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TINJAUAN PELAKSANAAN RETENSI REKAM MEDIS DI RSUD DR. H. MOCH. ANSARI SALEH BANJARMASIN Eka Rahma Ningsih; Husin Husin; Hijeratun Nisa
Jurnal Kajian Ilmiah Kesehatan dan Teknologi Vol 5 No 1 (2023)
Publisher : Politeknik Unggulan Kalimantan

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52674/jkikt.v5i1.101

Retention of medical records is carried out because medical records will continue to grow until the storage rack is full and there is no longer enough so that medical records will not be stored forever in the storage room. The results of observations in the preliminary study at RSUD Dr. H. Moch. Ansari Saleh, inactive medical records are still not stored in the inactive storage room as they should be. This study aims to review the retention of medical records in RSUD Dr. H. Moch. Ansari Saleh Banjarmasin from preparation, implementation to evaluation. This research method uses qualitative research with a case study design. The subjects of this study were taken using a purposive sampling technique with the subject of 1 Head of Medical Record and 3 Medical Record Officers at Dr. Hospital. H. Moch. Ansari Saleh Banjarmasin. The results of the study found that the preparation of medical record retention in RSUD Dr. H. Moch. Ansari Saleh Banjarmasin already has a policy, for the schedule there are still SOPs for retention, special human resources to carry out retention already exist, while the retention implementation facilities are still not sufficient to store inactive medical records. no treatment for 3 years and after being assessed for use, it will be destroyed using an incinerator machine, there are still obstacles, namely the limited space for storing inactive medical records. The conclusion of this study, the implementation of retention that is not in accordance with the existing SPO, an assessment is taken of a form that has value for storage, the obstacles found are the inactive medical record storage room in the active storage room.

TINJAUAN PROSES PELAPORAN EKSTERNAL UNIT REKAM MEDIS DI RSU SUAKA INSAN BANJARMASIN TRIWULAN 1 TAHUN 2022 Syahida Hayati; Eka Rahma Ningsih
JEMPOL : Jurnal Elektronik Mahasiswa Polanka Vol 1 No 1 (2023)
Publisher : UPPM Politeknik Unggulan Kalimantan

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52674/jmpl.v1i1.95

Based on the results of a preliminary study at RSU Asylum in San Banjarmasin In making hospital external reporting, it was found that there were obstacles, one of which was that the officers mistakenly entered data, so that the reported data still contained some errors. The purpose of this study was to find out the external reporting process of the medical record unit in RSU Asylum insan Banjarmasin, Type of research with descriptive research methods with a qualitative approach. How to collect data using observation and interview methods. The results showed that the types of reports were RL 1 basic hospital data, RL 4 patient morbidity and mortality data, and RL 5 monthly data. Sources of data from the emergency room, ward, census from SIMRS. The external reporting process is done manually by taking data in each unit and computerized data is available at SIRS Online. The conclusions of the results of this study include the types of reports used according to SIRS Online, data sources (RL 1 from basic hospital data, RL 4 from wards and RL 5 from census reports, SIMRS, and medical history), and the reporting process using manual and computerized

Identifikasi Risiko pada Rekam Medis Elektronik Rawat Inap Menggunakan Metode FMEA di Rumah Sakit Islam Banjarmasin Rizqi Aulia Husna; Eka Rahma Ningsih
JEMPOL : Jurnal Elektronik Mahasiswa Polanka Vol 1 No 2 (2024)
Publisher : UPPM Politeknik Unggulan Kalimantan

