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A literature review: Security Aspects in the Implementation of Electronic Medical Records in Hospitals Piping Asgiani; Chriswardani Suryawati; Farid Agushybana
MEDIA ILMU KESEHATAN Vol 10 No 2 (2021): Media Ilmu Kesehatan
Publisher : Universitas Jenderal Achmad Yani Yogyakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.30989/mik.v10i2.561

Abstract

Backgrounds: Electronic Medical Records have complete and integrated patient health data, and are up to date because RME combines clinical and genomic data, this poses a great risk to data disclosure The priority of privacy is data security (security) so that data will not leak to other parties. That way cyber attacks can be suppressed by increasing cybersecurity, namely conducting regular evaluation and testing of security levels.Objectives: To determine the security technique that maintains privacy of electronic medical records.Methods: This type of research uses a literature review methodResults: Data security techniques are determined from each type of health service. Data security techniques that can be applied are cryptographic methods, firewalls, access control, and other security techniques. This method has proven to be a very promising and successful technique for safeguarding the privacy and security of RMEConclusion: Patient medical records or medical records are very private and sensitive because they store all data about complaints, diagnoses, disease histories, actions, and treatments about patients, so the information contained therein must be kept confidential. As well as the hospital as a medical record manager is required to apply for patient privacy data security techniques.
Evaluasi Penerapan Sistem Informasi Manajemen Rumah Sakit di Bagian Rekam Medis Rumah Sakit Bhayangkara POLDA DIY Piping Asgiani; Andi Karisma Nurdiyansyah
MEDIA ILMU KESEHATAN Vol 11 No 1 (2022): Media Ilmu Kesehatan
Publisher : Universitas Jenderal Achmad Yani Yogyakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.30989/mik.v11i1.721

Abstract

Background: RS Bhayangkara POLDA DIY is one of any hospital who used SIMRS since 2011, but in fact they never do any evaluating which very important to the goods for the hospital itself.Objective: To evaluate the implementation of SIMRS in the medical records section of the Bhayangkara POLDA DIY Hospital.Methods: The data was collected by observation, interview, and documentation. Research population are all of 6 medical record employees, and the sample is from all of those 6 employees.Results: The performance and information aspects are considered not good, the economic, control, efficiency, and service aspects are considered good. The user's satisfaction, it has been considered good but there are still obstacles faced by the user, namely the system performance is not optimal, system error and network are slow.Conclusion: The hospital should follow up this complain from user and coordinate with IT officer for optimizing the system as soon as possible
Analisis Skrining Kesehatan Calon Pendonor untuk Meningkatkan Minat Donor Darah Masyarakat Patangpuluhan Reza Iqbal Suhada; Nurpuji Mumpuni; Piping Asgiani
Jurnal Indonesia Sehat Vol. 3 No. 2 (2024): JURINSE, Agustus 2024
Publisher : SAMODRA ILMU: Lembaga Penelitian, Penerbitan, dan Jurnal Ilmiah

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Abstract

Background: Blood donation activities can be carried out by all people aged 17 to 60 years old with a healthy body condition. Before donating blood, a health screening examination is carried out. Most of society has not know what health screening examinations are carried out before donating blood. The purpose of this research is to find out the results health screening examination at Patangpuluhan Community, Wirobrajan, Kota Yogyakarta before donating blood. Method:  The sample in this research used total sampling. This research is a descriptive analytical research. Data analysis using the SPSS application with descriptive analytical tests. Result: The results of data analysis show that the characteristics of donors are mostly aged 20-29 years, 8 donors (32%), male gender, 15 donors (60%), private sector employees, 15 donors (32%). Blood type O 12 (48%), weight 61-70 9 (36%), normal blood pressure 22 (88%), normal hemoglobin level 22 (88%). Conclusion: 20 donors were interested in donating blood (80%).
Kualifikasi Pendidikan Perekam Medis dan Informasi Kesehatan di Faskes Tingkat II Masih Belum Memenuhi Standar Profesi: Educational Qualifications for Medical Recorders and Health Information at Level II Health Facilities Still Do Not Meet Professional Standards Piping Asgiani
Infomasi dan Promosi Kesehatan Vol 2 No 1 (2023): Informasi dan Promosi Kesehatan
Publisher : Sahabat Publikasi Kuu

