Article Per Year (5 Year)
p-Index From 2021 - 2026
0.23
P-Index
This Author published in this journals
All Journal Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI)
Giyatno
Universitas Imelda Medan
Health Professions Public Health

Published : 2 Documents Claim Missing Document
Claim Missing Document
Check
Articles

Found 2 Documents
Search

 1 
ANALISIS KUANTITATIF KELENGKAPAN DOKUMEN REKAM MEDIS PASIEN RAWAT INAP DENGAN DIAGNOSA FRACTURE FEMUR DI RSUD DR. R.M. DJOELHAM BINJAI Giyatno; Maysyarah Yolla Rizkika
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.v5i1.349

Abstract

ABSTRAK Petugas rekam medis harus melakukan kegiatan analisa kuantitatif guna membantu dokter dalam kegiatan pencatatan dan pengisian rekam medis yang lengkap dan akurat. Tujuan penelitian ini adalah untuk mengetahui analisis kuantitatif kelengkapan dokumen rekam medis pasien rawat inap dengan diagnosa fracture femur di RSUD DR. R.M. Djoelham Binjai. Jenis penelitian ini yaitu deskriptif kualitatif. Sampel yang digunakan adalah seluruh jumlah populasi yaitu 36 dokumen rekam medis pasien rawat inap dengan diagnosa fracture femur tahun 2018. Pengumpulan data dilakukan dengan menggunakan tabel check list. Hasil penelitian kelengkapan identifikasi pasien tertinggi yaitu nama pasien, nomor rekam medis, dan tanggal lahir sebesar 20 dokumen (56%), persentase terendah yaitu jenis kelamin sebesar 10 dokumen rekam medis (28%). Kelengkapan pelaporan penting yaitu general consent sebesar 25 dokumen rekam medis (69%), persentase terendah yaitu informed consent sebesar 13 dokumen rekam medis (36%). Kelengkapan autentifikasi tertinggi yaitu tanda tangan dokter, nama perawat dan tanda tangan perawat sebesar 15 dokumen rekam medis (42%), persentase terendah yaitu nama dokter dan gelar profesional sebesar 11 dokumen rekam medis (31%). Kelengkapan pendokumentasian yang benar yaitu penggunaan singkatan sebesar 26 dokumen rekam medis (72%), persentase terendah yaitu pembetulan kesalahan sebesar 16 dokumen rekam medis (44%). Kelengkapan pengisian dokumen rekam medis belum lengkap 100%. Disarankan perlu adanya sosialisasi kepada seluruh petugas terkait dengan kelengkapan pengisian dokumen rekam medis dan mengikuti Standart Prosedur Operasional (SPO) terkait analisis kuantitatif kelengkapan dokumen rekam medis.
Pengaruh Faktor Predisposisi, Faktor Pendorong Dan Faktor Pendukung Terhadap Pencatatan Rekam Medis di RSUD Dr. RM Djoelham Binjai Giyatno; Megawati
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.v6i2.578

Abstract

Law of the Republic of Indonesia number: 29 of 2004 concerning Medical Practice, which includes the obligation of doctors and dentists to make medical records. The results of the evaluation of the completeness of medical records in RSUD Dr. RM Djoelham Binjai still found incomplete medical record files. This study aims to determine the effect of predisposing factors (knowledge, attitudes), driving factors (support from other officers) and supporting factors (facilities and facilities, regulations) on the behavior of doctors in recording medical records. The research design used in this study was a descriptive analytic survey with a cross sectional design, a sample of 29 doctors and quantitative data analysis with univariate, bivariate and multivariate analysis. Based on the results of the chi square test, it was obtained that Knowledge variable p = 0.001, Attitude power p = 0.002, other support staff p = 0.000, facilities and facilities p = 0.002 and settings p = 0.007 multivariate test showed that of the 5 variables tested multiple logistic regression showed variable which has a p-value > 0.05. Based on the results of the multiple logistic regression test, the significant value of the model together was obtained at 0.002 < 0.05, which means that the four variables used as models have a significant influence on Medical Record Recording, the factor that has the greatest influence on Medical Record Recording is the Support Personnel variable. Others are indicated by an OR value of 0.062. The conclusion in this study is that there is an influence, Knowledge, Attitude, Support of Other Personnel, Facilities and Facilities, and Regulations on the Completeness of Medical Record Recording. It is hoped that doctors do not delay in recording complete medical records.
Co-Authors Maysyarah Yolla Rizkika Megawati