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All Journal Jurnal Manajemen Informasi dan Administrasi Kesehatan Indonesian of Health Information Management Journal (INOHIM) Gaster
Haryanti, Rheni
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Computer Science & IT Health Professions Medicine & Pharmacology Nursing Public Health

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Analisis Kelengkapan Pengisian Berkas Rekam Medis Rawat Inap Di RS X di Kabupaten Klaten Syahputri, Rezyana Budi; Haryanti, Rheni; Rohma, Freshtasya Nora Putri
Jurnal Manajemen Informasi dan Administrasi Kesehatan Vol. 7 No. 2 (2024): JMIAK
Publisher : Program Studi D3 Rekam Medis dan Informasi Kesehatan

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.32585/jmiak.v7i2.5921

Abstract

One of the essential support services in hospitals is the completeness of medical records. The ability to properly maintain medical records facilitates healthcare providers in conducting patient treatments and interventions, while also serving as a valuable information source for hospital management in evaluating and developing healthcare services. However, common issues in medical record documentation include incomplete entries and physicians' insufficient specificity in documenting diagnoses. The aim of this study is to describe the medical records of inpatients at RS X Kabupaten Klaten. This research analyzes the completeness of medical record files at RS X Kabupaten Klaten. A quantitative study was conducted on 98 medical record files by reviewing four components. The results show varying levels of completeness, with some components reaching 100% (such as demographic data), while the lowest was 25.5% (ICD9CM procedures). Critical components like Diet (25.5%) indicate areas in need of improvement. The readability of medical records reached 94.9%. This study identifies areas that require enhancement and suggests strategies such as staff training, routine audits, standardized formats, and the implementation of electronic medical records. Improving the completeness of medical records is expected to enhance patient care quality and hospital operational efficiency.
Pulmonary Complaints Among Gas Station Operators: A Descriptive Study in Klaten Region Handayani, Sri; Agustiningrum, Ratna; Agustina, Nur Wulan; Haryanti, Rheni
Gaster Vol 23 No 2 (2025): AGUSTUS
Publisher : P3M Universitas 'Aisyiyah Surakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.30787/gaster.v23i2.1964

Abstract

Background Gas station environments pose a high risk for exposure to vehicle emissions, which may lead to respiratory health issues due to the accumulation of hazardous pollutants. Continuous exposure, particularly among gas station operators, increases susceptibility to pulmonary disorders. Objective This study aimed to describe the prevalence and characteristics of pulmonary complaints among gas station workers in the Klaten region. Methods A descriptive study was conducted at two gas stations (44.57406 and 44.57403), both located on major traffic routes and operating daily. The total sampling technique was employed, involving 51 workers. Data were collected using structured questionnaires that assessed personal characteristics, smoking habits, mask usage behavior, and respiratory symptoms. Descriptive statistics using frequency distribution were applied in the data analysis. Results Findings showed that 41.2% of respondents experienced pulmonary complaints. The most frequently reported symptoms included shortness of breath while walking briskly, shortness of breath after physical exertion, productive cough, and persistent coughing throughout the day. Contributing factors identified were long working hours, smoking behavior, and inconsistent use of face masks. Conclusion A significant proportion of gas station operators reported respiratory complaints potentially linked to prolonged exposure to vehicle emissions. Additional risk factors such as smoking and improper personal protective equipment use may further compromise respiratory health. These findings underscore the need for preventive measures, including occupational health education, routine screening, and environmental interventions.
Determinasi Faktor Individu terhadap Kelengkapan Pengisian Rekam Medis oleh Tenaga Kesehatan Syahputri, Rezyana Budi; Haryanti, Rheni; Andriani, Nurul Dwi; Hariyadi, Agustin Mahardika; Latifah, Dwi Nur
Indonesian of Health Information Management Journal (INOHIM) Vol 13, No 2 (2025): INOHIM
Publisher : Lembaga Penerbitan Universitas Esa Unggul

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.47007/inohim.v13i2.744

Abstract

Abstract Completeness of medical record documentation was an essential component of healthcare quality that supported patient safety, continuity of care, and hospital legal accountability. Individual factors such as knowledge, attitude, and work experience were assumed to influence healthcare workers’ compliance with medical documentation standards. This study aimed to analyze the effect of individual factors on the completeness of medical record documentation among healthcare workers at Hospital X. A cross-sectional design was applied, involving 82 healthcare workers selected through stratified random sampling. Data were collected using a structured questionnaire and observation sheet that had been tested for validity and reliability. Data were analyzed using Chi-square and multiple logistic regression with a significance level of 0.05. The results showed that most respondents had high knowledge (85.4%) and positive attitudes (75.6%). Bivariate analysis revealed significant relationships between knowledge and attitude with the completeness of medical record documentation (p=0.000). Multivariate analysis revealed that only knowledge had a significant effect on medical record completeness (OR=0.068; p=0.001), while attitude was not statistically significant. This study concludes that knowledge is the main determinant of complete medical record documentation. Strengthening knowledge through continuous training, medical record audits, and structured feedback is necessary to improve the quality of medical documentation in healthcare facilities. Keyword: medical record, knowledge, attitude, healthcare workers, documentation completeness Abstrak Kelengkapan pengisian rekam medis merupakan bagian penting dari mutu pelayanan kesehatan yang mendukung keselamatan pasien, kesinambungan asuhan, dan akuntabilitas hukum rumah sakit. Faktor individu seperti pengetahuan, sikap, dan pengalaman kerja diduga memengaruhi tingkat kepatuhan tenaga kesehatan terhadap standar dokumentasi medis. Penelitian ini bertujuan untuk menganalisis pengaruh faktor individu terhadap kelengkapan pengisian rekam medis oleh tenaga kesehatan di Rumah Sakit X. Penelitian ini menggunakan studi cross-sectional dengan jumlah responden sebanyak 82 tenaga kesehatan yang dipilih melalui stratified random sampling. Data dikumpulkan menggunakan kuesioner terstruktur dan lembar observasi yang telah diuji validitas dan reliabilitasnya. Analisis dilakukan menggunakan uji chi-square dan regresi logistik berganda dengan tingkat signifikansi 0,05. Hasil penelitian menunjukkan bahwa sebagian besar responden memiliki pengetahuan tinggi (85,4%) dan sikap positif (75,6%). Uji bivariat menunjukkan hubungan yang signifikan antara pengetahuan dan sikap dengan kelengkapan pengisian rekam medis (p=0,000). Hasil analisis multivariat menunjukkan bahwa hanya pengetahuan yang berpengaruh signifikan terhadap kelengkapan pengisian rekam medis (OR=0,068; p=0,001), sedangkan sikap tidak menunjukkan pengaruh yang signifikan. Penelitian ini menyimpulkan bahwa pengetahuan merupakan faktor determinan utama dalam kelengkapan pengisian rekam medis. Penguatan pengetahuan melalui pelatihan berkelanjutan, audit rekam medis, dan umpan balik terstruktur diperlukan untuk meningkatkan mutu dokumentasi medis di fasilitas pelayanan kesehatan. Kata Kunci: rekam medis, pengetahuan, sikap, tenaga kesehatan, kelengkapan dokumentasi
Co-Authors Agustina, Nur Wulan Agustiningrum, Ratna Handayani, Sri Hariyadi, Agustin Mahardika Latifah, Dwi Nur Nurul Dwi Andriani Rohma, Freshtasya Nora Putri Syahputri, Rezyana Budi