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All Journal Jurnal Manajemen Pendidikan Window of Health : Jurnal Kesehatan Jurnal Manajemen Informasi dan Administrasi Kesehatan Journal of Multidisciplinary Academic Jurnal Manajemen Informasi Kesehatan Indonesia (JMIKI) Indonesian of Health Information Management Journal (INOHIM) Health Sciences and Pharmacy Journal Surya Medika: Jurnal Ilmiah Ilmu Keperawatan dan Ilmu Kesehatan Masyarakat Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Jurnal Health Sains Jurnal Kesehatan Tambusai Jurnal Ilmiah Wahana Pendidikan Nusantara Hasana Journal Archives of The Medicine and Case Reports Arkus COMSERVA: Jurnal Penelitian dan Pengabdian Masyarakat Indonesian Journal of Health Information Management (IJHIM) Jurnal Ilmiah Kesehatan Masyarakat Sehat Rakyat: Jurnal Kesehatan Masyarakat Journal of Innovation Research and Knowledge Jurnal Rumpun Ilmu Kesehatan Jurnal Sosial dan Sains Journal of Hospital Management Cerdika: Jurnal Ilmiah Indonesia MEDICORDHIF Jurnal Rekam Medis Journal of Educational Innovation and Public Health Jurnal Medika Nusantara Vitamedica: Jurnal Rumpun Kesehatan Umum Vitalitas Medis : Jurnal Kesehatan Dan Kedokteran Vitamin: Jurnal Ilmu Kesehatan Umum Obat: Jurnal Riset Ilmu Farmasi dan Kesehatan Jurnal Rekam Medic Jurnal Komputasi
Widjaja, Lily
Universitas Esa Unggul
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GAMBARAN PENYEBAB TIDAK DITEMUKAN REKAM MEDIS RAWAT JALAN DIBAGIAN PENYIMPANAN RSUD BUDHI ASIH Azidah, Mega Puspita; Muniroh, Muniroh; Putra, Daniel Happy; Widjaja, Lily
Jurnal Manajemen Informasi dan Administrasi Kesehatan Vol. 4 No. 2 (2021): JMIAK
Publisher : Program Studi D3 Rekam Medis dan Informasi Kesehatan

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.32585/jmiak.v4i2.1853

Abstract

Rekam medis adalah berkas yang berisi catatan dan dokumen mengenai identitas pasien, pemeriksaan, pengobatan, tindakan dan pelayanan lain yang telah diberikan kepada pasien. Rekam medis harus disimpan karena berguna untuk perawatan pasien selanjutnya dan berpengaruh dalam kelancaran dan kepuasan pasien terhadap kualitas pelayanan kesehatan.  Tujuan umum dari penelitian ini adalah untuk mendeskripsikan penyebab tidak ditemukannya rekam medis untuk mengetahui penyebab tidak ditemukannya rekam medis rawat jalan di bagian penyimpanan RSUD Budhi Asih dengan 5 unsur manajemen yaitu man, money, method, material, machine. Metode penelitian menggunakan metode deskriptif dengan pendekatan kualitatif. Kejadian misfiled yang terjadi sebanyak 0,34%. Ada beberapa faktor yang mempengaruhi rekam medis salah tempat dan tidak ditemukan (misfiled). Dari hasil penelitian penyebab tidak ditemukannya rekam medis dari faktor manusia, terdapat petugas bukan dari D3 RMIK dan tidak mengikuti pelatihan. Faktor uang, anggaran pelatihan yang belum tentu waktunya. Faktor metode sudah memiliki SOP. Faktor bahan, penggunaan map yang tebal namun jika sedikit sobek hanya diperbaiki. kurangnya rak karena keterbatasan ruang, petugas ada yang tidak mengisi buku ekspedisi, Faktor mesin/alat tracer/outguides petugas terkadang lupa/salah penempatannya, masih terdapat map rekam medis lama tidak menggunakan kode warna.
TINJAUAN KEBUTUHAN KODER BERDASARKAN BEBAN KERJA UNIT REKAM MEDIS DI RS IMANUEL BANDAR LAMPUNG Bangun, Gabriella Eviana; Muniroh, Muniroh; Putra, Daniel Happy; Widjaja, Lily
Jurnal Manajemen Informasi dan Administrasi Kesehatan Vol. 4 No. 2 (2021): JMIAK
Publisher : Program Studi D3 Rekam Medis dan Informasi Kesehatan

