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All Journal Jurnal Informasi Kesehatan Indonesia (JIKI) Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI)
Marko Ferdian Salim, Marko Ferdian
Universitas Gadjah Mada
Health Professions Nursing Public Health

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Audit Rekam Medis dalam Upaya Peningkatan Kualitas Pengisian Rekam Medis di RSUD Sleman Sugeng; Dian Herawati; Salim, Marko Ferdian
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Vol. 9 No. 1 (2024): 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.v9i1.1402

Abstract

A hospital is a health service institution that provides complete individual health services for inpatient, outpatient, and emergency care. Hospitals as health service providers are required to maintain medical records. The administration of medical records for each hospital refers to the Regulation of the Minister of Health of the Republic of Indonesia. A medical record audit is needed to determine the completeness of data in medical records both in quantity and quality. The purpose of this study was to determine the medical record audit at RSUD Sleman. The type of research used is analytic observational with a cross-sectional study design. This research was conducted at RSUD Sleman, Special Region of Yogyakarta. The research was done from April to October 2022, during a period of 7 months. Simple random sampling was used to collect data from 94 medical records. The audit of 94 samples of medical records resulted in the following findings: completeness, patient identity 100%, professional identity in providing care 99.01%, date and time 70.21%, initial assessment 90.42%, subjective examination 98.84%, objective examination 66.01%, management plan 91.49%, clinical pathology examination 58.51%, radiological examination 75.53%, primary diagnosis 100%, secondary diagnosis 100%, and general agreement 100%. The lowest percentage of 58.51% was obtained for incomplete data.
ANALISIS FAKTOR PENGHAMBAT PELEPASAN INFORMASI KEPADA PIHAK KETIGA DI RUMAH SAKIT BHAYANGKARA LUMAJANG Wulandari, Dina Tsani; Salim, Marko Ferdian; Nugraha, Bagus Setyadi; Hartati, Oky Susiana; Muldyanti, Watik
Jurnal Informasi Kesehatan Indonesia (JIKI) Vol 9 No 1 (2023): Jurnal Informasi Kesehatan Indonesia
Publisher : Politeknik Kesehatan Kemenkes Malang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31290/jiki.v9i1.3841

Abstract

Latar Belakang: Peningkatan mutu dan efisiensi pelayanan rumah sakit melalui sensus harian rawat inap memerlukan implementasi sistem informasi kesehatan (SIK) yang baik. RSUD Muntilan telah memiliki modul Sensus Harian Rawat Inap (SHRI) dalam SIK, tetapi pelaksanaannya masih dilakukan secara manual, menyebabkan masalah ketidakakuratan data. Oleh karena itu, penelitian ini bertujuan menganalisis faktor-faktor penghambat implementasi SIK dalam kegiatan SHRI di RSUD Muntilan. Subjek dan Metode: Jenis penelitian ini yaitu penelitian kualitatif dan menggunakan rancangan penelitian studi kasus. Sampel yang diambil mencakup masing-masing satu orang petugas admin bangsal dan petugas pelaporan yang dipilih secara acak dari populasi yang terdiri dari tujuh orang petugas admin bangsal dan dua orang petugas pelaporan. Metode pengumpulan data yang digunakan yaitu observasi, studi dokumentasi, dan wawancara. Hasil: Faktor yang menjadi penghambat implementasi SIK adalah faktor man meliputi kurangnya petugas admin bangsal, money yaitu tidak adanya anggaran untuk pelatihan/sosialisasi dan penambahan petugas admin bangsal, method yaitu tidak adanya SOP sensus harian rawat inap secara elektronik, material yaitu data tempat tidur dan tanggal masuk yang tidak akurat. Kesimpulan: Faktor-faktor yang menjadi penyebab tidak digunakannya SIK dalam kegiatan sensus harian rawat inap adalah faktor man, money, method, dan material
ANALISIS KESIAPAN BRIDGING SIMRS DAN V-CLAIM DI RUMAH SAKIT PRATAMA KOTA YOGYAKARTA Salim, Marko Ferdian; Syakira, Imtinan Nasywa; Putri, Edvy Permata; Janah, Friska Miftachul
Jurnal Informasi Kesehatan Indonesia (JIKI) Vol 9 No 1 (2023): Jurnal Informasi Kesehatan Indonesia
Publisher : Politeknik Kesehatan Kemenkes Malang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31290/jiki.v9i1.3661

Abstract

Background: Hospital Information System (SIMRS) and Virtual Claim (V-Claim) are information systems used by hospitals in providing services. However, the different systems between SIMRS and V-Claim will have an impact on the effectiveness and efficiency of patient services, for example the patient registration process. Yogyakarta City Primary Hospital is conducting bridging between SIMRS and V-Claim so it is necessary to know the readiness level of the bridging system.Subjects and Method: This research method used a mixed methods with an exploratory design at the Yogyakarta City Primary Hospital in June-August 2022. This research was started with qualitative research and then continued with quantitative. Collecting data using interview techniques, observation, and questionnaires.Results: The SIMRS and V-Claim bridging systems have been successfully implemented at Yogyakarta Pratama Hospital with the support of man, money, machine, material, and method aspects that are well integrated with each other. The TRL measurement results show that the level of readiness for implementing the bridging system at the Yogyakarta City Pratama Hospital is at level 8.Conclusion: The SIMRS and V-Claim bridging systems have been successfully implemented at Yogyakarta Primary Hospital. Improving the Yogyakarta Pratama Hospital IT team to make repairs and improvements to TRL indicators that have not reached the maximum up to TRL level 9.
Co-Authors Dian Herawati Hartati, Oky Susiana Janah, Friska Miftachul Muldyanti, Watik Nugraha, Bagus Setyadi Putri, Edvy Permata Sugeng Syakira, Imtinan Nasywa Wulandari, Dina Tsani