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Tinjauan Penerapan Sistem Elektronik Rekam Medis di Rumah Sakit Royal Progress Tahun 2018 Innocentius Probosanjoyo; Joko Asmoro Widhi; Gama Bagus Kuntoadi
Indonesian of Health Information Management Journal (INOHIM) Vol 6, No 2 (2018): INOHIM
Publisher : Lembaga Penerbitan Universitas Esa Unggul

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (627.944 KB) | DOI: 10.47007/inohim.v6i2.20

Abstract

AbstractFrom the observations at Royal Progress Hospital, there were problems regarding the application of electronic medical record systems. The current system seems to be the thing that must be used in a hospital. The development of technology makes medical records that were once in the form of paper now begin to switch to electronics. But the application of electronic medical record systems that conform to standards makes it an interesting matter to be reviewed. Therefore on this occasion the writer will examine about it. The purpose of this research is to identify the application of electronic medical record systems. This research is using qualitative descriptive research methods, which is the data collection techniques based on observations and interviews that will be compared with existing theories. Based on the results of research conducted by the writer, it was obtained that the application of electronic medical record systems in Royal Progress Hospital is not all in accordance with the existing theory yet. Therefore the writer suggest to divert the hospital information system that is now used, especially the electronic medical record system into an electronic health record, so that the creation of better health information management.Keywords: Medical record, electronic medical record systems, hospital informationAbstrakDari hasil observasi di Rumah Sakit Royal Progress terdapat masalah tentang penerapan sistem elektronik rekam medis. Sistem tersebut sekarang ini seakan menjadi hal yang wajib digunakan di rumah sakit. Berkembangnya teknologi membuat rekam medis yang dulunya berupa kertas sekarang mulai beralih ke elektronik. Tetapi penerapan sistem elektronik rekam medis yang sesuai standar menjadikan suatu hal yang menarik untuk ditinjau. Maka dari itu pada kesempatan ini penulis akan meneliti tentang hal tersebut. Tujuan dari penelitian ini adalah mengidentifikasi penerapan sistem elektronik rekam medis di RS. Royal Progress. Di dalam penelitian ini menggunakan metode penelitian deskriptif kualitatif. Dimana dengan teknik pengumpulan data berdasarkan pengamatan dan wawancara yang akan dibandingkan dengan teori yang ada. Berdasarkan hasil penelitian yang dilakukan penulis didapat tentang penerapan sistem elektronik rekam medis di RS. Royal Progress belum semuanya sesuai dengan teori yang ada. Oleh karena itu penulis menyarankan untuk mengalihkan sistem informasi rumah sakit yang sekarang digunakan terutama sistem elektronik rekam medis menjadi rekam kesehatan elektronik supaya terciptanya manajemen informasi kesehatan yang lebih baik.Kata Kunci : Rekam medis, sistem rekam medis elektronik, informasi rumah sakit 
Tinjauan Ketidakpuasan Pasien Lama Terhadap Pelayanan Pendaftaran Rawat Jalan Di Rumah Sakit Menteng Mitra Afia Nur Endah Sari; Gama Bagus Kuntoadi
MEDICORDHIF Jurnal Rekam Medis Vol 5 (2018): MEDICORDHIF Jurnal Rekam Medis
Publisher : APIKES Bhumi Husada Jakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (11.031 KB)

Abstract

ABSTRACT The hospital is one of the health service facilities chosen by the community in obtaining health services. Registration is the initial gate of a hospital service, this is where the important role of the registration officer, must be able to give a comfortable impression so that patients can feel the satisfaction of hospital services. Patient satisfaction consists of 5 dimensions namely tangible, responsiveness, reliability, assurance, and empathy. This research was conducted based on 5 dimensions of service quality, which was felt by old patients towards outpatient registration officers, namely the statement "satisfied" there was empathy dimension of 83.2%, the statement "dissatisfied" in the tangible dimension of 7.4%, and the statement "neutral" on the dimensions of reliability that is equal to 9.4%. Suggestion to the old patient outpatient registration officer is to conduct periodic refresher program on "excellent service" namely tangible, reliability, responsiveness, assurance, and empathy in entering the hospital program, especially the review of waiting room facilities in outpatient registration Keywords :medical record, satisfaction, dissatisfaction, service quality dimension
Analisis Kualitatif Kasus Gangren Pulpa Di Poliklinik Gigi Dalam Upaya Meningkatkan Kualitas Pelayanan Rumah Sakit Tk. IV Cijantung Gama Bagus Kuntoadi; Rokiah Kusumapradja
MEDICORDHIF Jurnal Rekam Medis Vol 5 (2018): MEDICORDHIF Jurnal Rekam Medis
Publisher : APIKES Bhumi Husada Jakarta