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.32585/jmiak.v4i2.1854

Abstract

RS Imanuel merupakan salah satu rumah sakit tipe B di kota Bandar Lampung. Rata-rata kunjungan pasien rawat jalan dan rawat inap di RS Imanuel setiap harinya adalah 217 dan 28 pasien. Dalam penyelenggaraan kegiatan koding di RS Imanuel diketahui jumlah koder yang ada adalah 1 (satu) orang. Seiring bertambahnya jumlah pasien setiap tahunnya maka beban kerja pada setiap bagian juga akan terus meningkat yang menyebabkan perlunya penyesuaian antara jumlah tenaga dengan beban kerja yang ada khususnya pada bagian koding di RS Imanuel supaya pelayanan lainnya tidak terhambat. Tujuan penelitian ini adalah mengetahui jumlah kebutuhan tenaga bagian koding berdasarkan beban kerja di RS Imanuel. Jenis penelitian ini adalah deskriptif dengan pendekatan kuantitatif dan menggunakan metode perhitungan Analisis Beban Kerja Kesehatan(ABK-Kes). Teknik pengumpulan data melalui observasi dan wawancara kepada Kepala Instalasi Rekam Medis dan tenaga rekam medis yang melakukan kegiatan koding. Dari hasil penelitian diketahui waktu kerja tersedia (WKT) koder adalah 1.400 jam/tahun atau 84.000 menit/tahun. Rata-rata lama waktu kegiatan koding rawat jalan dan rawat inap adalah 0,84 menit dan 4,69 menit. Standar beban kerja (SBK) koder untuk rawat jalan dan rawat inap adalah 100.000 dan 17.910 rekam medis/tahun. Jumlah kebutuhan koder sebesar 2 (dua) orang sedangkan jumlah yang ada saat ini adalah 1 (satu) orang, maka perlu ditambah 1 (satu) orang.
Analisis Pelaksanaan Alih Media Rekam Medis Manual ke Elektronik di Pelayanan Rawat Inap RS Bhakti Mulia Mawardi, Arilla Nugrahi; Sonia, Dina Sonia; Widjaja, Lily Widjaja; Rumana, Nanda Aula Rumana
Jurnal Manajemen Informasi dan Administrasi Kesehatan Vol. 8 No. 2 (2025): JMIAK
Publisher : Program Studi D3 Rekam Medis dan Informasi Kesehatan

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.32585/jmiak.v8i2.7525

Abstract

The transition from manual medical records to electronic medical records (EMR) is a strategic policy of the Indonesian Ministry of Health through Ministerial Regulation No. 24 of 2022, which requires all healthcare facilities to implement digital recording. This study aims to investigate the implementation of the transition from physical documents to an electronic system in the inpatient unit at Bhakti Mulia Hospital. The research method used is qualitative descriptive, with data collection techniques including observation and interviews with six informants from the medical records unit. The research findings indicate that the hospital has established Standard Operating Procedures (SOPs) for the transition to electronic medical records, as well as retention policies for inactive documents, in accordance with national regulations. The transition process has been ongoing since 2022, supported by infrastructure such as scanners, computers, and the SIMRS application. Supporting factors are evaluated using the 5M management approach (People, Budget, Methods, Equipment, and Materials). As a result, implementation has not been optimal due to limitations in human resources, technical constraints with equipment, communication challenges, and human errors in the completeness of medical record documentation. It is recommended to increase the number and quality of human resources according to qualifications, provide further training, conduct regular system evaluations, and align communication between units. Therefore, support from management and regular evaluations are needed to ensure that the media transfer process can run optimally.
Analisis kesiapan peralihan rekam medis elektronik di RSUD Tebet Afra, Rara; Putra, Daniel Happy; Widjaja, Lily; Fannya, Puteri
Health Sciences and Pharmacy Journal Vol. 9 No. 3 (2025)
Publisher : STIKes Surya Global Yogyakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.32504/hspj.v9i3.1305

