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All Journal Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Jatilima : Jurnal Multimedia Dan Teknologi Informasi INFOKUM Jurnal Kesehatan Tambusai Jurnal Pengabdian Masyarakat (ABDIRA) Jurnal Ilmiah Pengabdian Kepada Masyarakat Pengabdian Kepada Masyarakat Indonesia SEAN (ABDIMAS SEAN) Jurnal Teknik Indonesia (JU-TI) Marsipature Hutanabe: Jurnal Pengabdian Kepada Masyarakat Pascal: Journal of Computer Science and Informatics
Cosmas Samuel Daeli
Microskil University
Aerospace Engineering Humanities Chemical Engineering, Chemistry & Bioengineering Civil Engineering, Building, Construction & Architecture Computer Science & IT Decision Sciences, Operations Research & Management Dentistry Economics, Econometrics & Finance Education Electrical & Electronics Engineering Engineering Health Professions Languange, Linguistic, Communication & Media Library & Information Science Medicine & Pharmacology Nursing Public Health Social Sciences Other

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ANALISIS RISIKO FISIK PADA PETUGAS DI UNIT PENYIMPANAN REKAM MEDIS RUMAH SAKIT UMUM MADANI MEDAN Andi Ritonga, Zulham; Karo-Karo, Siddik; Daeli, Cosmas Samuel; Partap, Joni
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Vol. 10 No. 1 (2025): 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.v10i1.1803

Abstract

The medical record storage room is a place to store patient medical record files. Physical risk factors faced by officers include inappropriate lighting, uncomfortable temperatures, narrow distances between shelves, and room locations far from registration. This research is descriptive qualitative in nature and was conducted in the RSU Medical Records filling room. Madani Medan, aims to analyze these physical risk factors. Data was collected from four informants through interviews and observations, then analyzed qualitatively. The research results show that the lighting in the filling room is inadequate, especially in the corner of the room with closed windows and high ceilings, causing the lights to flicker frequently which interferes with comfort and work efficiency. Dim lights impact productivity and accuracy of file placement, and can trigger drowsiness. The room temperature was uncomfortable because the AC was broken and there were only two fans which did not cool the room enough, making the officers feel hot and sweaty. Each shelf about 60 cm apart was considered too narrow, hampering movement and slowing document retrieval, while the height reached 2.8 meters. Even though the room is spacious, its capacity is not sufficient to accommodate all the files, causing file accumulation. However, the distance between the registration room and medical record storage is quite close and does not hinder daily operations. This research recommends improvements and additions to adequate facilities to increase the comfort of medical record officers.
Tahapan Audit Koding Rekam Medis dengan Menggunakan Analisa Kualitatif pada Pasien Rawat Inap di RS Khusus Mata SMEC Tahun 2025 Hutasoit, Theresia; Daeli, Cosmas Samuel; Sitorus, Mei Sryendang; Simanjuntak, Marta; Rotonga, Zulham Andi; Hasibuan, Ali Sabela; Liem, John Barker; Valentina, Valentina; Zulfahmi, Zulfahmi; Sitompul, Osayku Inesa
Jurnal Pengabdian Masyarakat (ABDIRA) Vol 6, No 1 (2026): Abdira, Januari
Publisher : Universitas Pahlawan Tuanku Tambusai

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31004/abdira.v6i1.1278

Abstract

Medical records are crucial documents that document all healthcare services. Accurate coding forms the basis for claims billing, research, and clinical decision-making. However, incomplete and inaccurate recording often presents obstacles, necessitating a coding audit. This Community Service project aimed to identify the stages of a coding audit using qualitative analysis of inpatients. The audit was conducted on four cases. The analysis used six review components: consistency of diagnosis and treatment, clinical recording, treatment justification, informed consent, documentation practices, and potential for compensation. The results of the medical record coding audit indicated that most components were consistent and met standards, including diagnosis, treatment, clinical recording, and completion of informed consent. However, inconsistencies were still found in instructions for discontinuing or replacing medications. There were no incidents that could potentially result in compensation. However, improvements are still needed in the documentation of instructions for discontinuing or replacing medications. The results emphasize the importance of ongoing socialization and monitoring to optimize the quality of medical records.
Design Of Accounting Information System for Transaction Management and Financial Reports at the Medan Pratama Haji Clinic Daeli, Cosmas Samuel; Lumbanbatu, Maristella J.; Naibaho, Anggi Wulandari
Pascal: Journal of Computer Science and Informatics Vol. 3 No. 01 (2025): Pascal: Journal of Computer Science and Informatics
Publisher : Devitara Innovations

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

Abstract

The rapid development of information technology requires healthcare institutions to digitize their financial data management to make administrative processes more effective and accurate. Medan's Pratama Haji Clinic currently still uses a manual system for recording transactions and preparing financial reports, resulting in frequent reporting delays, recording errors, and difficulties in tracking historical data. Based on these conditions, this study formulates three main problems, namely: how is the manual accounting information system currently implemented at Medan's Pratama Haji Clinic, what are the obstacles faced in managing financial reports manually, and how to design an accounting information system for managing transactions and financial reports. The purpose of this study is to design and build a computer-based accounting information system that can assist the process of recording transactions and preparing financial reports effectively at Medan's Pratama Haji Clinic. The research method uses the System Development Life Cycle (SDLC) with stages of analysis, design, implementation, and testing. Data were obtained through observation, interviews, and documentation. The system was designed using PHP and MySQL with the help of DFD, ERD, and Context Diagram tools. The results show that the system built is able to integrate all financial transaction processes and produce reports automatically, accurately, and efficiently. This system also facilitates management's oversight and decision-making. The study concluded that a computer-based accounting information system can replace manual systems and improve the efficiency of the clinic's finance department. A recommendation for further research is to develop this system with a web-based automated reporting module to make financial information more transparent and accessible.
Analisis Kesiapan Implementasi Rekam Medis Elektronik Menggunakan Pendekatan DOQ-IT Di Klinik Pratama Wulandari Tahun 2025 Daeli, Cosmas Samuel; Sitorus, Mei Sryendang; Hutasoit, Theresia; Sitompul, Osayku Inesa
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Vol. 11 No. 1 (2026): 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.v11i1.2185

