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ANALISIS KELENGKAPAN FORMULIR RINGKASAN MASUK DAN KELUAR RAWAT INAP NON BEDAH DI RUMAH SAKIT X Indira, Zahrasita Nur; Taharah, Dena; Damayanti, Rifka Oktavia
Jurnal Kesehatan Tambusai Vol. 6 No. 1 (2025): MARET 2025
Publisher : Universitas Pahlawan Tuanku Tambusai

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31004/jkt.v6i1.42579

Abstract

Rekam mediscyang tidak lengkap akan berpengaruh padaakeakuratan dari aspek legal dan isi rekam medis, salah satunya pada bagian formulir ringkasan masuk dan keluar rawat inap. Pelayanan rawat inap merupakan pelayanan kepada pasien yang masuk ke rumah sakit dan menggunakan tempat tidur untuk’keperluan observasi, diagnosis, terapi yang diberikan, rehabilitasi medik dan penunjang medik lainnya. Formulir ringkasan masuk dan keluar merupakan bagian yang diabadikan dan memiliki nilai guna serta tidak dimusnahkan. Tujuan penelitian ini untuk mengetahui presentase dan nilai kelengkapan rekam medis rawat inap pada formulir ringkasan masuk dan keluar di rumah sakit umum. Metode penelitian ini menggunakan analisis kuantitatif deskriptif dengan pengumpulan data pasien pada setiap bulannya di bagian pendaftaran rawat inap. Penelitian ini dilaksanakan di salah satu rumah sakit umum yang berada di wilayah Kabupaten Banyumas pada tahun 2024. Hasil penelitian ini didapatkan ketidaklengkapan pada bagian diagnosa sementara, keluarga terdekat dan penanggung jawab pembayaran, riwayat rawat inap, pelayanan (prioritas pelayanan dan jenis pelayanan) dan pada identitas sosial. Simpulan dari penelitian ini adalah formulir hampir sepenuhnya berisikan aspek penting seperti identitas pasien, laporan penting dan autentifikasi, sehingga wajib diisi secara lengkap, tetapi dalam hal ini masih terdapat formulir yang  tidak lengkap seperti pada laporan penting, yang mana kelengkapan diperlukan untuk meningkatkan mutu rekam medis dan digunakan untuk kepentingan administrasi lainnya.
Literature Review: The Effectiveness of Electronic Medical Records (RME) On Hospital Service Quality Indira, Zahrasita Nur; Widodo, Aris Puji; Agushybana, Farid
J-Kesmas: Jurnal Fakultas Kesehatan Masyarakat (The Indonesian Journal of Public Health) Vol 10, No 1 (2023): April 2023
Publisher : Universitas Teuku Umar

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.35308/j-kesmas.v10i1.7278

Abstract

Health Information System is a systematic way of managing information at all levels of government to provide healthcare services to the community. In providing services to the community, the health information system is a systemic management of information at all levels of government. Every healthcare facility in Indonesia must maintain electronic medical records based on Permenkes No. 24/2022. This shows that the role of Health Information Systems is needed in a health system. However, using electronic medical records (EMR) in Indonesian healthcare facilities must be uniformly and sufficiently implemented, so it cannot provide accurate and timely data. This study aims to assess the implementation of EMR in Indonesian hospitals. This study used the literature review method by reviewing 15 journal articles published between 2016 and 2022, retrieved through Google Scholar. The results showed that several hospitals in Indonesia had implemented EMR; some hospitals have effectively implemented it and benefit from the implementation of EMR, such as improving the efficiency of time and effort in providing health services to patients. Patients also receive better medical care. The study findings aim to encourage all healthcare facilities to optimize the use of EMR to enhance healthcare services.  
Analysis Implementation of Hospital Management Information System (SIMRS) at Place of Inpatient Registration (TPPRI) Using The PIECES Method at The Ajibarang Government Hospital Afgani, Abu Sofyan Al; Indira, Zahrasita Nur; Nadi, Danu Tirta; Marini, Budiana
Indonesian Journal of Electronics, Electromedical Engineering, and Medical Informatics Vol. 6 No. 2 (2024): May
Publisher : Jurusan Teknik Elektromedik, Politeknik Kesehatan Kemenkes Surabaya, Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.35882/k1wbwp80

Abstract

Hospital Management Information System (SIMRS) is an information communication technology system that processes and integrates the entire process flow of hospital services in the form of a network of coordination, reporting and administrative procedures to obtain information precisely and accurately, and is part of the Health Information System. The implementation of SIMRS at the Ajibarang Regional General Hospital (RSUD) has been carried out since 2014 in almost all units, one of which is the Inpatient Registration Place (TPPRI). This study aims to improve the shortcomings of the system that has been made at SIMRS RSUD Ajibarang. The method used in this study is qualitative. The data collection method used in this study was using in-depth interviews. The data analysis method uses Performance, Information, Economy, Control, Efficiency, and Service (PIECES) which aims to obtain information related to the implementation of SIMRS at the Ajibarang Regional General Hospital. Based on the results of the SIMRS analysis in the TPPRI section, there are still obstacles in its implementation, both in terms of Performance, Information, Economy, Control, Efficiency, and Service. The results showed that there are still several problems, namely the presence of menus that are not functioning optimally, different TPPRI and TPPRJ SIMRS, inaccurate data, Human error, server down, and no warning if an error occurs. SIMRS has been running according to user needs, but cannot be separated from various problems, so it is necessary to improve and develop SIMRS through researcher recommendations so that SIMRS can maintain and improve the quality of service to patients. Based on the description of the problem, as there is no warning if an error occurs, the user will easily continue to input data on SIMRS so that errors are not detected that result in losses for hospitals and produce inaccurate data.