Abstract

Implementasi Rekam Medis Elektronik (RME) menjadi prioritas nasional di Indonesia seiring dengan kewajiban bagi seluruh fasilitas kesehatan untuk beralih dari rekam medis manual ke sistem digital. Kesiapan yang tidak memadai dalam proses ini dapat mengganggu alur kerja klinis, menurunkan akurasi data, serta berdampak negatif pada mutu pelayanan, sehingga menjadikan kesiapan organisasi sebagai isu yang sangat penting. Penelitian ini bertujuan menilai tingkat kesiapan RSUD Tebet, Jakarta Selatan, dalam mengimplementasikan sistem RME serta mengidentifikasi potensi kendala yang dapat menghambat proses transformasi digital. Penelitian menggunakan desain deskriptif kuantitatif dengan kerangka DOQ-IT. Pengumpulan data dilakukan pada Desember 2023-Mei 2024 melalui kuesioner, wawancara, dan observasi terhadap 112 petugas dari berbagai unit klinis dan administratif. Hasil penelitian menunjukkan bahwa kesiapan rumah sakit pada dua domain utama penyelarasan organisasi dan kapasitas organisasi berada pada kategori “cukup siap”. Dimensi yang dinilai meliputi manajemen informasi, sumber daya manusia, pelatihan, alur kerja, akuntabilitas, pembiayaan, keterlibatan pasien, serta dukungan manajemen dan infrastruktur TI. Temuan ini mengindikasikan bahwa meskipun RSUD Tebet telah memiliki fondasi awal untuk mendukung implementasi RME, penguatan strategi dan peningkatan terarah tetap diperlukan untuk mencegah hambatan operasional. Kesiapan yang optimal sangat penting guna memastikan transisi digital yang aman, efektif, dan berkelanjutan.
Analysis of the Factors Influencing the Coding Quality in East Java Hospital of Indonesia: Diabetes Mellitus as A Case Study Markam, Hosizah; Ningsih, Kori Puspita; Widjaja, Lily; Nisak, Umi Khoirun; Marzo, Roy Rillera; Siswati
Window of Health : Jurnal Kesehatan Vol 8 No 2 (April 2025)
Publisher : Fakultas Kesehatan Masyarakat Universitas Muslim Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33096/woh.v8i2.1702

Abstract

Code precision has received significant attention due to the increased utilization of encoded procedural data. Coding errors have been documented in multiple research investigations. This study aims to assess the variables that affect coding quality. The prevalence of diabetes has increased substantially in the past two decades and is a significant cause of morbidity and mortality. Method: This study was conducted in 2 hospitals in East Java, Indonesia, that were selected through simple random sampling from a population of hospitals meeting the predefined inclusion criteria. The bed capacities of these hospitals are 211, with details of 62 and 149, respectively, for the specialised ones. The sample in this study was 60 medical record files taken randomly in 2022 in the case of diabetes mellitus. The result showed coding quality testing uses six elements: reliability, accuracy, relevancy, timeliness, completeness, and legibility. Data analysis was carried out analytically using the Fisher Exact test. The results of the study from 60 samples showed that four elements were significant out of a total of 6 aspects of coding quality elements. The four essential elements consisted of Accuracy (p=0.001), Reliability (p=0.001), Completeness (p=0.046), and Legibility (p=0.046). Reliability elements also impact coding accuracy or vice versa (p=0.001); Completeness also affects Legibility and vice versa (p=0.046). The odds ratio value of each component shows that Reliability and Accuracy are 8.782, which means that Reliability can increase Accuracy 8 times and vice versa. Meanwhile, completeness and legibility are at 3.818, which means completeness also increases legibility by three times and vice versa. The Hospitals should consider four significant coding quality elements, including completeness, accuracy, reliability, and legibility, for use in coding audits. Timeliness and Relevance were insignificant.
Inactive Medical Record Governance at St. Carolus Hospital Jakarta Menna, Yasinta Rosalia; Widjaja, Lily; Muniroh, Muniroh; Putra, Daniel Happy
Indonesian Journal of Health Information Management Vol. 2 No. 2 (2022)
Publisher : Sekolah Tinggi Ilmu Kesehatan Mitra Husada Karanganyar

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.54877/ijhim.v2i2.62

Abstract

Medical record depreciation is an activity of reducing archives from storage shelves by moving inactivated medical records archives from active shelves to inactivated shelves according to the year of visit. Preliminary observation results show the process of media transfer in the medical record unit has not reached the target of a minimum number of 50 medical records per day. This research aims to find out the governance of inactivated medical records at St. Carolus Hospital Jakarta. The research methodology used is a descriptive method. It can be concluded that the standard operating procedure for shrinking medical records in St. Carolus Jakarta already exists but is not complete because the depreciation stage related to transfer, value assessment, media transfer has not been listed in the standard operating procedure. The medical records unit has carried out the depreciation process with the male medical record officer as its executor but the implementation is not based on the assessment of the value for medical records due to the absence of an assessment team. The constraint factors in the medical record unit are related to the man, money, material, method, and machine.
Analisis Kuantitatif Kelengkapan Formulir Pengkajian Medis Awal Dokter Pada RM Pasien Rawat Inap Di RS Vertikal Jakarta Timur Sarah Khonsa; Widjaja, Lily; Muniroh, Muniroh; Fannya, Puteri; Syafitri, Yenni
Indonesian Journal of Health Information Management Vol. 2 No. 2 (2022)
Publisher : Sekolah Tinggi Ilmu Kesehatan Mitra Husada Karanganyar

