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Tinjauan Pelepasan Informasi Medis Kepada Pihak Ketiga di Rumah Sakit Setia Mitra Lidia Kanaf; Hudiyati Agustini; Tite Kabul
MEDICORDHIF Jurnal Rekam Medis Vol 4 (2017): MEDICORDHIF Jurnal Rekam Medis
Publisher : APIKES Bhumi Husada Jakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (11.033 KB)

ABSTRACT The health ministry`s regulation number 269 2008 on Medical Record, stating that Information about identity, diagnosis, history of disease, history of examination and history of treatment can be opened in accordance with the provisions. Based on the observations made, there is no official who handles the release of medical information and there is no specific responsibility for handling it, so the problem is: how the implementation of the release of medical information to the third party at Setia Mitra Hospital Jakarta ?. The purpose of this research is to know the process of releasing medical information to third party at Setia Mitra Hospital. This research was conducted by using descriptive design. Conclusion, Setia Mitra Hospital already has a policy on the release of medical information in the form of standard operational procedures and general consent form. However, there is no specific regulatory policy regarding the release of medical information. 73.7% of Medical Record Officers understand the importance of SPO (standard operational procedures) made and adhered to. In practice most of them are in accordance with the procedures and theories of health law, while not yet appropriate is the recording and the use of book of expedition and the absence of deadline for the use of written permission from patients. Keywords: the release of medical information

TINJAUAN ASPEK KEAMANAN DAN KERAHASIAAN BERKAS REKAM MEDIS DI RUANG PENYIMPANAN REKAM MEDIS RUMAH SAKIT "X" JAKARTA TIMUR Hudiyati Agustini; Erma Febriyani,
MEDICORDHIF Jurnal Rekam Medis Vol 7 (2021): MEDICORDHIF Jurnal Rekam Medis
Publisher : APIKES Bhumi Husada Jakarta

ABSTRACT Security is a method of securing information against unauthorized change access. Confidentiality is a limitation for disclosing certain personal information. Based on preliminary observations, it was found that the medical record storage room of the "X" Hospital was not protected and confidential. The door storage room was not locked so that officers other than medical records could enter, it was found that the patient brought his own medical record without being accompanied by a medical record officer, and there were damaged medical records. The result of this research is that security and confidentiality policies and standard operating procedures already exist, but have not been maximally implemented. Security and confidentiality aspects of medical records have not been properly maintained. Judging from the intrinsic factor there are still folders that have not used plastic coated material. From the extrinsic factors there are medical record doors that have not used an access code and always open, and there are damage to medical record files due to rats and cockroaches. it is advisable to reaffirm and socialize the provisions set out in the policy and standard operating procedures to carry out activities in accordance with applicable regulations. Keywords: Security and confidentiality; stronge space; medical record

TINGKAT KEPERCAYAAN PASIEN TERHADAP KEAMANAN UNIT PENDAFTARAN RAWAT JALAN DI MASA PANDEMI COVID-19 DI RUMAH SAKIT IMC BINTARO Hudiyati Agustini; Nurul Ulfa
MEDICORDHIF Jurnal Rekam Medis Vol 8 (2022): MEDICORDHIF Jurnal Rekam Medis
Publisher : APIKES Bhumi Husada Jakarta

This study was conducted to obtain an overview of the patient's level of trust in safety in the outpatient registration unit of IMC Bintaro hospital during the COVID-19 pandemic. The number of patients visiting IMC Bintaro Hospital decreased at the beginning of the pandemic, there where 55,101 people who registered outpatients in January-July 2019 while in January-July 2020 only 37,121 people (decreased 32%). This condition is thought to be due to the patient's concern about the transmission of COVID-19. The level of confidence research was carried out using a descriptive method in the outpatient registration unit of the IMC Bintaro Hospital, in February-April 2021. A randomly selected sample of 100 patients where registered in December 2020-February 2021. The technique of collecting data was by interviewing the head of the registration unit, observation, and an electronic questionnaire containing 10 questions related to the patient's level of confidence. The results showed that IMC Bintaro Hospital does not yet have an SOP for outpatient registration adapted to the pandemic conditions. However, health workers and registration areas have implemented health protection based on the Director's memo. While data from questionnaires to patients showed a high level of patient knowledge about COVID-19 (an average of 94.8% answered agree), accompanied by a high level of patient confidence in safety in the outpatient registration unit (an average of 88% answered agree). Most of the samples gave a positive response, they have received services in line with expectations. Patients feel safe for treatment at the IMC Bintaro Hospital during the COVID-19 pandemic. However, it should be understood that the sample was taken from patients who came to the hospital after the pandemic lasted for about 1 year, while number of patients who visited the hospital during the study was not carried out. Keywords: Level of trust, security. COVID-19 pandemic, registration unit

