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Analisis Waktu Penyediaan Dokumen Rekam Medis Rawat Jalan Menurut Model 5M di RSUD Ungaran Hervina Gustian Susilo; Anton Kristijono; Niko Tesni Saputro
Indonesian of Health Information Management Journal (INOHIM) Vol 10, No 2 (2022): INOHIM
Publisher : Lembaga Penerbitan Universitas Esa Unggul

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.47007/inohim.v10i2.450

AbstractThe time for providing outpatient medical record documents based on Permenkes No.129, 2008 is 10 minutes starting from the patient registering until the patient's medical record document is provided at the polyclinic. In a preliminary study conducted on 10 medical record documents, there were 7 (70%) whose time of provision of medical record documents was not following minimum service standards. If the time of provision of medical record documents is not improved, it will have an impact on the quality of service and patient satisfaction. The type of research used is descriptive quantitative research with a cross-sectional approach. The population is the number of outpatient visits totaling 85,727 from 13 existing polyclinics. Determination of the sample size using the Slovin formula obtained 100 medical record documents. Determination of samples from 13 polyclinics proportionally. Methods of data collection by observation and interviews. The results of the study showed that the average time for providing medical record documents was 19.94 minutes, not following the established minimum service standards and standard operating procedures. Factors affecting the delay in providing outpatient medical record documents from the 5M models were found to be 2M that had an effect, namely human factors and methods. Human resources in the filling department are only 4 officers (57.14%) of 7 officers who have a diploma education background of three medical records and only 2 officers (28.57%) who have received training in filling management. The method factor, standard operating procedures does not regulate and emphasizes ways, methods, or tools in providing medical record documents at the polyclinic on time according to minimum service standards. The implementation of the standard operating procedures has not yet been evaluated.Keywords: medical records, time providing, 5M AbstrakWaktu penyediaan dokumen rekam medis (DRM) pasien rawat jalan berdasarkan Permenkes No.129, 2008 adalah ≤10 menit dimulai dari pasien mendaftar sampai DRM pasien disediakan di poliklinik. Studi pendahuluan yang dilakukan dari 10 DRM terdapat 7 (70%) yang waktu penyediaan DRM tidak sesuai standar pelayanan minimum (SPM). Jika waktu penyediaan DRM sesuai data tersebut tidak dilakukan perbaikan, akan berdampak pada mutu pelayanan dan kepuasan pasien. Jenis penelitian yang digunakan adalah penelitian deskriptif kuantitatif dengan pendekatan cross sectional. Populasi adalah jumlah DRM kunjungan pasien rawat jalan berjumlah 85.727 dari 13 poliklinik yang ada. Penentuan besar sampel menggunakan rumus Slovin, didapatkan 100 DRM. Penentuan sampel dari 13 poliklinik secara proporsional. Metode pengumpulan data dengan observasi dan wawancara. Hasil penelitian rata-rata waktu penyediaan DRM adalah 19,94 menit, belum sesuai dengan SPM RS dan standar prosedur operasional (SPO) yang sudah ditetapkan. Faktor-faktor yang mempengaruhi keterlambatan penyediaan DRM rawat jalan dari 5M model ditemukan 2 M yang berpengaruh, yaitu faktor manusia dan metode. SDM di bagian filing baru 4 petugas (57,14%) dari 7 petugas yang mempunyai latar belakang pendidikan diploma tiga rekam medis dan hanya 2 petugas (28,57%) yang sudah mendapatkan pelatihan dalam pengelolaan filling. Faktor metode, SPO tidak mengatur dan menekankan cara, metode atau alat dalam menyediakan DRM di poliklinik dengan tepat waktu sesuai SPM. Pelaksanaan SPO juga belum dilakukan evaluasi.Kata Kunci: rekam medis, waktu penyediaan, 5M

Pengembangan desain formular kelayakan isolasi mandiri di rumah bagi pasien COVID-19 untuk mendukung surveilans epidemiologi di DI Yogyakarta Anton Kristijono; Niko Tesni Saputro
Jurnal Kesehatan Pengabdian Masyarakat (JKPM) Vol. 2 No. 1 (2021): 1
Publisher : Poltekkes Kemenkes Yogyakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.29238/jkpm.v2i1.1177