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.54877/ijhim.v2i2.64

Abstract

Rekam medis wajib dibuat oleh rumah sakit dan diisi lengkap dan jelas baik secara tertulis maupun elektronik. Formulir pengkajian medis awal dokter pasien rawat inap merupakan isi dari bagian rekam medis. Di RS Vertikal Jakarta Timur, pengisian formulir pengkajian medis awal dokter pasien rawat inap masih belum lengkap sehingga nilai gunanya menjadi kurang maksimal. Data yang dianalisis adalah formulir pengkajian medis awal dokter rm pasien rawat inap bulan desember 2020. Tujuan dilakukan penelitian ini adalah untuk mengidentifikasi SPO pengisian pengkajian medis awal dokter pasien rawat inap, menghitung kelengkapan pendokumentasian lembar pengkajian medis awal dokter pasien rawat inap berdasarkan analisis kuantitatif, mengidentifikasi faktor-faktor yang menghambat kelengkapan pengkajian medis awal dokter pasien rawat inap. Analisis kuantitatif merupakan melihat keseluruhan isi dari rekam medis untuk mengidentifikasi terjadinya kekurangan. Penelitian menggunakan metode secara deskriptif kuantitatif dan pengambilan sampel menggunakan simple random sampling. Berdasarkan hasil penelitian SPO pengisian pengkajian medis awal dokter pasien rawat inap sudah ada. Hasil analisis kuantitatif terhadap 90 formulir pengkajian medis awal dokter pasien rawat inap didapat rata-rata kelengkapan sebesar 81%. Faktor penyebab ketidaklengkapan pengisian formulir pengkajian medis awal dokter pasien rawat inap adalah kurangnya tingkat kepatuhan dokter dalam mengisi formulir pengkajian medis awal rawat inap, sehingga banyak formulir tidak terisi secara lengkap. Oleh karena itu, disarankan agar meningkatkan sosialisasi SPO pengisian formulir pengkajian medis awal dokter rawat secara lengkap terutama kepada dokter dan tenaga kesehatan terkait.
Kepuasan Pasien terhadap Aplikasi Pendaftaran Online Menggunakan Metode EUCS (End User Computing Satisfaction) di RSUP Fatmawati Rumana, Nanda Aula; Putra, Daniel Happy; Widjaja, Lily; Noviandi, Noviandi; Maharami, Iradah; Hidayat, Rahmat
Journal of Hospital Management Vol 4, No 01 (2021): Journal of Hospital Management
Publisher : Lembaga Penerbitan Universitas Esa Unggul

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.47007/johm.v4i01.4459

Abstract

Online registration is one application that can reduce queues at the hospital. However, its application must meet the standards so that patients are satisfied with the online registration application. This research was conducted to determine the description of patient satisfaction with online registration applications using end user computing statisfaction. Samples obtained in this study were 73 respondents taken by incidental sampling. The design of this study is cross sectional where research is only measured one time to find out the picture of satisfaction. The level of patient satisfaction is measured using the EUCS (End User Computing Statisfaction) model which consists of five components namely content, accuracy, format, ease of use and timeliness. Data in this study were obtained from questionnaires to patients or families of patients who registered through the online registration application. The results showed that of 73 respondents 45 respondents (61,6%) were dissatisfied and 28 respondents (38,4%) were satisfied. This study concludes that there are still many patients or users who feel unsatisfied with the online registration application. Suggestions aimed at online registration applications are to design the interface on the application so that it is more user friendly, reducing errors during data processing, updating the doctor's schedule, speeding up access when registering online and speeding up the process of downloading barcodes on the online registration application.Keywords: Online registration, satisfaction, content, accuracy, format, ease of use and timeliness.
Perilaku Petugas Terhadap Inovasi Sistem Informasi Kesehatan di Rumah Sakit Kanker Dharmais Hairun Nisa; Daniel Happy Putra; Puteri Fannya; Lily Widjaja
Jurnal Komputasi Vol. 12 No. 1 (2024): Jurnal Komputasi
Publisher : Jurusan Ilmu Komputer Fakultas MIPA Universitas Lampung