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.58439/ipk.v2i1.110

Abstract

Introduction: Educational Qualifications of medical recorders are the minimum requirements related to educational background that must be possessed by medical record officers in order to be able to carry out their duties in accordance with their job descriptions in health care facilities. The level of education influences the understanding and ability of officers regarding the security and confidentiality of medical records. Purpose: Know the qualification standards and implementation of job descriptions for medical record officers in hospitals. Method: The type of research used is Qualitative Descriptive research. The research design used is a case study. Determination of research subjects using purposive sampling techniques where the subjects are all medical record officers. The main informants in this study were 4 medical record officers. Results: The number of officers in the medical record section is 35 people. The details per unit are as follows: 8 IT people, 7 RM people and 20 registration officers. Based on educational qualifications, only 4 medical record officers had a D3 Medical Record background, the rest came from SMA, D1 Non RM, D3 Non RM, and S1 Non RM qualifications. The implementation of the job description is in accordance with the organizing guidebook, but there are still several obstacles, namely related to the absence of human resource development, there are double jobs, lack of understanding of confidentiality and delays in returning medical records. Conclusion: There are still educational qualifications that do not have a medical record educational background. There are several obstacles in the implementation of job descriptions, especially for officers who do not have a non-RMIK educational background.
Sosialisasi Peran Perawat Tehadap Kelengkapan Pengisian Anamnese Dalam Mendukung Pengodean Diagnosis Cidera Penyebab Luar di RS Mitra Paramedika Nurdiyansyah, Andi Karisma; Darussalam, Miftafu; Asgiani, Piping; Ayu, Sandrita Mustika; Maulidina, Resky Nurul
Jurnal Pengabdian Sosial Vol. 1 No. 9 (2024): Juli
Publisher : PT. Amirul Bangun Bangsa

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.59837/22zqmy86

Abstract

Informasi external causes digunakan untuk menentukan klasifikasi kode external causes. Informasi external causes dianalisa oleh petugas koder untuk menentukan kode external causes dengan lengkap sampai karakter kelima, meliputi kategori tiga karakter yang menunjukkan bagaimana kecelakaan terjadi, karakter keempat yang menunjukkan lokasi terjadinya kecelakaan, dan karakter kelima yang menunjukkan aktivitas pasien saat terjadinya kecelakaan. Jika anamnesa dilakukan dengan detail maka akan didapatkan informasi yang benar-benar dibutuhkan dalam pelayanan kesehatan tersebut. Oleh karena itu, tenaga medis atau dokter yang menangani pasien harus menuliskan anamnesa secara lengkap agar diperoleh informasi yang tepat dalam penegakan suatu diagnosa. Seorang perawat harus mampu melaksanakan dokumentasi asuhan keperawatan dalam catatan perkembangan pasien terintegrasi dengan lengkap, jelas, akurat, dan dapat dipahami oleh PPA (Profesional pemberi asuhan) yang lain. Tujuan dari pengabdian kepada masyarakat ini adalah untuk menyampaikan informasi tentang Kelengkapan Pengisian Anamnese Dalam Mendukung Pengodean Diagnosis Cidera Penyebab Luar di RS Mitra Paramedika. Lokasi PKM di RS Mitra Paramedika. Metode yang digunakan dalam menyelesaikan permasalahan mitra melalui pelatihan dan substitusi ipteks. Kegiatan pelatihan dilakukan dengan memberikan penyuluhan. Kegiatan pengabdian diawali dengan mengumpulkan coder rekam medis dan perawat IGD. Dalam kegiatan terbagi menjadi 4 kegiatan yang diawali pendataan peserta  dilanjutkan melaksanakan pre test kemudian dilakukan penyamaian materi sosialisasi. Diahkir kegiatan dilakukan post test untuk untuk mengetahui tingkat pengetahui Perawat Tehadap Kelengkapan Pengisian Anamnese Dalam Mendukung Pengodean Diagnosis Cidera Penyebab Luar setelah dilaksanakan sosialisasi.
Manajemen Rekam Medis dalam Mendukung Alih Media Medis Rekam Elektronik di RSUD Nyi Ageng Serang Asgiani, Piping; Sari, Rizky Yuspita; Purwanti, Endang; Suryaningsih, Yuni
Jurnal Pengabdian Masyarakat Bangsa Vol. 1 No. 11 (2024): Januari
Publisher : Amirul Bangun Bangsa