The Ministry of Health revealed that the stigma and negative stereotypes given by individuals or community groups towards health workers or COVID-19 patients contributed to the high mortality rate due to the corona virus. Stigma will lead to marginalization, and worsen health status and cure rates, in this case stigma contributes to high mortality rates, when people exposed to COVID-19 must self-isolate at home. The purpose of this community service is to develop a design for a self-isolation eligibility form at home for COVID-19 patients to support epidemiological surveillance at the Tempel 1 Health Center, Sleman. The service method is carried out in stages: (1) FGD to equalize perceptions and identify data needs and information on the feasibility of self-isolation at home for COVID-19 patients without symptoms or with mild symptoms, (2) design form, (3) socialization of form design and (4) evaluation of implementation (input, process, and output) as well as recommendations in the form of form design results. It is recommended that the design of the resulting form is part of the recording and reporting of Covid-19 epidemiological surveillance at primary health facilities, and as a guide for primary health care workers to recommend that Covid 19 patients in their work areas can self-isolate at home or not. The targets consisted of epidemiological surveillance officers, Health Promotion officers, Medical Records and Health Information (RMIK) officers and community leaders. The results of the service are in the form of 4 form designs, namely: (1) Self-Isolation Eligibility Form at home for COVID-19 patients without symptoms or with mild symptoms to support epidemiological surveillance at the Tempel 1 Health Center Sleman (Form 1A.2021.rev0), (2) Forms Self-Isolating Home Information (Form 1B.2021.rev0), (3) Contact History List Form (Form 1C.2021.rev0) and (4) Monitoring Form (Form 2A.2021.rev0).

Tingkat Pengetahuan Pasien Rawat Jalan Tentang Penggunaan Aplikasi Bethesda Mobile di Rumah Sakit Bethesda Tahun 2026 Fatma Aulia Ramadhanti; Arif Nugroho Triutomo; Anton Kristijono; Nita Budiyanti; Darsono
Journal of Health Information Management and Medical Record Vol. 2 No. 1 (2026): Volume 2 No 1 ( Juni ) 2026
Publisher : Poltekkes Kemenkes Yogyakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.29238/himmr.v2i1.3259

Perkembangan teknologi digital di bidang kesehatan mendorong rumah sakit untuk mengadopsi sistem layanan berbasis mobile. Rumah Sakit Bethesda Yogyakarta telah mengimplementasikan Aplikasi Mobile RS Bethesda sejak tahun 2018 sebagai sarana pendaftaran pasien secara online. Namun, capaian pendaftaran mandiri melalui aplikasi baru mencapai 46%, jauh di bawah target indikator sebesar 70%. Hal ini mengindikasikan masih rendahnya pengetahuan pasien terhadap keberadaan dan fitur aplikasi tersebut. Penelitian ini bertujuan untuk mengetahui gambaran tingkat pengetahuan pasien rawat jalan terhadap Aplikasi Mobile RS Bethesda, meliputi persentase pasien yang mengetahui keberadaan aplikasi, pemahaman terhadap fitur-fitur aplikasi, faktor-faktor yang berkaitan dengan tingkat pengetahuan, serta hambatan yang dialami pasien dalam menggunakan aplikasi. Jenis penelitian kuantitatif deskriptif dengan desain cross-sectional. Diperoleh sebanyak 100 responden yang dipilih melalui teknik accidental sampling. Pengumpulan data dilakukan menggunakan kuesioner yang telah melalui uji validitas. Analisis data menggunakan analisis deskriptif kuantitatif berupa frekuensi dan persentase dengan kategorisasi tingkat pengetahuan: baik (76–100%), cukup (56–75%), dan kurang (<56%). Penelitian ini menghasilkan gambaran tingkat pengetahuan pasien rawat jalan terhadap Aplikasi Mobile RS Bethesda berdasarkan dimensi tingkat tahu (know). Hasil penelitian dianalisis berdasarkan karakteristik responden meliputi jenis kelamin, pendidikan terakhir, usia, pekerjaan, dan frekuensi kunjungan yang berkaitan dengan tingkat pengetahuan terhadap aplikasi. RS Bethesda perlu melakukan optimalisasi sosialisasi dan edukasi kepada pasien. Faktor karakteristik seperti usia, pendidikan, dan frekuensi kunjungan memiliki keterkaitan dengan tingkat pengetahuan pasien terhadap aplikasi. Diperlukan upaya peningkatan sosialisasi yang lebih terarah agar pemanfaatan Aplikasi Mobile RS Bethesda mencapai indikator yang ditetapkan.

