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All Journal JOURNAL OF MEDICAL RECORDS AND HELATH INFORMATION Cakrawala Medika: Journal of Health Sciences Jurnal Rekam Medis dan Informasi Kesehatan Indonesia Indonesian Journal of Health Insurance and Medical Records (IJHIMR)
Isnaini Qoriatul Fadhilah
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Humanities Computer Science & IT Dentistry Education Health Professions Medicine & Pharmacology Nursing Public Health Social Sciences

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TINJAUAN FAKTOR - FAKTOR PENYEBAB TERJADINYA DUPLIKASI NOMOR REKAM MEDIS DI PUSKESMAS BAWANG II Sri Widiyanti; Isnaini Qoriatul Fadhilah
JOURNAL OF MEDICAL RECORDS AND HEALTH INFORMATION Vol 2 No 1 (2021): JOURNAL JOURNAL OF MEDICAL RECORDS AND HELATH INFORMATION
Publisher : Malang: Sekolah Tinggi Ilmu Administrasi Malang

Show Abstract | Download Original | Original Source | Check in Google Scholar

Abstract

Latar Belakang: Duplikasi yang terjadi di Puskesmas Bawang II sebanyak 8 berkas pada bulan Januari 2020, yang berdampak pada aspek legalitas berkas rekam medis terganggu apabila terjadi kasus hukum dan kesalahan dalam melakukan tindakan dikarenakan diagnosa terakhir atau tindakan terakhir yang tertera di berkas rekam medis bukan terakhir dipergunakan pada saat pasien mendapatkan pelayanan medis.Tujuan: Penelitian ini bertujuan untuk mengidentifikasi penyebab terjadinya duplikasi nomor rekam medis di Puskesmas Bawang II.Metode: Jenis penelitian adalah kualitatif dengan pengumpulan data wawancara, observasi, dan dokumentasi serta melalui pendekatan cross sectional, dimana pendekatan ini dilakukan dengan melihat kondisi pada saat pelaksanaan penelitian, yang dapat dilakukan sewaktu-waktu. Peneliti melakukan wawancara terhadap kepala instalasi rekam medis dan petugas pendaftaran, kemudian observasi dilakukan terhadap kegiatan pendaftaran dan proses kegiatan penomoran pasien.Hasil: Hasil penelitian yang didapatkan bahwa sistem penomoran yang digunakan di Puskesmas Bawang II adalah unit numbering system. Penyebab masalah adanya duplikasi nomor rekam medis meliputi faktor man, material, dan method, salah satunya yaitu pendidikan petugas yang belum sesuai kualifikasi D3 Rekam Medis.Kesimpulan: Sistem penomoran rekam medis di Puskesmas Bawang II menggunakan Sistem Penomoran Unit (Unit Numbering System) dengan jenis penomoran personal folder,dan menggunakan sistem penyimpanan SNF (Serial Number Filing) sistem yang berurut dari nomor yang terkecil.
PENERAPAN MANAJEMEN RISIKO DI UNIT KERJA RMIK: STUDI KASUS PADA TEMPAT PENDAFTARAN PASIEN RAWAT JALAN (TPPRJ) RUMAH SAKIT Zefan Adiputra Golo; Arief Azhari Ilyas; Isnaini Qoriatul Fadhilah; Sugiharto
JRMIK Vol 4 No 1 (2023): JOURNAL OF MEDICAL RECORDS AND HEALTH INFORMATION
Publisher : Malang: Sekolah Tinggi Ilmu Administrasi Malang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.58535/jrmik.v4i1.49

Abstract

Background: TPPRJ as a leading unit that provides services to patients needs to minimize the risks and hazard that can be experienced by officers and patients. From a preliminary study at one of the local government hospitals in the Central Java region, it was found that at the outpatient registration point there was no Standar Procedur Operational (SPO) regarding risk management, so there was no standard set for risk control for officers and patients.Objective: The purpose of this study is to identify the application of risk management in the outpatient registration site (TPPRJ) of the hospital.Method: The type of research used in this study is qualitative descriptive with a case study design. The subjects of the study were 4 informants determined by purposive sampling techniques. Data collection through interviews and observationsResults: There are several risk factors in TPPRJ, namely from physical aspects (air temperature, lighting, radiation), biological aspects and ergonomic aspects. From the results of interviews and observations, it is known that the implementation of risk management in hospitals has been running, but it is still not optimal because it has not yet reached a comprehensive evaluation from the hospital's quality management.Conclusion: Risk management has been running but has not been maximized, because there is no SPO that specifically regulates risk management at TPPRJ. The risk management process that has been running is to identify risks, risk analysis and risk control.Keywords: Risk Management, RMIK Work Unit, TPPRJ
BUHATI: APLIKASI BERBASIS IOT UNTUK MENCEGAH STUNTING DENGAN MEMANTAU PERKEMBANGAN JANIN IBU HAMIL Sari, Ananda Wahyu Muncarsari; Isnaini Qoriatul Fadhilah
Cakrawala Medika: Journal of Health Sciences Vol. 2 No. 2 (2024): Cakrawala Medika: Journal of Health Sciences
Publisher : Lembaga Penelitian dan Pengabdian Masyarakat Universitas Medika Suherman