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Abstract

ABSTRACT “Rumah Sakit Tingkat IV Cijantung” is a type D hospital owned by Indonesian Armed Force (TNI-AD) which is located at 2nd Mahoni Street, Cijantung – Kesdam Jaya, East Jakarta, Indonesia. This hospital is equiped with 85 beds and also has several medical services unit such as an Emergency Unit, Polyclinic, Laboratory, Radiology, Pharmacy, and Operation Room. As a part of a Policlinic Unit, Dental Care Clinic have become a hospital frontline in interaction with their patients. By having a low medical services quality, it will affect on their patient satisfaction and then it will influence on their hospital revenue. There are so many ways to increase medical services quality, one of them is by doing a medical audit. As the result of this medical audit, the hospital manager will have an accurate data on certain level his medical unit services quality gained so far. Furthemore, this audit report will become a reference to determine their hospital policy to increasing hospital services quality. This research main purpose is to gain a medical quality services illustration on pulp gangrene case at hospital dental polyclinic. Research methodology which had been use is qualitative descriptive analysis by using checklist tool and then by interviewing all dental polyclinic staff at the hospital. The other result of this research is describing the existence of Medical Service Standard and Hospital Standard Operation Procedure (S.O.P) for pulp gangrene case, which will become their basic reference when treating their pulp gangrene patients. On the other hand, this research is also tried to describing dental polyclinic staff obstacles in providing pulp gangrene medical services to their patients. Keywords : medical record, medical audit, service quality, pulp gangrene
Tinjauan Lama Waktu Tunggu Pendaftaran di Tempat Penerimaan Pasien Rumah Sakit Kepolisian Pusat R.S. Sukanto Risky Adiprana; Gama Bagus Kuntoadi
MEDICORDHIF Jurnal Rekam Medis Vol 4 (2017): MEDICORDHIF Jurnal Rekam Medis
Publisher : APIKES Bhumi Husada Jakarta

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Abstract

ABSTRACT This research is based on several problems present, such as queue when the patient register at Patient Admission Center (TPP), the patient complain about the length of time required to wait for the process of activities performed at the time of registering at TPP, and the absence of standard waiting time of registration at TPP which can be used as reference by registration staff at RSKP R.S. Sukanto. The purpose of this descriptive study is to get an idea of ​​the length of waiting time of patients at registration at TPP Outpatient Unit RSKP R.S. Sukanto by observing patient waiting time at registration for new patient and old patient. As well as finding the cause of the long waiting time of registration in TPP Outpatient Unit. The observation is conducted for 9 working days, starting from 28 May to 8 June. From this study found that the average length of waiting time of patients when registering in TPP for new patients is 8 minutes, while for the old patient is 7 minutes. The source of the problem of the length of waiting time is caused by several factors, such as the old patient's inadvertence which often forgot to bring the medication card if will re-treatment, and the absence of standard time in reference in providing services at the time of registration of new and old patients in TPP Outpatient Unit . Another problem that was found was the lack of number of registration staff in TPP Outpatient Unit. Keywords: length of waiting time, patient registration, central police hospital ABSTRAK Penelitian ini dilatar belakangi oleh karena adanya beberapa permasalahan, seperti adanya antrian saat pasien melakukan pendaftaran di Tempat Penerimaan Pasien (TPP), adanya keluhan dari pasien terhadap lamanya waktu yang dibutuhkan untuk menunggu proses kegiatan yang dilakukan pada saat mendaftar di TPP, dan tidak adanya standar waktu tunggu pendaftaran di TPP yang dapat dijadikan acuan oleh staff pendaftaran di Rumah Sakit Kepolisian Pusat R.S. Sukanto. Tujuan dari penelitian deskriptif ini adalah untuk mendapatkan gambaran tentang lama waktu tunggu pasien pada saat pendaftaran di TPP Unit Rawat Jalan R.S.K.P R.S. Sukanto dengan cara mengamati waktu tunggu pasien pada saat pendaftaran untuk pasien baru dan pasien lama. Serta menemukan penyebab terjadinya lamanya waktu tunggu pendaftaran di TPP Unit Rawat Jalan.Pengamatan dilakukan selama 9 hari kerja, terhitung dari tanggal 28 Mei sampai 8 Juni. Dari penelitian ini ditemukan bahwa rata-rata lama waktu tunggu pasien saat mendaftar di TPP untuk pasien baru adalah 8 menit, sedangkan untuk pasien lama adalah 7 menit. Sumber permasalahan lamanya waktu tunggu yang terjadi disebabkan oleh beberapa faktor, seperti ketidakdisiplinnya pasien lama yang sering lupa membawa kartu berobat apabila akan berobat kembali, serta tidak adanya standar waktu yang menjadi acuan didalam memberikan pelayanan pada saat pendaftaran pasien baru dan lama di TPP Unit Rawat Jalan. Permasalahan lainnya yang ditemukan adalah kurangnya jumlah personel/staff bagian pendaftaran di TPP Unit Rawat jalan. Kata kunci: lama waktu tunggu, pendaftaran pasien, rumah sakit kepolisian pusat
Kelengkapan dan Keakuratan Sertifikat Medis Penyebab Kematian di Rumah Sakit Umum Pusat Fatmawati Yuni Marugun; Gama Bagus Kuntoadi
MEDICORDHIF Jurnal Rekam Medis Vol 2 (2015): MEDICORDHIF Jurnal Rekam Medis
Publisher : APIKES Bhumi Husada Jakarta

