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All Journal Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Indonesian Journal of Health Information Management Services (IJHIMS) Jurnal Ilmiah Pengabdian Kepada Masyarakat
Valentina
Universitas Imelda Medan
Computer Science & IT Decision Sciences, Operations Research & Management Economics, Econometrics & Finance Health Professions Medicine & Pharmacology Nursing Public Health Social Sciences

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Tinjauan Penolakan Pada Klaim Pasien BPJS Kesehatan di RSUD Tanjung Pura Valentina; Mita Sari; Tri Widya Sandika
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Vol. 7 No. 1 (2022): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Februari
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v7i1.695

Abstract

Rejection of claims is one of the obstacles in the BPJS Kesehatan claim collection process. The purpose of this study was to determine the description of administrative verification on the rejection of BPJS Kesehatan patient claims at Tanjung Pura Hospital. This type of research is descriptive qualitative. The population is all BPJS patient medical record files that were rejected in June 2021 counted 135 files and BPJS Kesehatan claiming officers at Tanjung Pura Hospital, totaling 2 people. The samples of this study were the medical record files of BPJS patients who were rejected in June 2021 and the BPJS claiming officers who were taken by saturated sampling. The instruments used are check list sheets and interview guidelines. Data was collected by using documentation, observation and interview methods. Data analysis was done descriptively. The results showed that there were 123 claim files (2.9%) which were rejected by BPJS Kesehatan from 4,253 claim files submitted. The reason for the rejection of the claim file was because all of them did not pass the verification of the service administration which consisted of the absence of a DPJP signature on the resume and proof of service, no referral letter attached, no inpatient indication/order sheet, and no indication of anesthesia attached to the operation report. This incompleteness is due to the lack of thorough examination of the completeness of the medical record file by the data analysis section and the absence of SOPs in the implementation of the claim process. It is recommended to the hospital director to make an SOP for claiming BPJS Kesehatan and to the claims officer and data analysis to be more thorough in checking the completeness of the BPJS Kesehatan claim file.
HUBUNGAN WAKTU PENYEDIAAN DOKUMEN REKAM MEDIS DENGAN KEPUASAN PASIEN PADA BAGIAN PENDAFTARAN DI RUMAH SAKIT UMUM PERMATA BUNDA MEDAN Valentina
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Vol. 5 No. 1 (2020): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Februari
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v5i1.345

Abstract

ABSTRAK Salah satu aspek yang perlu diperhatikan dalam pelayanan kesehatan yang bermutu adalah akses terhadap pelayanan yang ditandai dengan waktu penyediaan dokumen rekam medis di bagian pendaftaran. Tujuan penelitian adalah untuk mengetahui hubungan waktu penyediaan dokumen rekam medisdengan kepuasan pasien pada bagian pendaftaran di Rumah Sakit Umum Permata Bunda Medan. Jenis penelitan yang digunakan adalah deskriptif dengan desain cross sectional. Populasi penelitian ini adalah seluruh pasien rawat jalan di RSU Permata Bunda Medan yang dihitung dari rata-rata kunjungan pasien yang datang dalam satu minggu yaitu 307. Sampel dalam penelitian ini adalah 76 orang yang diambil secara accidental sampling. Instrumen yang digunakan dalam penelitian ini adalah lembar observasi dan pedoman wawancara. Analisis data dilakukan secara univariat dan analisis bivariat yaitu untuk mencari hubungan dua variabel menggunakan uji statistik t-test independen dengan CI 95%. hasil penelitian menunjukkan ada hubungan waktu penyediaan dokumen rekam medis dengan kepuasan pasien pada bagian pendaftaran di Rumah Sakit Umum Permata Bunda Medan (p=0,0001).Disarankan untuk mempersingkat waktu penyediaan dokumen rekam medis dan meningkatkan kepuasan pasien dengan dengan melaksanakan manajemen rekam medis yang baik benar. Kata Kunci: Waktu, Penyediaan Dokumen Rekam Medis, Kepuasan Pasien, Pendaftaran ABSTRACT One aspect that needs to be considered in health services as assessed for access to services is affected by the provision of medical records in the registration section. The purpose of this study is to determine the relationship between the time of providing medical records and patient satisfaction in the registration section at Permata Bunda General Hospital, Medan. The type of research is descriptive with cross sectional design. The population are patients in RSU Permata Bunda Medan, which was calculated from the average number of patient visits that came in a week as many as 307. The sample is 76 people taken by accidental sampling. Data collection was carried out using the observation method using an observation sheet and the interview method with a questionnaire. Data were analyzed univariate and bivariate using the independent t-test with 95% CI. The results showed that there is a correlation between the time of providing medical records and patient satisfaction in the registration section at Permata Bunda General Hospital, Medan (p = 0,0001). It is recommended to shorten the time for the provision of medical record documents and increase patient satisfaction by helping to manage medical records properly.
GAMBARAN KETIDAKLELENGKAPAN PENGISIAN FORMULIR LAPORAN ANESTESI KASUS BEDAH DI RSU IMELDA PEKERJA INDONESIA MEDAN Valentina; Sri Mulia Melayu
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Vol. 5 No. 2 (2020): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Agustus
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v5i2.415

