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All Journal Indonesian of Health Information Management Journal (INOHIM) Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Jurnal Indonesia Sehat (JURINSE)
Zakharias Kurnia Purbobinuko
Prodi RMIK D-3 Fakultas Kesehatan Universitas Jenderal Achmad Yani Yogyakarta
Health Professions Immunology & microbiology Mechanical Engineering Public Health

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Journal : Jurnal Indonesia Sehat (JURINSE)

 1 
Tinjauan Pelaksanaan Informed Concent Pemeriksaan Kontras Colon in Loop di Instalasi Radiologi RSUD Kota Yogyakarta Zhazha Sulistya Nengrum; Eniyati Eniyati; Zakharias KP; Ika Fitria A
Jurnal Indonesia Sehat Vol. 1 No. 03 (2022): JURINSE, Desember 2022
Publisher : SAMODRA ILMU: Lembaga Penelitian, Penerbitan, dan Jurnal Ilmiah

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Abstract

Background: Medical records play a major role in improving the quality of medical services in hospitals. In the patient’s medical record section, there are several sheets, one of which is the Informed Consent sheet. Informed consent plays a major role for service providing medical facilities, because on the sheet it can create an agreement on health actions. Meanwhile, in the implementation of informed consent there are still discrepancies in its implementation. Purpose: To determine the implementation of informed consent for colon in loop contrast examination at the radiology installation of the Yogyakarta City Hospital. Method: This research was used the descriptive research methods using a qualitatif approach that is in depth interviews. Result: The results showed that the implementation of informed consent at the Yogyakarta City Hospital was not in accordance with the rules, namely in the implementation of informed consent there were still some that were carried out orally. Items in the delivery of informed consent include, at least include the patient’s diagnosis, the action to be given, the procedur for action, action, and actions and alternative actions. Overall, the completeness of the informed consent was not comprehensive and precise. Conclusion: The implementation of informed consent has not been carried out properly and there are still incomplete and correct sheets. It is recommended to the officer who is responsible for filing out the sheet.
Analisis Kuantitatif dan Kualitatif Dokumen Rekam Medis Pasien Bersalin di Klinik Pratama Aisyiyah Siti Khotijah Salam Magelang Eniyati Eniyati; Zakharias KP; Lily Yulaikhah; Ratna Prahesti
Jurnal Indonesia Sehat Vol. 2 No. 1 (2023): JURINSE, April 2023
Publisher : SAMODRA ILMU: Lembaga Penelitian, Penerbitan, dan Jurnal Ilmiah

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Abstract

Background:  The implementation of health services cannot be carried out properly without good medical record documentation as well. The medical record unit is one of the units that plays an important role from registration to recording the patient's disease history. Medical records are the most important aspect in the hospital management process in medical services. Quality assurance is an effort to periodically review various conditions that affect services, monitor services, and trace the output produced, so that various deficiencies and causes of deficiencies can be known and improvement efforts can be made to further improve the level of health and welfare. Quantitative and qualitative analysis is part of this effort. Purpose:  quantitatively and qualitatively analyze medical record documents of maternity patients at the Aisyiyah Siti Khatijah Salam Magelang primary clinic. Result:  Based on the results of quantitative observation/analysis, the average total completeness of maternity patient medical records was 93.01%, and did not meet the standards that should be 100%, the Delinguent Medical Record (DMR) had the highest incompleteness, which was in January 2021 at 50%. there were no incompleteness (0%) in April, May and September 2021. The results of the qualitative analysis are completeness of 90%. Conclusion:  The average completeness in the medical record of maternity patients is 93.01%, and has not met the standard that should be 100%, the Delinguent Medical Record (DMR) has the highest incompleteness, which is in January 2021 at 50%. The results of the qualitative analysis are completeness of 90%.
Co-Authors Eniyati Ika Fitria A Lily Yulaikhah Puspita, Kori Ratna Prahesti Ratna Prahesti Riska Wurianing Zhazha Sulistya Nengrum