TINJAUAN KELENGKAPAN LAPORAN OPERASI PASIEN RAWAT INAP DI RUMAH SAKIT UMUM SETIA MITRA Hudiyati Agustini; Ummul Mufidah
MEDICORDHIF Jurnal Rekam Medis Vol 9 No 1 (2022): MEDICORDHIF Jurnal Rekam Medis
Publisher : APIKES Bhumi Husada Jakarta

ABSTRACT The operation report must be filled in completely by the doctor in charge, immediately after the operation is completed. The completeness of the operation report on the status of the patient's medical record is very important as information and documentation of the operation, which can be used by the paying party (insurance) or the court (if a case occurs). The general objective of this study was to determine the completeness of the operating report for inpatients at Setia Mitra Hospital. The research method used is descriptive, with a population of inpatient surgery reports in the period February-August 2020, with a sample of 136 inpatient surgery reports. Based on the results of the research, it is known that Setia Mitra Hospital does not yet have a special SOP regarding filling out operational reports that must be complete. Hospitals only have SOPs in general entitled Planned/Elective Surgical Services, where these SOPs do not follow applicable standards or references. From the results of quantitative analysis calculations, it was found that only 9 statuses (6.6%) had complete operation reports. The component that is filled out 100% is the patient identification, while the least completely filled out is the important notes by 66%. The cause of the incomplete filling of the operation report form is the lack of awareness of human resources about the importance of the operation report, and there is no monitoring and evaluation regarding the completeness of its completion. Keywords: completeness, operation report ABSTRAK Laporan operasi wajib diisi lengkap oleh dokter yang bertanggung jawab segera setelah operasi selesai. Kelengkapan laporan operasi pada status rekam medis pasien sangat penting sebagai informasi dan pendokumentasian operasi, yang dapat digunakan oleh pihak pembayar (asuransi) atau pengadilan (apabila terjadi suatu kasus). Tujuan Umum dari penelitian ini adalah untuk mengetahui kelengkapan laporan operasi pasien rawat inap di RSU Setia Mitra. Metode penelitian yang digunakan adalah deskriptif, dengan populasi laporan operasi pasien rawat inap pada periode bulan Februari−Agustus 2020, dengan sampel sebanyak 136 laporan operasi pasien rawat inap. Berdasarkan hasil penelitian, diketahui bahwa RSU Setia Mitra belum memiliki SPO khusus tentang pengisian laporan operasi yang harus lengkap. Rumah sakit hanya memiliki SPO secara umum yang berjudul Pelayanan Bedah Terencana/Eleketif, di mana SPO ini belum mengikuti standar atau acuan yang berlaku. Dari hasil perhitungan analisis kuantitatif, didapatkan hanya 9 status (6,6%) yang memiliki laporan operasi terisi lengkap. Komponen yang terisi lengkap 100% adalah identifikasi pasien, sedangkan yang paling sedikit terisi lengkap adalah catatan penting sebesar 66%. Penyebab ketidaklengkapan pengisian formulir laporan operasi adalah kurangnya kesadaran sumber daya manusia tentang pentingnya laporan operasi, serta tidak ada monitoring dan evaluasi mengenai kelengkapan pengisiannya. Kata kunci: kelengkapan, laporan operasi

Tinjauan ketepatan kode diagnosa diabetes melitus pasien rawat inap di Rumah Sakit Umum Universitas Kristen Indonesia Hudiyati Agustini; Atikah Ramadhani
MEDICORDHIF Jurnal Rekam Medis Vol 10 No 1 (2023): MEDICORDHIF Jurnal Rekam Medis
Publisher : APIKES Bhumi Husada Jakarta