Abstract

Every health service provided to patients must recorded in the medical records completely because the completeness of filling the medical record is used as an indicator of the quality of health services in the hospital. The purpose of this study is to determine the incomplete picture of filling out an anesthetic case report form in a surgical case at the Imelda Indonesian Workers Hospital in Medan. The type of research is descriptive. The populations of this study are all forms of anesthesia patient case reports for the first quarter of 2020 with a total of 728 forms. The samples are 88 forms taken using systematic random sampling. Data collection was carried out using the checklist sheet. Data were analyzed univariate to describe the characteristics of each research variable by producing a frequency distribution and percentage of each variable. The results showed that there were 24 anesthetized report forms that were completely filled and 64 anesthetic report forms that were not completely filled. The highest percentage of incompleteness of filling in the patient identity component on the item date of birth was 10 forms (11%), on the anesthesia time component on the old surgical item by 39 forms (44%), on the diagnostic component on the post-surgical diagnostic item by 28 forms (32%), the examination component on the preoperative state item was 63 forms (72%) and the signature component was 2 forms (2%). It is recommended that every health worker who provides health services to surgical case patients fill out the anesthetic report form in accordance with the SPO authorizing the medical record filling, and to the medical record officer to conduct an assembling or complete analysis of medical record documents.
Dampak Penumpukan Dokumen Rekam Medis Terhadap Waktu Pengambilan Dokumen Rekam Medis Di RSU Sinar Husni Medan Valentina; Selvia Sari Ritonga
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Vol. 6 No. 1 (2021): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Februari
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v6i1.478

Abstract

The filling system is one of the administrators of medical records which is responsible for orderly administration in an effort to improve health services in hospitals. Accumulation of medical record documents will affect of work of officers in the filling section. The purpose of this study is to determine the impact of the bildup of medical records documents on the time of taking medical record documents at Sinar Husni Hospital. This research is a descriptive study with a qualitative approach. The population is all filling officers at the Sinar Husni Hospital and all patient medical records calculated on average in the third quarter of 2020, counted 719 documents. The samples in this study were 2 filling officers at the Sinar Husni Hospital and part of the medical record documents totaling 86 medical record documents that were taken incidentally. The instrument used was an interview guide. The measurement of time to take medical record documents uses a stopwatch. Data were analyzed descriptively. The results showed that the accumulation of medical record documents had an impact on the time to take medical record documents at the Sinar Husni Hospital, because the officers had difficulty carrying out filling activities because the access between shelves was narrower and the documents piled on the floor were not properly aligned, with an average of 10.05 minute. We recommend to add more storage space and shelves so that medical record documents that are stacked on the floor can be moved to the storage racks.
Pelaksanaan Penyimpanan Rekam Medis Berdasarkan Unsur Manjemen 5M di Puskesmas Medan Johor Valentina; Winda Andryani Sinaga
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Vol. 6 No. 2 (2021): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Agustus
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v6i2.590

