 67,42%. sehingga hasil tersebut dapat dikatakan bahwa lembar ringkasan masuk dan keluar Covid-19 belum baik yang dilihat dari aspek kelengkapan. Disarankan melakukan evaluasi dan tinjauan ulang terhadap Standar Prosedur Operasional, serta diadakan sosialisasi dan evaluasi terhadap dokter, perawat dan tenaga terkait lainnya.
TINJAUAN PELAYANAN PELEPASAN INFORMASI MEDIS DAN PENGISIAN BERKAS KLAIM JASA RAHARJA PADA KORBAN KECELAKAAN LALU LINTAS DI RSUD AL-IHSAN KABUPATEN BANDUNG PROVINSI JAWA BARAT Rizqy Dimas Monica; Vina Vinandiani; Luqmanul Hakim; Encep Hada; Edih Gunawan; Neni Rohaeni
Jurnal TEDC Vol 18 No 3 (2024): JURNAL TEDC
Publisher : UPPM Politeknik TEDC Bandung

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.70428/tedc.v18i3.873

Abstract

This study is entitled Review of Medical Information Release Services and Filling in Raharja Service Claim Files for Traffic Accident Victims at Al Ihsan Hospital, Bandung Regency, West Java Province. The purpose of this study is to determine the Medical Information Release Service and Filling in Jasa Raharja Claim Files for Traffic Accident Victims at Al Ihsan Hospital, Bandung Regency, West Java Province. The method used in this study is: using a descriptive method with a qualitative approach. The subject of this study is the Medical Information Release Service and Filling in the Raharja Service Claim File at Al-Ihsan Hospital, Bandung Regency, West Java Province. The object of this study is the standard operating procedure for releasing medical information and Jasa Raharja claim forms for traffic accident victims who claim Jasa Raharja insurance at RSUD AlIhsan Bandung Regency. Data collection techniques by observation, interview and documentation. Research results: medical information release services at Al-Ihsan Hospital are in accordance with SOPs. There is no written procedure for filling Jasa Raharja's claim file but the implementation is in accordance with the SOP.
TINJAUAN DESAIN TRACER BERKAS REKAM MEDIS DALAM MENCEGAH KEJADIAN MISSFILE GUNA MENUNJANG KELANCARAN PELAYANAN DI RSAU LANUD SULAIMAN BANDUNG Rizqy Dimas Monica; Shabila Rizky Rahmatika; Intan Pujilestari; Wowo Trianto; Luqman Nulhakim
Jurnal TEDC Vol 18 No 2 (2024): JURNAL TEDC
Publisher : UPPM Politeknik TEDC Bandung

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.70428/tedc.v18i2.832

Abstract

The results of the Preliminary Study when searching for medical record documents there were missfile incidents of 10 medical record documents, with 4 medical record files in March, 3 medical record files in April, and 3 medical record files in May. This is because the storage room at Sulaiman Air Force Air Force Base is still a mess The research method used is descriptive method with a qualitative approach. The subjects in this study were medical record officers, the object of this study was the procedure for using medical record file tracers. Data collection techniques used are observation, interviews, and documentation. The results of the research conducted by the author, show that the data for taking medical record files in March were 150 medical record files, the occurrence of missfiles was 4 medical record files due to an error in the sequence of numbers and file storage errors, in April there were 120 medical record files, 3 medical record files due to errors in the order of numbers, reading errors, and mistaking numbers, while in May there were 100 medical record files with missifles as many as 3 medical record files due to sequence errors and file storage errors. The tracer used is 10.5 x 32 cm in size, yellow and orange. The constraints on using a tracer to prevent missfile incidents are the time factor, the accuracy factor, the expedition book and the storage rack. Efforts were made to overcome the problem of using a tracer in preventing missfile incidents, namely if the medical record file is not found, the storage officer will create a medical record file to replace the missing medical record file.
Co-Authors Achadiyani Astrid F. Khairani Ayu Hendrati Rahayu Dini Rohmayani Edih Gunawan Encep Hada Fauzan Elang Dirgantara Fia Oktarica Fury Try Lestary Intan Pujilestari Intan Pujilestari Karina Wulan Safitri Luqman Nul Hakim Luqman Nul Haqim Luqman Nulhakim Luqmanul Hakim Matoeari Soelistijaningroem Michael V.L Tumbol Neni Rohaeni Neni Rohaeni Shabila Rizky Rahmatika Vina Vinandiani Wowo Trianto