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Abstract

Abstract Fatmawati Central General Hospital (RSUP) is a government’s hospital of type A which has the purpose of providing a full service. To achieve its objectives, the RSUP Fatmawati will always strive to improve the quality of service, including providing complete and accurate medical information. To achieve the full service, RSUP Fatmawati has work units that have their duties and obligations. One of them is Medical Record Installation and Health Information (IRMIK) which one of its duty is to make monthly report of mortality. In order to create a good and complete mortality report, IRMIK requires a complete and accurate data source in the form of Medical Cause of Death Certificate (SMPK) from Forensic Installation (IFPJ). From the initial research found the existence of some SMPK columns that are not filled completely by the doctor in charge. The incompleteness of filling the SMPK in Fatmawati Central General Hospital is the reason behind this followed research. The research was conducted in May 2013 located in RSUP Fatmawati, South Jakarta, Indonesia. The research was conducted using qualitative descriptive approach by focusing on completeness and accuracy of SMPK form filling. From the result of the research, it was found that most of the incompleteness of the contents occurred in the Population Identity Number column as much as 100%, then in the cause of death collum also found not fully filled, so it can be concluded the average completeness of filling of Medical Cause of Death Certificate in RSUP Fatmawati in May 2013 is 84%. Keyword : medical record, medical cause of death certificate, incompleteness, inaccuracies
GAMBARAN WAKTU PENYEDIAAN REKAM MEDIS PASIEN LAMA PELAYANAN UNIT RAWAT JALAN DI RSU ADHYAKSA Gama Bagus Kuntoadi; Paryono
MEDICORDHIF Jurnal Rekam Medis Vol 7 (2021): MEDICORDHIF Jurnal Rekam Medis
Publisher : APIKES Bhumi Husada Jakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (11.033 KB) | DOI: 10.59300/mjrm.v7i0.51

Abstract

Penelitian ini dilakukan untuk mengetahui waktu penyediaan rekam medis pasien lama pelayanan rawat jalan di Rumah Sakit Umum Adhyaksa. Adapun tujuan khususnya yaitu untuk mengidentifikasi kebijakan dan standar prosedur operasional (SPO) penyediaan rekam medis pasien lama, mengetahui standar waktu yang diperlukan untuk penyediaan rekam medis rawat jalan, dan mengidentifikasi faktor-faktor yang menyebabkan ketidaktepatan waktu dalam penyediaan rekam medis. Dari hasil penelitian yang dilakukan di unit rekam medis, ditemukan belum adanya kebijakan dan SPO penyediaan rekam medis pasien lama yang mencantumkan standar waktu penyediaan rekam medis pasien lama rawat jalan. Faktor-faktor yang menyebabkan ketidaktepatan penyediaan rekam medis rawat jalan yaitu tidak ditemukannya rekam medis di rak penyediaan, ruang penyimpanan belum sentralisasi dan adanya rekam medis yang belum kembali dari unit rawat jalan dan rawat inap. Kata kunci: Rekam Medis, Waktu Penyediaan, Rawat Jalan
TINJAUAN KELENGKAPAN PENGISIAN FORMULIR PELAYANAN GIGI KLINIK GIGI RS DIK PUSDIKKES Gama Bagus Kuntoadi; Rendi Iryawandi
MEDICORDHIF Jurnal Rekam Medis Vol 7 (2021): MEDICORDHIF Jurnal Rekam Medis
Publisher : APIKES Bhumi Husada Jakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (11.033 KB) | DOI: 10.59300/mjrm.v7i0.52