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.59837/jpmba.v1i11.614

Abstract

Digitalisasi rekam medis adalah sebuah proses peralihan media dokumen rekam medis yang berbasis kertas menjadi sebuah dokumen digital yang berupa file berekstensi misal, PDF atau JPG. Pengelolaan data hasil digitalisasi rekam medis membantu tenaga rekam medis dalam pemilahan, pencarian, dan pemanggilan informasi pasien tanpa perlu membuka dokumen lama. Kami melakukan sosialisasi yang bertujuan memberikan edukasi tentang pengelolaan dan pengorganisasian hasil digitalisasi rekam medis, mencakup pengertian umum, dasar hukum, dan tata cara digitalisasi. Kegiatan ini dilaksanakan di RSUD Nyi Ageng Serang dengan metode Focus Group Discussion kepada staf Rekam Medis. Kesimpulan: RSUD Nyi Ageng Serang belum melaksanakan alih media rekam medis secara menyeluruh dan kegiatan alih media baru diprioritaskan untuk kondisi tertentu, seperti dokumentasi hasil laboratorium dari luar Rumah Sakit dan formulir yang masih menggunakan tanda tangan manual. Hasil PkM ini diharapkan dapat menjadi bahan pertimbangan dalam penyusunan regulasi dan standar prosedur pelaksanaan alih media serta RSUD Nyi Ageng Serang mengharapkan adanya PkM lanjutan dari periode saat ini berupa pendampingan dalam pelaksanaan alih media rekam medis manual ke elektronik
The Role of Electronic Medical Records as a Professional Communication Tool for Caregivers at Nyi Ageng Serang Hospital: Peran Rekam Medis Elektronik sebagai Alat Komunikasi Profesional Pemberi Asuhan di RSUD Nyi Ageng Serang Nurdiyansyah, Andi Karisma; Wuryanto, Sis; Asgiani, Piping; Setiawan, Fendi
Procedia of Engineering and Life Science Vol. 7 (2025): Prosiding Seminar Nasional dan Rakernas PORMIKI X
Publisher : Universitas Muhammadiyah Sidoarjo

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.21070/pels.v7i0.2100

Abstract

To improve the quality and efficiency of health services in hospitals, there needs to be good communication from care professionals working at the service facility. Communication between care-giving professionals can be done by data communication through Electronic Medical Records (RME). RSUD Nyi Ageng Serang has implemented an outpatient RME to support patient care. However, the existing application has not been optimally utilised. The aim was to determine the role of RME as a communication tool between care professionals at Nyi Ageng Serang Hospital. The type of research used was descriptive qualitative research with a cross sectional design. This study used observation and focused group discussion (FGD) methods for data collection. The subject of this research is professional caregivers in outpatient installations while the object is RME. The data analysis technique used was qualitative data analysis technique starting with data reduction, data presentation, and continued with conclusion drawing. The role of electronic medical records in the implementation of interprofessional communication and collaboration is as a means of communication, especially where every finding and opinion of health professionals by care-giving professionals is poured and put together in electronic medical records, the findings of the medical history and actions given to patients and documented in writing or recorded. However, all of these provide benefits such as more complete RM content, business and communication efficiency, strategic benefits, and easy access to information. The completeness of patient data documentation in the RME at Nyi Ageng Serang Hospital can be improved through strengthening supporting regulations for documentation, training on the completeness of patient data filling for PPAs, adding features to check the completeness of documentation and designing a reward and punishment system for PPAs in terms of completeness of documentation in the RME. The addition of optional features to determine the diagnosis of disease by adding a list of disease diagnoses based on ICD-10 to the RME system database which makes writing a patient's medical diagnosis more concise and standardised and writing the main diagnosis is only written one diagnosis.
Implementasi Rekam Medis Elektronik Belum Menjamin Ketepatan Kode Diagnosis Kasus Gagal Ginjal Praptana; Piping Asgiani; Dewi Retno Pamungkas; Reza Iqbal Suhada; Ida Aninda
Jurnal Adijaya Multidisplin Vol 3 No 01 (2025): Jurnal Adijaya Multidisiplin (JAM)
Publisher : PT Naureen Digital Education