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.59981/nh6ak969

Abstract

Pernikahan dini menjadi salah satu faktor risiko utama yang berkontribusi pada tingginya angka stunting di Indonesia. Stunting, yang merupakan kondisi gagal tumbuh pada anak-anak akibat kekurangan gizi kronis, memiliki dampak jangka panjang yang serius terhadap kesehatan, perkembangan, dan produktivitas individu serta masyarakat secara keseluruhan. Hal ini jika dibiarkan terus menerus akan mempengaruhi kualitas sumber daya manusia Indonesia di masa depan. Pemerintah telah memiliki beberapa program terkait pencegahan perkawinan usia anak, namun belum meratanya sosialisasi yang didapatkan oleh seluruh masyarakat menyebabkan adanya kesenjangan dalam implementasinya. Pelayanan kesehatan dalam pencegahan perkawinan usia anak berupa pelayanan promotif dan preventif. Penelitian ini menggunakan metode riset dan pengembangan (R&D) sampai tahap pengembangan prototipe. Hasil penelitian berupa aplikasi BUHATI, dimana pengguna dapat mengakses informasi mengenai hal-hal yang berkaitan dengan kesehatan reproduksi, pernikahan dini dan dapat berkonsultasi secara langsung dengan tenaga kesehatan. Aplikasi BUHATI memiliki target utama yaitu remaja. Penerapan aplikasi ini merupakan salah satu bentuk transformasi layanan kesehatan secara digital. Program aplikasi BUHATI ini sinergis dengan tujuan pembangunan berkelanjutan 2030.
TINJAUAN PELAKSANAAN SISTEM PEMELIHARAAN REKAM MEDIS DI UPTD PUSKESMAS WANAYASA I KABUPATEN BANJANEGARA PROVINSI JAWA TENGAH Harsono Harsono; Isnaini Qoriatul Fadhilah
Jurnal Rekam Medis dan Informasi Kesehatan Indonesia Vol. 1 No. 1 (2021): Jurnal Rekam Medis dan Informasi Kesehatan Indonesia
Publisher : program studi Rekam Medis dan Infomasi Kesehatan ITSK RS dr Soepraoen Malang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.62951/jurmiki.v1i1.9

Abstract

At the Wanayasa I Health Center UPTD, it was found that the medical record folder was torn so that the identity of the patient's medical record number could not be read and the officers often turned the folder over to view the contents of the medical record. Another factor is the lack of knowledge of medical record officers because their educational background is not a medical record graduate and has never attended training related to medical record management. The purpose of the study was to describe the implementation of the medical record maintenance system at the Wanayasa I Public Health Center UPTD. The type of research used was a qualitative descriptive study with a cross sectional approach. The results of the research on physical document maintenance systems for space management, do not use air conditioning, storage, use 2 wooden document racks, but should be replaced with filing cabinets or roll o'packs. Preventive materials, by carrying out activities to put camphor. There is no specific prohibition regarding the medical record maintenance system. Extrinsic factors are not in accordance with the theory. The document maintenance system for preventing document damage includes mountainous air with a temperature range of 18°-23°C which is quite good for preventing document damage. For fumigation, archival restoration and microfilm are not currently carried out but preventive measures should be taken
Analisis Faktor-Faktor Yang Memengaruhi Ketidakakuratan Kode Diagnosis Penyakit Di Ruang Rawat Inap Rumah Sakit TNI AD Bhirawa Bhakti Kota Malang Isnaini Qoriatul Fadhilah; Ni Luh Putu Komala; Eiska Rohmania Zein
Indonesian Journal of Health Insurance and Medical Records (IJHIMR) Vol. 2 No. 1 (2025): Indonesian Journal of Health Insurance and Medical Records (IJHIMR)
Publisher : Kementerian Kesehatan Poltekkes Malang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31290/ijhimr.v2i1.5288

Abstract

Classification and codification of diagnoses are the most important aspects of medical record services. In coding there is accuracy and inaccuracy of diagnosis codes related to claims or costs. The coding of disease diagnoses at the Bhirawa Bhakti Hospital, there are still inaccuracies, so the aim of this research is to analyze the factors that influence the accuracy of inpatient disease diagnosis codes at the hospital. The type of this research is a mixed method with research instruments using checklist sheets, observation, and interview guidelines. This research was conducted at the Bhirawa Bhakti Army Hospital, Malang City. The population used in this research is medical records in quarter 3 of 2023, amounting to 625 files, with a sample calculated using the Slovin formula amounting to 86 files were taken randomly. Accuracy of the diagnosis code as the dependent variable and factors using 5M as the independent variable. Based on the research, completeness of files obtained is 88.4%, or 76 files, while the incompleteness of files is 11.6%, or 10 files. The accurate diagnosis coding results amount to 65.1%, or 56 files, while inaccurate diagnosis coding amounts to 34.9%, or 30 files. Based on interviews and observations with the head of the installation and codification officers, it is found that coding accuracy can be influenced by the 5M factors which include educational background (Man), implementation of codification guided by SPO not yet optimal (Method), absence of reward and punishment systems and there is an impact on the claim if an error occurs in the fourth and fifth characters (Money), legibility of doctor's handwriting and incomplete filing form (Material), and a system that is still transitioning to electronic (Machine). Training for improving coder qualifications, monitoring, along with evaluation, as well as a system of penalties and rewards to incentivize officers, would be preferred.
Co-Authors Arief Azhari Ilyas Eiska Rohmania Zein Harsono Harsono Ni Luh Putu Komala Sari, Ananda Wahyu Muncarsari Sri Widiyanti Sugiharto Zefan Adiputra Golo