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Formulir Pelayanan Gigi adalah dokumen terstruktur yang digunakan untuk memasukkan data atau informasi tertentu mengenai identitas pasien, pemeriksaan, pengobatan, tindakan dan pelayanan lain yang telah diberikan oleh dokter gigi dan perawat gigi yang harus dicatatkan dan didokumentasikan dalam rekam medis kedokteran gigi. Penelitian ini dilakukan untuk mengetahui kelengkapan pengisian Formulir Pelayanan Gigi di Rumah Sakit DIK PUSDIKKES. Jenis penelitian ini adalah penelitian deskriptif kualitatif. Dari penelitian ini didapatkan hasil, untuk persentasi kelengkapan bagian pengisian nomor rekam medis 100 %, nama pasien 100 %, nama keluarga 69.4 %. Untuk bagian tanggal kunjungan, pemeriksaan, diagnosis/kode penyakit, pengobatan/tindakan sebesar 100 %, keadaan gigi sebesar 60 %, nama dokter gigi sebesar 82.4 %, tanda tangan dokter sebesar 71.7 %. Untuk bagian tidak ada coretan dan penghapusan sebesar 100 %, dan tidak ada bagian yang kosong sebesar 94.1 %. Ditemukan pula bahwa Rumah Sakit DIK PUSDIKKES belum memiliki Standar Prosedur Operasional tentang Pengisian Formulir Pelayanan Gigi. Rumah Sakit harus segera membuat kebijakan dan SPO tentang Pengisian Formulir Pelayanan Gigi. Rumah Sakit juga harus melakukan secara berkala pengawasan dan evaluasi tentang kelengkapan pengisian Formulir Pelayanan Gigi agar dapat memberikan pelayanan yang lebih maksimal kepada pasien-pasiennya.Kata kunci: rekam medis, kelengkapan pengisian, formulir pelayanan gigi
Gambaran Pengisian Pada Formulir Catatan Perkembangan Pasien Terintegrasi Di Rumah Sakit Yadika Kebayoran Lama Gama Bagus Kuntoadi; Ai Purwati
MEDICORDHIF Jurnal Rekam Medis Vol 9 No 1 (2022): MEDICORDHIF Jurnal Rekam Medis
Publisher : APIKES Bhumi Husada Jakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (11.033 KB) | DOI: 10.59300/mjrm.v9i1.62

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The integrated patient progress record is the documentation of care professionals about the progress of the patient's condition in an integrated form in the standard format in the patient's medical record. The general purpose of this study was to analyze the filling of medical care results on the integrated patient development record form at Yadika Kebayoran Lama Hospital. While the specific objectives are to identify policies and standard operating procedures in the implementation of filling out the results of medical care on the integrated patient progress record form, identify incomplete filling of the integrated patient progress record form and identify the factors causing the incomplete filling of the integrated patient progress record form. This research uses a descriptive method. From the results of the quantitative analysis of research on the completeness of filling out the integrated patient development record form for the period October to December 2018 with a sample of 180, it is known that 90% are incomplete and 10% are filled. The highest incomplete patient identity component consists of medical record number and patient gender with a percentage of 33.4%. In the important note’s component, it was found that 100% of the forms were filled out. The highest incomplete authentication component is the doctor's signature with a percentage of 44.5%. In the component of good notes, the highest is in the "no streak" section with a percentage of 26.7%. Suggestions from this study, it is better to evaluate and monitor periodically the completeness of filling out the integrated patient progress record form. Keywords: medical record, filling out, integrated patient progress record form
TINJAUAN DESAIN FORMULIR REKAM MEDIS GIGI DI RSIA BUAH HATI PAMULANG TAHUN 2020 Gama Bagus Kuntoadi; Dena Apriliana Lestari
MEDICORDHIF Jurnal Rekam Medis Vol 8 (2022): MEDICORDHIF Jurnal Rekam Medis
Publisher : APIKES Bhumi Husada Jakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (11.033 KB) | DOI: 10.59300/mjrm.v8i1.65