Abstract

The implementation of Electronic Medical Records (EMR) is a mandatory requirement for all healthcare facilities in Indonesia to improve service quality, accelerate patient information access, and support data interoperability through a national platform. The purpose of this study was to analyze the readiness for the implementation of EMR using the DOQ-IT approach by assessing the influence of human resources, organizational work culture, governance and leadership, and IT infrastructure in healthcare services. This research used a descriptive quantitative method with total sampling of 16 respondents from various healthcare professions at Wulandari Primary Clinic. Data were collected using the DOQ-IT questionnaire consisting of multiple-choice questions. The analysis results showed that the overall assessment score was 74.44, which falls into Category II (fairly ready). This indicates that while there are strong capabilities in certain readiness components, weaknesses remain in others. Based on the four readiness aspects, only IT Infrastructure had the lowest classification score (2.50). The most prepared aspect was Human Resources (2.86), followed by Organizational Culture (2.67), and Governance and Leadership (2.58). Recomendation that need to be considered: Improve IT infrastructure, conduct regular training for staff, strengthen the role of leaders, conduct regular evaluations so that RME runs effectively
PERAN E-SIGNATURE DALAM MENJAMIN LEGALITAS DAN KEAMANAN DATA REKAM MEDIS ELEKTRONIK DI RUMAH SAKIT UMUM IMELDA PEKERJA INDONESIA Daeli, Cosmas Samuel; Khairani, Khairani; Gea, Indah Lestari
Jurnal Kesehatan Tambusai Vol. 7 No. 1 (2026): MARET 2026
Publisher : Universitas Pahlawan Tuanku Tambusai

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31004/jkt.v7i1.51688

Abstract

Transformasi digital di bidang kesehatan mendorong penggunaan Rekam Medis Elektronik (RME), termasuk pemanfaatan e-Signature sebagai upaya menjamin legalitas dan keamanan data. Penelitian ini bertujuan untuk menganalisis peran e-Signature dalam menjamin legalitas dan keamanan rekam medis elektronik di RSU Imelda Pekerja Indonesia. Penelitian menggunakan metode kualitatif deskriptif dengan empat informan, yaitu petugas IT, kepala unit rekam medis, perawat, dan dokter. Pengumpulan data dilakukan melalui wawancara dan observasi selama bulan April–Juni 2025. Hasil penelitian menunjukkan bahwa e-Signature memberikan dampak positif terhadap efisiensi pengelolaan RME, terutama dalam mempercepat proses validasi, autentikasi, dan penyimpanan dokumen. Meskipun menggunakan e-Signature tidak tersertifikasi, rumah sakit telah mengeluarkan kebijakan internal berupa SPO dan SK Direktur untuk memberikan legitimasi internal atas keabsahan tanda tangan elektronik. Dari aspek keamanan, sistem telah dilengkapi dengan algoritma hashing SHA-3, kontrol akses berbasis user, pencatatan log aktivitas, serta dukungan firewall dan backup berkala untuk mitigasi risiko keamanan. Kendala utama terletak pada aspek jaringan serta belum adanya sertifikasi resmi yang memperkuat kekuatan hukum dokumen elektronik. Penelitian menyimpulkan bahwa e-Signature berperan penting dalam meningkatkan efisiensi, integritas, dan keamanan data RME. Namun, penggunaan e-Signature tersertifikasi masih diperlukan guna memperkuat legalitas dan perlindungan data secara menyeluruh sesuai standar nasional.
Co-Authors Andi Ritonga, Zulham Denni M Rajagukguk Erlindai, Erlindai Erwin Setiawan Panjaitan Gea, Indah Lestari Gusla Nengsih, Yeyi Hasibuan , Khoirul Fadli Hulu, Delisman Hulu, Mery Windhy Kristina Ika Yusnita Sari Khairani Khairani Khairunisa, Khairunisa Khairunnisa Khairunnisa Liem , Jhon Barker Liem, John Barker Lumbanbatu, Maristella J. Manalu, Mamed Rofendi Maulana, Fajar Naibaho, Anggi Wulandari Panjaitan, Muhammad Iqbal Partap, Joni Rahmi, Elvika Rajagukguk, Denni M. Roni Yunis Rotonga, Zulham Andi Sabela Hasibuan, Ali Siddik Karo-Karo Sihite, Geovani Arta Sihombing, Marjones H.H Sihombing, Marjones H.H. Sihombing, Marjones Hardy H Sihombing, Monang JT Simanjuntak, Marta Sinulingga, Nurbeti Sitompul, Osayku Inesa Sitorus , Mei Sryendang Sitorus, Mei Sryendang Theresia Hutasoit Valentina Valentina, Valentina Zulfahmi Zulfahmi