Abstract

The implementation of medical records carried out at the puskesmas requires management in managing all existing activities with the aim of creating good health services, in accordance with procedures and guidelines. To achieve the goal of processing medical records, 5 elements of management are needed, namely man, money, material, machine, and method. The purpose of this study was to determine the management elements of man, money, material, machine, and method in the implementation of medical records carried out at the Medan Johor Health Center. This type of research uses qualitative research methods with a phenomenological approach. The study was conducted from May to July 2020. The population was all medical record officers at the Medan Johor Health Center. The research sample amounted to 5 people who were taken by saturated sampling. The research instrument is an interview guide and recorded using an audio recorder and a check list sheet for observation. The results showed that the man element was 5 people and none of them had a medical record background and had never received training, the money element was the funding obtained from JKN and APBD, the material element was that a family folder was used to store all patient forms, while the use of tracers and register books has not been used to control the borrowed files out of the storage rack, and the filling cabinet is used as a tool to store medical record files, the machine element is a primary care application to register patients, the SIMPUS application is used for reporting, the method element is Not all SOPs in medical records exist. The advice given is to provide training to medical record officers so that their officers better understand the importance of medical records.
Redesain Map Rekam Medis Di Puskesmas Medan Johor Esraida Simanjuntak; Valentina; Mei Sryendang Sitorus; Azizah Putri Syafa Harahap
Indonesian Journal of Health Information Management Services Vol. 2 No. 2 (2022): Indonesian Journal of Health Information Management Services (IJHIMS)
Publisher : APTIRMIKI

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (207.267 KB) | DOI: 10.33560/ijhims.v2i2.42

Abstract

Map is a thick paper cover used to store medical record sheets, which serves to unite all patient sheets so that they become a unified whole history, protect the medical record files in it so they are not easily damaged, torn and folded. as well as facilitate storage, search and transfer. medical record file. The purpose of this community service is to redesign the medical record folder in terms of anatomy, physicality and content, as well as the boundaries of form between forms of family members (father, mother and child) at the Medan Johor Health Center. The community service methods used are public education, consultation, and the diffusion of science and technology. This service activity was carried out for 4 months. The result of this community service activity is a product in the form of a medical record folder (folder) at the Medan Johor Health Center.
PENYULUHAN SISTEM PENYIMPANAN REKAM MEDIS DI PUSKESMAS GLUGUR DARAT KOTA MEDAN Valentina; Esraida Simanjuntak
Jurnal Ilmiah Pengabdian Kepada Masyarakat (Ji-SOMBA) Vol. 1 No. 1 (2021): Jurnal Ilmiah Pengabdian Kepada Masyarakat (Ji-SOMBA)
Publisher : Universitas Imelda Medan

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (183.729 KB) | DOI: 10.52943/ji-somba.v1i1.649

Abstract

Puskesmas sebagai fasilitas kesehatan tingkat pertama perlu melakukan tertib administrasi dengan pengelolaan rekam medis yang baik agar dapat menghasilkan sebuah informasi yang berkualitas dan bermutu bagi berkembangnya pembangunan kesehatan di wilayah kerjanya. Kegiatan pengabdian kepada masyarakat ini dilaksanakan di Puskemas Glugur Kota, dengan tujuan memberikan penyuluhan kepada petugas penyimpana rekam medis tentang sistem penyimpanan di puskesmas dengan family folder. Metode yang digunakan dalam pengabdian ini adalah memberikan penyuluhan secara langsung ke puskemas dengan memaparkan materi dan demonstrasi mengenai sistem penyimpanan rekam medis yang baik dan benar. Hasil dari kegiatan pengabdian kepada masyarakat ini adalah bertambahnya pengetahuan petugas tentang sistem penyimpanan family forlder, penggunaan tracer dan buku ekspedisi untuk meminimalisir terjadinya kehilangan berkas rekam medis (misfile) dan duplikasi penomoran rekam medis. Selain itu petugas juga mampu melakukan penyediaan dokumen rekam medis rawat sesuai prosedur untuk meminimalisir waktu tunggu pasien.
Co-Authors Azizah Putri Syafa Harahap Esraida Simanjuntak Mei Sryendang Sitorus Mita Sari Selvia Sari Ritonga Sri Mulia Melayu Widya Sandika, Tri Winda Andryani Sinaga