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Penelitian ini dilakukan untuk mengidentifikasi, menganalis dan menentukan Standar Prosedur Operasional (SPO) yang mengatur desain Formulir Rekam Medis Gigi, gambaran desain Formulir Rekam Medis Gigi, dan faktor penyebab desain Formulir Rekam Medis Gigi tidak sesuai dengan standar Panduan Rekam Medis Kedokteran Gigi serta mendesain ulang Desain Formulir Rekam Medis Gigi berdasarkan standar Panduan Rekam Medis Kedokteran Gigi tahun 2015. Metode penelitian yang digunakan yaitu metode deskriptif kualitatif dengan memperoleh gambaran tentang tinjauan desain Formulir Rekam Medis Gigi di RSIA Buah Hati Pamulang. Metode pengumpulan data dengan cara observasi dan wawancara. Dalam penelitian karya tulis ilmiah ini tidak menggunakan populasi dan sampel. Hasil penelitian ini memperlihatkan di RSIA Buah Hati Pamulang belum memiliki SPO tentang desain Formulir Rekam Medis Gigi, tetapi yang ada hanya SPO Perubahan Formulir Rekam Medis. Desain Formulir Rekam Medis Gigi di RSIA Buah Hati Pamulang yang digunakan sekarang belum sesuai dengan standar Panduan Rekam Medis Kedokteran Gigi oleh karena itu dibuatlah desain Formulir Rekam Medis Gigi baru yang sesuai dengan standar Panduan Rekam Medis Kedokteran Gigi dan faktor penyebab desain Formulir Rekam Medis Gigi tidak sesuai dengan standar Panduan Rekam Medis Kedokteran Gigi karena belum ada SPO yang mengatur desain Formulir Rekam Medis Gigi dan berdasarkan 5M dari Man karena belum mempunyai orang atau tenaga kerja yang bertanggungjawab dalam mendesain atau merevisi desain Formulir Rekam Medis Gigi, Isi Rekam Medis pasien masih ada dokter tidak menulis dengan lengkap atau mencatat Rekam Medis pasien, Method karena belum memiliki SPO yang mengatur tentang desain formulir rekam medis gigi dan Machine karena untuk ukuran standar rumah sakit formulir gigi memang belum sesuai dengan standar Panduan Rekam Medis Kedokteran Gigi.
Screening Penyakit Tidak Menular (PTM) Dan Konseling Kesehatan Pada Civitas Academica STIKes Widya Dharma Husada Tangerang Rita Dwi Pratiwi; Riris Andriati; Fenita Purnama Sari Indah; Gina Aulia; Nurwulan Adi Ismaya; Gita Ayuningtyas; Siti Novy Romlah; Lukman Handoyo; Ida Listiana; Dewi Fitriani; Uswatun Hasanah; Veri Veri; Gama Bagus Kuntoadi; Sucipto Sucipto; Sheli Sheli; Dini Arum Alita; Puji Lestari; Raka Fahri Ramdan; Asep Hidayat
Pelita Masyarakat Vol. 6 No. 1 (2024): Pelita Masyarakat, September
Publisher : Universitas Medan Area

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31289/pelitamasyarakat.v6i1.11271

Abstract

This community service activity is conducted regularly every semester by lecturers involving 450 students from various study programs, collaborating with local health centers (Puskesmas) in South Tangerang. The purpose of the activity is to conduct health screenings to prevent and control Non-Communicable Diseases (NCDs) such as anemia, hypertension, diabetes mellitus, and obesity. The methods used include health education for students on NCD prevention and control, measurements of height, weight, upper arm circumference, blood pressure checks, random blood glucose tests, and a questionnaire on smoking habits. The results showed that 3 participants had a history of hypertension and 1 had diabetes mellitus. Additionally, 23 participants were identified as being at risk of chronic diseases. Follow-up actions included in-depth counseling and referral to the nearest Puskesmas. All participants were also found to be non-smokers. This activity aims to raise awareness about NCD prevention, followed by further health checks and sponsorship support in the future.