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All Journal J-Kesmas: Jurnal Kesehatan Masyarakat (Indonesian Journal of Public Health) Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Jurnal Kesehatan Tambusai J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Journal of Nursing and Health (JNH) Akper Yakpermas Banyumas MAHESA : Malahayati Health Student Journal PELS (Procedia of Engineering and Life Science) Journal of Innovation Research and Knowledge Indonesian Journal of Electronics, Electromedical Engineering, and Medical Informatics
Zahrasita Nur Indira
Universitas Muhammadiyah Purwokerto
Humanities Computer Science & IT Control & Systems Engineering Decision Sciences, Operations Research & Management Dentistry Economics, Econometrics & Finance Education Electrical & Electronics Engineering Engineering Health Professions Law, Crime, Criminology & Criminal Justice Materials Science & Nanotechnology Medicine & Pharmacology Nursing Public Health Social Sciences

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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.
Perbandingan Penerapan Electronic Medical Record Ditinjau dari Regulasi, Integrasi Sistem, Sistem Casemix, Fokus Pengolahan Emr dan Sop di RSUD Cilacap dan Hospital Sultan Abdul Aziz Shah Malaysia Ummah, Shofiatul; Yektiningtyastuti, Yektiningtyastuti; Nadi, Danu Tirta; Indira, Zahrasita Nur; Rahim, Norizanne Binti Abd; Pratama, Riskrisna Adi
MAHESA : Malahayati Health Student Journal Vol 6, No 5 (2026): Volume 6 Nomor 5 (2026)
Publisher : Universitas Malahayati

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33024/mahesa.v6i5.24819

Abstract

ABSTRACT Medical records are an essential component of healthcare services as they function to document the entire process of patient care. The development of information technology has encouraged the transformation of medical record management from manual paper-based systems to Electronic Medical Records (EMR), which are considered capable of improving service efficiency, facilitating faster access to patient information, and supporting healthcare financing and reporting systems. However, the implementation of EMR still varies across hospitals and countries due to differences in regulatory frameworks, technological infrastructure readiness, and institutional policies. This study aims to identify and compare the implementation of Electronic Medical Records (EMR) at RSUD Cilacap, Indonesia, and Hospital Sultan Abdul Aziz Shah (HSAAS), Malaysia, in terms of regulation, system integration, casemix system, EMR data processing focus, and Standard Operating Procedures (SOP). This research employed a qualitative descriptive method with a cross-sectional and comparative design. Data were collected through observation and document review as the primary sources, supported by interviews. The results show that RSUD Cilacap implements EMR based on national regulations using a one integrated platform system, integrates EMR with the INA-CBG’s casemix system, and utilizes EMR for both internal and external reporting with SOP management under the medical records unit. In contrast, HSAAS Malaysia implements EMR based on internal hospital policies using multiple platform systems, applies the MY-DRG casemix system which is not integrated with EMR, focuses EMR processing on internal reporting, and manages SOPs under the information technology unit. In conclusion, the implementation of EMR in both hospitals differs in terms of regulation, system integration, casemix system, EMR data processing focus, and Standard Operating Procedures. Keywords: Casemix, Comparative Study, Electronic Medical Record, Integrated System, Regulation. ABSTRAK Rekam medis merupakan komponen penting dalam pelayanan kesehatan karena berfungsi sebagai sarana pendokumentasian seluruh proses pelayanan pasien. Perkembangan teknologi informasi mendorong transformasi pengelolaan rekam medis dari sistem manual berbasis kertas menuju Electronic Medical Record (EMR) yang mampu meningkatkan efisiensi pelayanan, mempercepat akses informasi pasien, serta mendukung sistem pembiayaan dan pelaporan kesehatan. Namun, implementasi EMR masih menunjukkan variasi antar rumah sakit dan antar negara akibat perbedaan regulasi, kesiapan infrastruktur teknologi, serta kebijakan institusional. Penelitian ini bertujuan untuk mengetahui dan membandingkan penerapan EMR di RSUD Cilacap, Indonesia dan Hospital Sultan Abdul Aziz Shah (HSAAS) Malaysia yang ditinjau dari aspek regulasi, integrasi sistem, sistem casemix, fokus pengolahan EMR, dan Standar Operasional Prosedur (SOP). Penelitian ini menggunakan metode deskriptif kualitatif dengan rancangan cross-sectional dan desain komparatif. Data dikumpulkan melalui observasi dan studi dokumentasi sebagai sumber utama serta wawancara sebagai data pendukung. Hasil penelitian menunjukkan bahwa RSUD Cilacap menerapkan EMR berdasarkan regulasi nasional dengan sistem one integrated platform, sistem casemix INA-CBG’s yang terintegrasi dengan EMR, serta pemanfaatan EMR untuk pelaporan internal dan eksternal dengan pengelolaan SOP oleh unit rekam medis. Sementara itu, HSAAS Malaysia menerapkan EMR berdasarkan kebijakan internal rumah sakit dengan sistem multiple platform, sistem casemix MY-DRG yang belum terintegrasi dengan EMR, fokus pengolahan EMR pada pelaporan internal, serta pengelolaan SOP oleh unit teknologi informasi. Kesimpulannya, penerapan EMR di kedua rumah sakit menunjukkan perbedaan pada aspek regulasi, integrasi sistem, sistem casemix, fokus pengolahan EMR, dan SOP. Kata Kunci: Casemix, Electronic Medical Record, Integrasi Sistem, Regulasi, Studi Komparatif.
Co-Authors Aep Saepulloh Afgani, Abu Sofyan Al Aldi Pratama Anggraeni, Okti Aris Puji Widodo Aris Puji Widodo Budiyanti, Shifa Amanda Cahyani, Lintang Dwi Cindy Rozza Bella Damayanti, Rifka Oktavia Dion Romodon Farid Agushybana Farid Farid Agushybana Febriana, Dina Hakim, Agya Osadawedya Harry Fauzi Harry Fauzi, Harry Marini, Budiana Mayasari, Winda Nur Meylia, Nadira Zalfa Mulyani, Agustina Dwi Nadi, Danu Tirta Najwa Azkia Rahma Nurami, Amara Nabiila Sekar Parmesti, Khoirunnisa Riski Permatasari, Merdiana Ika Praptanti, Agustina Fitri Pratama, Riskrisna Adi Prisai Purnama Adi Purnama Adi, Prisai Rahim, Norizanne Binti Abd Setyaningsih, Fahmi Siregar, Rahmadhani Taharah, Dena Ummah, Shofiatul Utami Budi Lestari Wahyudi, Rusli Diki Wibowo, Dimas Ari Wijayanti, Wahyu Nur Yektiningtyastuti Yektiningtyastuti Yustafia, Atiqah Filda