Tinjauan Faktor Penyebab Ketidaklengkapan Pengisian Rekam Medis Rawat Jalan dengan Metode Fishbone dan USG di RSUD X Zanu Nury Latifah; Anton Kristijono; Syarah Mazaya Fitriana; Abdul Hadi Kadarusno
Journal of Health Information Management and Medical Record Vol. 2 No. 1 (2026): Volume 2 No 1 ( Juni ) 2026
Publisher : Poltekkes Kemenkes Yogyakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.29238/himmr.v2i1.3260

Kelengkapan rekam medis merupakan bagian penting dalam proses pencatatan pelayanan, pengobatan pasien, dan pengajuan klaim asuransi, sehingga perlu dilakukan evaluasi terhadap ketidaklengkapan pengisiannya, terutama pada pelayanan rawat jalan dengan jumlah kunjungan pasien yang tinggi. Kelengkapan pengisian Rekam Medis Elektronik rawat jalan di Rumah Sakit X belum memenuhi standar sesuai ketentuan yaitu 100%. Tujuan mengetahui tingkat kelengkapan rekam medis rawat jalan periode bulan Oktober–Desember 2025 dan mengetahui faktor penyebab ketidaklengkapan menggunakan metode Fishbone dan USG. Penelitian deskriptif dengan metode campuran dilakukan pada Januari–April 2026. Pengumpulan data melalui Google Form, wawancara, dan kuesioner kepada tiga responden. Hasil penelitian menunjukkan rata-rata kelengkapan pengisian rekam medis rawat jalan 88,72%. Berdasarkan Analisis Fishbone ditemukan faktor penyebab ketidaklengkapan rekam medis yaitu tingginya beban kerja, sosialisasi pengisian RME, anggaran, tidak ada penghargaan atau punishment, belum ada SOP Pengisian RME, perangkat masih terbatas, dan format, tampilan, serta fitur RME yang belum tersedia. Berdasarkan analisis USG prioritas utama penyebab ketidaklengkapan rekam medis yang harus segera ditindaklanjuti adalah belum optimalnya penerapan sistem RME. Oleh karena itu, diperlukan evaluasi, pengembangan sistem RME secara berkelanjutan untuk meningkatkan kelengkapan rekam medis, dan mendukung pelayanan kesehatan.

Perancangan User Interface Sistem Pelepasan Informasi Dengan Metode Design Thinking di Rumah Sakit XYZ Malikah Auni Nurjeha Auni; Nita Budiyanti; Anton Kristijono; Arif Nugroho Triutomo
Journal of Health Information Management and Medical Record Vol. 2 No. 1 (2026): Volume 2 No 1 ( Juni ) 2026
Publisher : Poltekkes Kemenkes Yogyakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.29238/himmr.v2i1.3269

Latar Belakang: Pelepasan informasi medis merupakan salah satu bentuk pelayanan rekam medis yang harus dilakukan secara tepat, efektif, dan tetap menjaga kerahasiaan data pasien. Berdasarkan hasil observasi di Rumah Sakit XYZ, proses pelepasan informasi medis masih dilakukan secara manual dengan rata-rata 70 permintaan per bulan dan ditemukan ketidakterbacaan tulisan dokter pada kolom diagnosis sehingga pelayanan kurang efektif dan efisien. Tujuan: Menghasilkan prototype user interface sistem pelepasan informasi medis di Rumah Sakit XYZ menggunakan metode Design Thinking. Metode: Penelitian ini menggunakan pendekatan Research and Development (R&D) dengan metode Design Thinking melalui tahapan empathize, define, ideate, prototype, dan test. Pengumpulan data dilakukan melalui wawancara, observasi, dokumentasi, serta evaluasi usability menggunakan System Usability Scale (SUS) kepada 5 informan. Prototype user interface dikembangkan menggunakan Figma. Hasil: Pengguna membutuhkan sistem yang sederhana, mudah digunakan, terintegrasi, dan mampu mempercepat proses pelayanan. Prototype yang dihasilkan terdiri dari halaman login, daftar permohonan, formulir permohonan, verifikasi dokumen, pengisian diagnosis, serta cetak dokumen. Pengujian usability menggunakan SUS menunjukkan skor rata-rata 81 (Acceptable, Grade B, Excellent). Kesimpulan: User interface sistem pelepasan informasi medis berhasil dirancang menggunakan metode Design Thinking dan aplikasi Figma. Hasil pengujian SUS menunjukkan bahwa prototype memenuhi standar usability yang baik serta dapat digunakan sebagai dasar pengembangan pelepasan informasi medis berbasis elektronik di Rumah Sakit XYZ.

Menuju Rekam Medis Elektronik: Seberapa Jauh Kesiapan Klinik? Aryanti Desty Ramadhani; Anton Kristijono; Niko Tesni Saputra
Journal of Health Information Management and Medical Record Vol. 1 No. 1 (2025): Vol 1. No. 1 (Juni) 2025
Publisher : Poltekkes Kemenkes Yogyakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.29238/himmr.v1i1.2153