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52674/jmpl.v1i2.142

Electronic medical records that occur are a threat to hospitals, because they can cause problems with electronic medical records. The purpose of this study was to identify the risks in the inpatient electronic medical records using the FMEA method at the Islamic Hospital of Banjarmasin. This research method uses quantitative. The risk of incomplete data on inpatient electronic medical records using the FMEA method at Banjarmasin Islamic Hospital can find out failures that occur by calculating the RPN in the NIK section with a score of 270 in the high category, Name with a score of 81 in the very low category, Age with a score of 42 very disturbing, and Address a score of 30 is very annoying. This occurs because there is no SOP regarding data completeness, and there is no system that can control when the patient's identity is not filled in completely in the inpatient electronic medical record. The risk of inaccuracy of data in the inpatient electronic medical record using the FMEA method at Banjarmasin Islamic Hospital can identify failures that occur by calculating the RPN in the NIK section with a score of 900 in the very dangerous category, Name score 90 in the very low category, Age score 35 slightly disturbing, and Address score 25 is a bit annoying. This occurs as a result of the absence of an SOP regarding data accuracy, and the absence of a system that can recognize when the patient's identity is incorrect or the need for quantitative analysis to find out inaccurate data in the inpatient electronic medical record. The risk of data duplication in the inpatient electronic medical record using the FMEA method at Banjarmasin Islamic Hospital can find out failures that occur by calculating the RPN in the NIK section with a score of 270 in the high category, Name score 243 in the medium category, Age score 54 in the low category, and Address score 54 with low category. This happens due to the absence of an SOP regarding duplication of data, and the absence of a support system when inputting data that fails to be stored, so it cannot be re-entered. In order to avoid duplication of data in the inpatient electronic medical record.

Analisis Sistem Informasi Formulir Pendftaran Rawat Jalan di RSUD dr. H. MOCH. Ansari Saleh Banjarmasin Mutia Dewi; Nirma Yunita; Eka Rahma Ningsih
JEMPOL : Jurnal Elektronik Mahasiswa Polanka Vol 1 No 2 (2024)
Publisher : UPPM Politeknik Unggulan Kalimantan

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52674/jmpl.v1i2.143

The medical record form is used in carrying out the process of recording and processing data in the patient's medical record. The information system on the contents of the outpatient registration form implemented by RSUD dr. H. Moch Ansari Saleh Banjarmasin is guided by or still follows the Regulation of the Minister of Health Number 269/Menkes/Per/III/2008 Article 3 concerning the contents of medical records. This study aims to analyze the information system for outpatient registration forms at dr. H. Moch Ansari Saleh Hospital Banjarmasin in 2023. This type of research uses descriptive qualitative research with data collection methods in the form of observation and interviews with 1 registration officer and head of the medical record unit related to analysis registration form information system. The results of the study are based on anatomical aspects, physical aspects and content aspects. The content aspects are guided or still follow the Regulation of the Minister of Health Number 269/Menkes/Per/III/2008 so that the variables and meta data need to add value to the item name of parents, gender , religion and marital status. And on the user interface for the ease and usefulness of using electronic forms. Based on the results of the study, it can be concluded that dr. H. Moch Ansari Saleh Banjarmasin Hospital to adjust the contents of the registration form is guided by the Decree of the Minister of Health of the Republic of Indonesia Number HK.01.07/MENKES/1423/2022 concerning Guidelines for Variables and Meta Data in the Implementation of Electronic Medical Records. aspects.

Manajemen Kesiapan Rekam Medis Elektronik Di Rumah Sakit TK III DR. R. Soeharsono Banjarmasin: Management of Electronic Medical Record Readiness in HospitalsTK III DR.R. Soeharsono Banjarmasin Fatmawati Bakri Noor; Nirma Yunita; Eka Rahma Ningsih
Jurnal Kajian Ilmiah Kesehatan dan Teknologi Vol. 6 No. 1 (2024)
Publisher : Politeknik Unggulan Kalimantan