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.23960/komputasi.v12i1.244

Abstract

Dharmais Cancer Hospital has implemented a SIMRS called SIMpel since 2016. The application has been successfully applied to computer systems used by various medical record service units, including admission, filling, coding, and reporting. However, in the implementation of the existing SIMRS, there are still challenges and barriers related to user adoption. So a study was conducted related to the evaluation of the use of SIMRS at Dharmais Cancer Hospital. The purpose of this study is to identify various elements that influence the acceptance of SIMRS among officers in order to increase their level of consistency and commitment in using SIMRS. The Unified Theory of Acceptance and Use of Technology (UTAUT) model was used as the theoretical framework for this study. This study uses inferential analysis, with a total sample size of 58 respondents and the test used is the chi-square test. Based on the results of the analysis, it was found that there is a relationship between the constructs of performance expectancy, effort expectancy, and social influence with interest in using SIMRS. In addition, facilitating conditions were found to have a relationship with usage behavior. It can be concluded that there is a correlation between officers' acceptance and usage attitudes towards SIMRS for each construct in the UTAUT model. Therefore, it is necessary to maintain the interest and usage behavior of SIMRS at Dharmais Cancer Hospital while maintaining the quality of the system.
Co-Authors -, Muniroh Adelia Anggraini Adi Widodo Adil Hidayat Adinda Pratiwi Afra, Rara Alex Sander Alfi Shiddiq Syafrian Aliyani Aliyani Amirah Syafiqah Zahra Anas Fajry Rhomadon Angelina Angelina Anggraini, Adelia Annisa Nur Salsabila Arip Budiana Azhar Muttaqin Azhar Muttaqin Azidah, Mega Puspita Bahlani Bangga Agung Satrya Bangun, Evi Vania Bangun, Gabriella Eviana Bayu Fajar Ilhami Bella Safitri Choirunisa Choirunisa Dani Sagitha Daniel Happy Putra Daniel Happy Putra Della Rati Saputri della Dewi, Deasy Rosmala Dewi, Sisilia Kartika Dian Nur Muslimah Dina Sonia Dwi Chandrarika Putri Aulia Dwijayanti, Risma Mei Eka Widya Rita P. Endika Rachmad Fadia Eka Septiawati Fannya, Puteri Fauzan Habibilah Fauziah Irfany Ferina Ferina Ferina, Ferina Firmansye Ika Panggulu Fredrika Welhelmina Gabriella Eviana Bangun Gina Sonia Gita, Elsa Chandra Hairun Nisa Harahap, Maulidiah Rizki Hosizah Hosizah Ilham Abdurohman Indawati, Laela Intan Rusdiana Dewi Jeillia Jihan Swaradwibhagia Khoirunnisa Sabiladina Kusumapradja, Rokiah Laela Indiawati Lautsan, Christina M. Fuad Iqbal Maharami, Iradah Marzo, Roy Rillera Maulidiah Rizki Harahap Mawardi, Arilla Nugrahi Mega Puspita Azidah Menna, Yasinta Rosalia Muhamad Fazriyansah Muniroh - Muniroh Muniroh Muniroh, Muniroh Nanda Aula Rumana Natsir Nugroho Nindia Septa Tiana Noviandi Noviandi Nurmalasari, Dinda Nurmalasari, Mieke Octa Rina Sari Pratiwi, Adinda Puspita, Kori Putri Fannya Putri Nurindahsari Putri, Alifatul Aulia Sagita Rahayu, Ririn Rahelia Putri Rahmat Hidayat Rani Puspita Ningrum Regina Yulianti T. S Rezal, Muhammad Rifda Ulfa Andini Ririn Rahayu Risma Sisni Fadilla Saarah Salsabila Putri Yadita Sabiladina, Khoirunnisa Salsabila, Annisa Nur Sarah Khonsa Sarah Khonsa Setiawan, Mohammad Yusuf Siswati Siti Rahmawati Handayani siti Widya Astuti, siti Sofi Romando Putri Sonia, Dina Sonia Suciyanti Suciyanti Suriyantoro, Suriyantoro Surlialy, Dewi Syafitri, Yenni Tantri Wilananda Tri Harti Maya Utami Uli Shalatiya uli Umi Khoirun Nisak Vania Rachma Putri Viatiningsih, Wiwik Wiranata, Tyansa Eka Sampoerna Yasinta Rosalia Menna Yenni Syafitri Yulia, Noor