Medical records have been urged by requiring health care facilities, including clinics, to organize electronic medical records. The implementation of Electronic Medical Records needs to be done by analyzing readiness first. The analysis can be done using the DOQ-IT method. Readiness analysis is needed before implementing RME to determine the level of RME readiness at the Primary Clinic of the Poltekkes Kemenkes Yogyakarta based on the Docto's office quality-information technology (DOQ-IT) method. This type of research is descriptive with a quantitative approach accompanied by qualitative. Research data were collected through questionnaires using googleform and in-depth interview guidelines. The sample used was total sampling of 15 respondents and 1 informant. Primary Clinic of Poltekkes Kemenkes Yogyakarta is very ready (119.71) in implementing RME. Judging from human resources, the clinic is quite ready, with an average score of 3.78. Judging from the organizational work culture, the clinic is very ready, with an average score of 4.31. In terms of leadership, the clinic is very well prepared with an average score of 4.03. In addition, seen from the infrastructure, with an average score of 4.23. Of the four components, the HR component has a fairly low value so that in-depth exploration is needed. The Primary Clinic of the Poltekkes Kemenkes Yogyakarta obtained a score of 119.71, which is said to be very ready. The strategy in dealing with Electronic Medical Records in the conditions of the Primary Clinic of the Poltekkes Kemenkes Yogyakarta is to take advantage of the internship program with third parties and form a special team responsible for supporting the implementation of electronic medical records.

Analisis Risiko Keselamatan dan Kesehatan Kerja Bagi Petugas Filing di Fasilitas Kesehatan Tingkat Lanjut Rifa Windy Choirunnisak Rifa; Nanik Setiyawati; Anton Kristijono
Journal of Health Information Management and Medical Record Vol. 1 No. 1 (2025): Vol 1. No. 1 (Juni) 2025
Publisher : Poltekkes Kemenkes Yogyakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.29238/himmr.v1i1.2155

Filing room that does not pay attention to and does not apply anthropometric ergonomics aspects can pose a risk to Occupational Safety and Health. The risk factors in the filing room are direct and indirect factors. The direct factors are the area of ??the room, the distance between the storage shelves, the size of the storage shelves, temperature, humidity, noise and lighting. While the indirect factors are SOPs and work instructions for filing officers. Identification of Occupational Safety and Health policies in the form of SOPs, filing room infrastructure and K3 risk analysis in the filing room of Nur Hidayah Hospital, Bantul. This research is a qualitative research with observation, interview, documentation, and Focus Group Discussion methods and uses descriptive data analysis. The results of this study explain that Occupational Safety and Health policies in the form of guidelines, manuals, SOPs, and general work instructions already exist in written form. However, they do not yet have SOPs that regulate Occupational Safety and Health in the filing room. The availability of equipment in the filing room is incomplete, but the condition of the equipment is still suitable for use. Air temperature and humidity in the filing room have not met the ideal standard. The results of the work risk analysis in the filing room show that the highest score for the risk of work accidents is falling and slipping. The SOP for Occupational Safety and Health for the filing room does not yet exist, so hospitals need to make this SOP. The facilities and infrastructure in the filing room are incomplete. The highest work accident risk is 140 and is included in the substantial criteria.

Analisis Desain Ulang Formulir General Consent di Bagian Pendaftaran Rawat Jalan Azkiya Salsabilla Setyaputra Salsa; Anton Kristijono; Yuliantisari Retnaningsih
Journal of Health Information Management and Medical Record Vol. 1 No. 1 (2025): Vol 1. No. 1 (Juni) 2025
Publisher : Poltekkes Kemenkes Yogyakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.29238/himmr.v1i1.2156

The use of data items in the outpatient registration general consent form at Nyi Ageng Serang Hospital Kulon Progo is not in accordance with the data items contained in the Decree of the Minister of Health of the Republic of Indonesia Number HK.01.07/MENKES/1423/2022. Regarding Guidelines for Variables and Metadata in the Implementation of Electronic Medical Records The impact of incomplete data is that when there is case of malpractice, the data cannot be used as means of protection for both the hospital and the patient, so it was necessary to redesign the general consent form. The purpose of this research was Identify, analyze, design, and describe the acceptability of redesigning general consent forms from paper to electronic at Nyi Ageng Serang Hospital, Kulon Progo. This research used qualitative descriptive study with a case study approach. This research was conducted in April–May 2023. Respondents in this study were 2 registration officers, 1 IT team, 1 DPJP person, 1 education and training employee, 1 HPK working group team, and 1 head of medical records at Nyi Ageng Serang Hospital Kulon Progo. The results of the identification and analysis show that the anatomical aspects and the contents of the general consent form at Nyi Ageng Serang Kulon Progo General Hospital are not in accordance with the form design standards. When the redesign was carried out, there were changes to the form material, headings, instructions, margins, rules, font and size, way of recording, closing, and completeness of data items. Based on the description of the acceptance of the general consent redesign, the average score of the seven respondents was 81%-100%, so it was included in the "very good" criteria. The conclusion of this research was the redesign of the general consent form obtained a "very good" rating, so it was feasible to use.

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