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All Journal Infokes : Jurnal Ilmiah Rekam Medis dan Informasi Kesehatan jurnal abdimas saintika Jurnal Rekam Medis dan Informasi Kesehatan Indonesia
Oktamianiza Oktamianiza
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Computer Science & IT Dentistry Health Professions Medicine & Pharmacology Nursing Public Health Veterinary

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PENERAPAN SISTEM INFORMASI MANAJEMEN PUSKESMAS (SIM-PUS) PADA UNIT REKAM MEDIS DAN INFORMASI KESEHATAN DI PUSKESMAS LUBUK BUAYA KOTA PADANG Deni Maisa Putra; Dicho Zhurhriano Yasli; Oktamianiza Oktamianiza; Devid Leonard; Yulfa Yulia
Jurnal Abdimas Saintika Vol 2, No 2 (2020): November Jurnal Abdimas Saintika
Publisher : Stikes Syedza Saintika Padang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.30633/jas.v2i2.824

Abstract

Sistem rujukan yang terdapat pada puskesmas menggunakan sebuah sistem informasi yang biasa dinamakan SIMPUS. Sistem Informasi Manajemen Puskesmas merupakan suatu tatanan atau peralatan yang menyediakan informasi untuk membantu proses manajemen puskesmas dalam mencapai sasaran kegiatannya (Depkes RI, 1997). Sistem informasi di Puskesmas banyak dikembangkan untuk mengatasi permasalahan sepertinya pengimputan data Rekam Medis sebagai sumber data primer yang digunakan untuk mengolah data asuhan medis menjadi statistik kesehatan. Oleh karena itu seorang perekam medis dituntut untuk bisa mengelola data yang ada sehingga menghasilkan sebuah informasi. Sistem informasi merupakan sarana untuk menyediakan informasi yang berguna dalam pengambilan keputusan organisasi dan menambah pengetahuan sehingga dapat mengurangi ketidak pastian bagi para pemakai informasi (Deni Maisa Putra & Dila Vadriasmi, 2020). Tahap PKM diawali dengan penjajakan dan studi pendahuluan dalam rangka pengumpulan data, permohonan izin lahan, dan kesepakatan terkait MOU yang akan dibahas. Persiapan kegiatan PKM dalam bentuk pembekalan ilmu pengetahuan, praktek terhadap penerapan SIMPUS yang ada di Puskesmas setelah mendapatkan izin dari Dinas Kesehatan Kota Padang, pelaksanaan PKM dilaksanakan selama 3 hari (15, 16, 17 Agustus 2019). Kegiatan PKM ini diharapkan dapat menghasilkan peningkatan pengetahuan dan bisa memberikan kontribusi terhadap petugas rekam medis untuk melih meningkatkan skill dalam penerapan SIMPUS.Kata kunci : SIMPUS, Rekam Medis, Puskesmas
TINJAUAN KETIDAKLENGKAPAN PENGISIAN FORMULIR RINGKASAN MASUK DAN KELUAR REKAM MEDIS RAWAT INAP PADA PENYAKIT HIPERTENSI DI RSUD LUBUK BASUNG Yulfa Yulia; Oktamianiza Oktamianiza; Dian Sari; Kalasta Ayunda Putri; Vitratul Ilahi; Gopinda Deska Putra
Jurnal Rekam Medis dan Informasi Kesehatan Indonesia Vol. 1 No. 2 (2022): Jurnal Rekam Medis dan Informasi Kesehatan Indonesia
Publisher : program studi Rekam Medis dan Infomasi Kesehatan ITSK RS dr Soepraoen Malang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.62951/jurmiki.v1i2.12

Abstract

The admission and discharge summary is a medical record form that is used to record a summary of the course of the disease from the time the patient entered the hospital until the patient was discharged. The research used is quantitative research with a descriptive approach. Data collection was carried out at Lubuk Basung Regional Hospital from 27 May to 1 July 2023 and the sample consisted of 88 entry and discharge summary forms from the medical records of patients suffering from hypertension. Research through observation with a checklist table. Computerization is used to process data and carry out univariate analysis. The research results showed that there were still incomplete filling out of the entry and discharge summary forms on patient identification items (40.9%), important patient reports (20.5%), patient authentication (12.5%), good record keeping (15.9%). ), and scribbled and clearly legible (17.05%). The results showed that the summary form for admission and discharge for hypertensive patients was still incomplete. In conclusion, this shows that the summary form for admission and discharge for hypertensive patients is still incomplete. It is recommended to carry out evaluations and reviews, as well as outreach and evaluation with doctors, nurses and other related personnel. It mainly deals with the quantitative analysis of incoming and outgoing summary forms.
Review of The Completeness of Filling In The Form (CPPT) of The Inpatient Midwifery Ward of Aisyiyah Hospital Rahmadhani Rahmadhani; Dewi Mardiawati; Oktamianiza Oktamianiza; Heru Rahmat Wibawa; Yopia Priyanti; Siti Handam Dewi
Jurnal Infokes Vol 16 No 1 (2026): Jurnal Ilmiah Rekam Medis dan Informatika Kesehatan
Publisher : Universitas Duta Bangsa Surakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.47701/dz57rc03

Abstract

Incompleteness of Inpatient (CPPT) form affects the quality of medical records in hospitals. The (CPPT) form must be filled out completely to improve the quality of hospital services and can be accounted for if there are errors in service, action or medication administration. The purpose of this study was carried out because there are still many problems found related to incompleteness of the (CPPT) form by PPA at Aisyiyah Hospital. The study was conducted at Aisyiyah Hospital from January to March 2025, this type of research is quantitative research with a descriptive approach. The population was 144, with the Accidental Sampling sample technique, obtained 59. Data processing techniques were editing, coding, processing, and cleaning. The results of the study obtained a percentage of identification data as much as 1 (1.7%) incomplete 58 (98.3%) complete, in important reports 17 (28.8%) incomplete 42 (71.2%) complete. In authentication 50 (84.7%) incomplete 9 (15.3%) complete. In good record keeping, 21 (35.6%) were incomplete, 38 (64.4%) were complete. In filling out the form (CPPT), 51 (86.4%) were incomplete, 8 (13.6%) were complete. This was due to a lack of awareness among officers in filling out the CPPT form. The conclusion in this study was that incompleteness was still found, especially in the Authentication and Completion of the CPPT Form. This has an impact on patient safety and the accountability of medical personnel. It is recommended that officers fill out the CPPT form completely and accurately to support safe and quality health services.
Co-Authors Devid Leonard Dian Sari Dicho Zhurhriano Yasli Gopinda Deska Putra Heru Rahmat Wibawa Ilahi, Vitratul Kalasta Ayunda Putri Mardiawati, Dewi Putra, Deni Maisa Rahmadhani Rahmadhani Siti Handam Dewi Yopia Priyanti Yulfa Yulia