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Abstract

Gagal ginjal merupakan penyakit kronis dengan angka kematian tinggi dan pembiayaan besar oleh BPJS Kesehatan. Salah satu kendala utama dalam klaim BPJS adalah ketidaktepatan kode diagnosis. Implementasi rekam medis elektronik (RME) diharapkan dapat meningkatkan akurasi kode diagnosis dengan memperbaiki keterbacaan dan kelengkapan informasi medis. Penelitian kuantitatif dengan desain studi kasus ini membandingkan ketepatan kode diagnosis sebelum dan setelah implementasi RME di RSU Mitra Paramedika. Sampel terdiri dari 400 kasus gagal ginjal, masing-masing 200 kasus sebelum dan sesudah implementasi. Ketepatan kode diagnosis sebelum implementasi RME sebesar 89% dan setelah implementasi meningkat menjadi 90%, dengan selisih hanya 1%. Ketidaktepatan kode masih terjadi akibat inkonsistensi penulisan dan pemilihan kode diagnosis. Implementasi RME belum menunjukkan perbedaan signifikan dalam meningkatkan ketepatan kode diagnosis. Diperlukan penelitian lebih lanjut untuk mengidentifikasi penyebab utama ketidaktepatan guna meningkatkan kualitas dokumentasi rekam medis.
Burnout during Electronic Medical Record Migration among Healthcare Providers: A Cross-Sectional Study at Mitra Paramedika Hospital, Indonesia Dwi Raharjo, Untoro; Widianingrum , Bina; Riyadi, Sujono; Aninda, Ida; Nurdiyansyah , Andi Karisma; Asgiani , Piping
Journal of health research and technology Vol. 2 No. 1 (2024): Journal of health research and techonology
Publisher : Sahabat Publikasi Kuu

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.58439/jhrt.v2i1.170

Abstract

Health Care Professionals (HCPs) are professionals who provide comprehensive care to patients, including medical documentation. During the migration from manual medical records to electronic medical records (EMR), the documentation process can pose additional challenges and induce stress, as HCPs must adapt to a new documentation process and face the risk of errors in documentation. This situation can lead to burnout related to the migration of medical records. This study aimed to identify the factors influencing burnout among HCPs during the migration of medical records at Mitra Paramedika Hospital. A correlational study was conducted involving 67 HCPs in the outpatient unit of Mitra Paramedika Hospital. Burnout data were collected through the distribution of a modified Maslach Burnout Inventory (MBI) questionnaire, and statistical analysis was performed using SPSS version 25 with the Cramer's V & Somer’s D statistical test. The evaluation revealed that the average burnout score among HCPs related to the migration of medical records was 1.86, categorizing it as moderate burnout. Factors such as respondents' age, gender, marital status, years of service, and profession had no significant impact on burnout among HCPs in the outpatient unit of Mitra Paramedika Hospital. Only educational status that significantly correlated to burnout in our study. Further assessment is required to explore another factors of burnout among HCPs during EMR migration.
PERSEPSI PERAWAT TERHADAP PEMANFAATAN REKAM MEDIS ELEKTRONIK DALAM MENDUKUNG MANAJEMEN PELAYANAN DI RSUD dr. REHATTA Piping Asgiani; Yohana, Yohana
VISIKES Vol. 24 No. 1 (2025): VISIKES
Publisher : Dian Nuswantoro Semarang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.60074/visikes.v24i1.12074

Abstract

Electronic Medical Records (EMRs) are beneficial in improving patient care management in healthcare facilities. RSUD dr. Rehatta, Central Java Province, has implemented EMRs since 2023, but no evaluation has yet been conducted regarding nurses' satisfaction with their utilization. This study is descriptive with a qualitative approach. The research design is a case study, and data were collected through in-depth interviews with seven informants. The content dimension was rated as less satisfactory due to the complexity of the anamnesis module. The accuracy dimension did not fully meet user expectations. The format dimension was also rated as suboptimal due to inefficiencies. The timeline dimension was considered good, while the ease of use dimension was rated positively, as data entry was deemed simple. The implementation of the Inova system in the outpatient clinic of RSUD dr. Rehatta has shown benefits, but some user complaints remain. Immediate improvement strategies include simplifying content, reducing information delivery delays, and enhancing system usability.