Pemberian kode terhadap diagnosis pasien harus tepat, karena akan memengaruhi informasi laporan morbiditas dan mortalitas, serta administrasi rumah sakit termasuk data klaim biaya pengobatan. Penelitian ini bertujuan untuk mengetahui ketepatan kode diagnosa diabetes melitus di RSU UKI, sesuai dengan standar WHO berdasarkan ICD 10. Penelitian dimulai bulan April−Juni 2022, berdasarkan metode penelitian deskriptif kuantitatif dengan teknik pengumpulan data secara observasi, lembar checklist, dan wawancara. Penelitian ini mengambil sampel 75 ringkasan pulang dari pasien yang dirawat inap dengan diagnosis diabetes melitus. Hasil penelitian mendapatkan 25 kode tidak tepat (33,33%) dan 50 kode tepat (66,67%). Dapat disimpulkan bahwa RSU UKI sudah memiliki standar prosedur operasional pengkodean diagnosa. Namun, masih terdapat pengkodean yang tidak tepat. Faktor utama menjadi ketidaktepatan kode disebabkan oleh dokter yang tidak lengkap menulis diagnosa, dan petugas koding yang tidak tepat dalam menetapkan digit ke-4. Kata kunci: Ketepatan kode diagnosa, Diabetes Melitus, Ringkasan Pulang

Tinjauan Ketepatan Kode Diagnosa Gastroenteritis pada Pasien Rawat Inap di Rumah Sakit Umum Daerah Budhi Asih Hudiyati Agustini; Fathirsa Ariya Wirayuda; Indah Kristina
MEDICORDHIF Jurnal Rekam Medis Vol 10 No 2 (2023): MEDICORDHIF Jurnal Rekam Medis
Publisher : APIKES Bhumi Husada Jakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.59300/mjrm.v10i2.104

The results of early observations at the Budhi Asih Hospital, on the medical record files of inpatients with a diagnosis of gastroenteritis, found that there were still coding errors. The Gastroenteric Code is divided into two, namely infectious gastroenteritis and non-infectious gastroenteritis. Infectious gastroenteritis can be coded A09.0 (acute infectious gastroenteritis) or A09.9 (unspecified infectious gastroenteritis). Meanwhile, non-infectious gastroenteritis can be coded K52.- and non-infectious gastroenteritis in neonates is coded P78.3. The completeness and accuracy of gastroenteritis coding comes from doctors and nurses who record information on the patient's condition, as well as coding officers providing coding. The purpose of this study was to determine the completeness and accuracy of coding in cases of gastroenteritis in hospitalized patients based on ICD-10. Keywords: Diagnostic code accuracy, Gastroenteritis, Discharge Summary.

Analisis Waktu Penyediaan Berkas Rekam Medis Rawat Jalan di Rumah Sakit Setia Mitra Jakarta Selatan Hudiyati Agustini; Ririn Sri Lestari; Joko Asmoro W
MEDICORDHIF Jurnal Rekam Medis Vol 10 No 2 (2023): MEDICORDHIF Jurnal Rekam Medis
Publisher : APIKES Bhumi Husada Jakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.59300/mjrm.v10i2.105

Provision of medical record files must be able to support health services, including outpatient services at hospitals. The time for providing medical record files since the old patient registered has a service standard of 10 minutes or less. The purpose of this study was to find out when to provide outpatient medical record files at Setia Mitra Hospital. The research design used was observative and quantitative descriptive, with a total sample of 98 medical record files taken by random sampling. The results showed that the average provision of outpatient medical record files was 11 minutes, of which 0 files (0%) within 1âˆ’5 minutes, 43 files (43.9%) within 6âˆ’10 minutes, 49 files (50.0%) within 11âˆ’15%, and 6 files (6.1%) within 16âˆ’20 minutes. Factors causing this delay include disruption to the network connection on the TMU printer machine and registration computer, misplaced files (miss files), and the lack of socialization and evaluation of the SPO which regulates the time for providing medical record files. Keywords : delays, provision, time line, outpatient medical record file.

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