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52674/jkikt.v6i1.130

Health facilities are currently required to implement electronic medical records. Minister of Health Regulation Number 24 of 2022 concerning medical records. Every health service facility is required to implement electronic medical records. Therefore, readiness is needed to see the success of implementing RME in hospitals, which is currently still in the process of including forms available at the hospital into SIMRS to be applied. This study aims to determine the readiness of electronic medical records at the TK III Dr.R.Soeharsono Banjarmasin Hospital. This research method uses qualitative research with a descriptive research design. This research instrument uses interview and observation guidelines. The research subjects were the head of medical records, IT officer, inpatient registration officer and outpatient registration officer. The results of this research are that readiness in terms of quantity is adequate and in terms of quality is not yet adequate, readiness in terms of methods, there are no standard operating procedures, readiness in materials, there are no facilities, hardware is not ready and software is not ready, readiness of materials in manual medical records is currently it is still in use and will be transferred in stages, while the electricity or generator and computer network are not yet ready because there are still frequent problems with power outages and network disruptions. Based on the research results, it can be concluded that the readiness to implement electronic medical records at TK III Dr Hospital. R. Soeharsono Banjarmasin is not yet fully ready.

STUDI DESKRIPTIF PELAKSANAAN SENSUS HARIAN RAWAT INAP RUMAH SAKIT BHAYANGKARA TINGKAT III HOEGENG IMAN SANTOSO BANJARMASIN Nirma Yunita; Aus Al Anhar; Eka Rahma Ningsih
Jurnal Kajian Ilmiah Kesehatan dan Teknologi Vol. 7 No. 1 (2025)
Publisher : Politeknik Unggulan Kalimantan

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52674/jkikt.v7i1.240

Inaccurate filling of the daily inpatient census impacts the discrepancy in the hospital's performance (statistics). This study aims to examine the daily inpatient census at Bhayangkara Level III Hospital Hoegeng Iman Santoso Banjarmasin. This research uses a qualitative study with a descriptive approach, collecting data through observation and interviews. The subjects of this study are 7 individuals, including the Head of the Medical Records Unit, the Head of the Care Room, and IT staff. The results show that the implementation of the daily inpatient census involves one person responsible for each care room, while the daily census recap is performed by one person from the medical records department. The quality of census officers has been enhanced through training and socialization on how to manually fill out the inpatient daily census. The last education of the medical record staff responsible for the daily inpatient census recap is a DIII in medical records. The daily manual census recap is done using Microsoft Excel. The machine used for the daily inpatient census meets the needs of the staff. Additionally, there is a Standard Operating Procedure (SOP) for the manual daily census, but none for the SIMRS daily census. The implementation of the manual inpatient daily census does not fully comply with the hospital's SOP, as some staff inconsistently record the census for more than 24 hours. Materials used include Microsoft Excel with a daily census format created by the head of the medical records unit.

Pendistribusian Data Rekam Medis Elektronik Antar Klaster melalui Sistem e-Puskesmas di Puskesmas X Banjarmasin: Distrubtion of Electronic Medical Record Data Between Clusters Through The E-Puskesmas System at Puskemas X Banjarmasin Eka Rahma Ningsih; Nirma Yunita
Jurnal Kajian Ilmiah Kesehatan dan Teknologi Vol. 7 No. 2 (2025)
Publisher : Politeknik Unggulan Kalimantan

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52674/jkikt.v7i2.288

Digital transformation in the health sector encourages every healthcare facility to manage medical record data electronically, in an integrated and real-time manner. One of the key implementations is the e-Puskesmas system, which functions to automatically manage patient data, services, and health reporting. This study aims to analyze the distribution flow of electronic medical record (EMR) data across service clusters through the e-Puskesmas system at Puskesmas X, as well as to identify its effectiveness and the technical challenges in its implementation.This research employed a qualitative approach with an exploratory case study design. Data were collected through observations, in-depth interviews with registration officers, medical staff, and IT personnel, and document analysis of SOPs and system activity logs.The results indicate that the distribution process of EMR data at Puskesmas X operates automatically and is fully integrated across service clusters using the e-Puskesmas system, covering patient registration, data entry, inter-cluster distribution, recording of medical services, and automatic synchronization with the Banjarmasin City Health Office server. This process improves efficiency, data accuracy, and the continuity of patient information. However, several challenges remain, including internet instability, data input errors, limited IT personnel, and reliance on manual entry. In conclusion, the e-Puskesmas implementation at Puskesmas X has proven effective and supports Indonesia’s national Satu Sehat Platform for digital health transformation.

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