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All Journal Indonesian of Health Information Management Journal (INOHIM) Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Indonesian Journal of Health Information Management Services (IJHIMS) Abdibaraya: Jurnal Pengabdian Masyarakat
Nungky Nurkasih Kendrastuti
Program Studi Manajemen Informasi Kesehatan, Universitas Esa Unggul
Computer Science & IT Decision Sciences, Operations Research & Management Health Professions Public Health Social Sciences

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Evaluasi Penyelenggaraan Rekam Medis dalam Pemenuhan Standar Akreditasi di Puskesmas Kedaung Barat Kabupaten Tangerang Nungky Nurkasih Kendrastuti; Muhammad Fahmi Nursyabani
Indonesian of Health Information Management Journal (INOHIM) Vol 11, No 1 (2023): INOHIM
Publisher : Lembaga Penerbitan Universitas Esa Unggul

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.47007/inohim.v11i1.508

Abstract

Abstract Implementation of medical record services based on accreditation standards would improve the quality and safety of patients at Public Health Center . Public Health Center accreditation must be carried out so that the optimization of its functions could run optimally, both in terms of service performance and the resources used. Objectives clicking this study was to evaluate the implementation of medical records service in meeting the standard 8.4 at chapter IV accreditation standard at Kedaung Barat Public Health Center, Tangerang District. This standard had 4 criterias and 13 assessment elements. This research was a quantitative research with descriptive methods. The population of this study were all medical record files that were available at the time of the study. The data source is primary adn secondary data with a total sample of 30 taken by simple random sampling. The results of the study were 3 elements of assessment that were fully achieved (23.1%), 3 elements of assessment were partially achieved (23.1%) and 7 elements of assessment that were not achieved (53.8%). The total score obtained was 45 out of 130 (34.6%). Conclusion: the implementation of medical records based on the accreditation standard of 8.4 in Kedaung Public Health Cente has only been partially fulfilled, and needs to be improved until 100% fulfillmentKeyword: Medical Records, Public Health Center, Accreditation StandardsAbstrakPelayanan rekam medis berdasarkan standar akreditasi akan meningkatkan mutu dan keselamatan pasien di puskesmas. Akreditasi puskesmas wajib dijalankan agar optimalisasi fungsi puskesmas dapat berjalan secara optimal, baik dari kinerja pelayanan maupuan sumber daya yang digunakan. Tujuan penelitian ini adalah melakukan evaluasi penyelenggaraan rekam medis berdasarkan standar akreditasi bab IV standar 8.4 di Puskesmas Kedaung Barat Kabupaten Tangerang. Standar ini memiliki 4 kriteria dan 13 elemen penilaian Jenis penelitian ini adalah penelitian kuantitatif dengan metode deskriptif. Populasi penelitian ini adalah seluruh berkas rekam medis yang ada saat waktu penelitian. Sumber data merupakan data primer dan sekunder dengan jumlah sampel 30 yang diambil dengan cara simple random sampling. Hasil dari penelitian ini adalah terdapat 3 elemen penliaian yang tercapai penuh (23,1%), 3 elemen penilaian tercapai sebagian (23,1%) dan 7 elemen penilaian yang tidak tercapai (53,8%). Total skor yang didapat adalah 45 dari 130 (34,6%). Kesimpulan: penyelenggaraan rekam medis berdasarkan standar akreditasi 8.4 di Puskesmas Kedaung baru terpenuhi sebagian, dan perlu ditingkatkan lagi agar terpenuhi 100%.Kata Kunci: Rekam medis, Puskesmas, Standar akreditasi
Indikator Mutu Prioritas Unit Pelayanan Pendaftaran di RSU Bethesda Serukam Rubina, Tirzhana Jean; Kendrastuti, Nungky Nurkasih; Hosizah, Hosizah; Mieke Nurmalasari
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Vol. 10 No. 2 (2025): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Agustus
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v10i2.1928

Abstract

Improving patient quality and safety (PMKP) is a key component in ensuring hospital service quality. One measurement tool used is the quality indicator, which includes the National Quality Indicator (INM), Priority Unit Quality Indicator (IMPU), and Hospital Priority Quality Indicator (IMPRS). The Registration Unit at the Medical Records Installation of Bethesda Serukam General Hospital plays a strategic role in supporting PMKP implementation. However, the unit still requires service improvements to promote systematic quality enhancement. This study aims to design a suitable priority quality indicator for the Registration Unit. A descriptive qualitative method was used, with data collected through interviews, observation, scoring, and Focus Group Discussions (FGD). The study was conducted from November to December 2024 at Bethesda Serukam General Hospital, located at Jalan Raya Singkawang–Bengkayang KM.49, Pasti Jaya Samalantan, Desa Suka Maju, Kecamatan Sungai Betung, Kabupaten Bengkayang, Kalimantan Barat. The results identified the completeness of patient identity data in the Electronic Medical Record (EMR) as the priority quality indicator. This was selected because it met the most criteria, although the current completeness rate is still low (50%). Establishing this indicator is expected to improve service quality, patient safety, and foster a culture of quality at Bethesda Serukam General Hospital.
Peningkatan Pemahaman Standar Pendokumentasian Rekam Medis Elektronik melalui Kegiatan Edukasi bagi Pemberi Asuhan Profesional di RS St. Carolus Jakarta Anastasia Cyntia Dewi Kurniawati; Witri Zuama Qomarania; Husni Abdul Muchlis; Imam Sutanto; Nungky Nurkasih Kendrastuti
Abdibaraya Vol 5 No 01 (2026): Abdibaraya
Publisher : Universitas Ma'arif Nahdlatul Ulama Kebumen

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.53863/abdibaraya.v5i01.2294

Abstract

The implementation of Electronic Medical Records (EMR) is an important component of digital transformation in healthcare services aimed at improving service quality, patient safety, and hospital accreditation compliance. St. Carolus Hospital Jakarta has implemented EMR since 2019; however, several documentation-related issues remain, including inconsistencies in Integrated Patient Progress Notes (CPPT), delays in medical discharge summaries, and variations in documentation practices among healthcare professionals. This community service program aimed to enhance healthcare professionals’ understanding of standards for complete, accurate, and timely documentation of medical and electronic medical records in accordance with regulations and hospital accreditation standards. The program was held on February 27, 2026, at St. Carolus Hospital in Jakarta and included 32 participants, comprising physicians, nurses, medical record professionals, pharmacists, and other healthcare workers. The intervention was delivered through educational sessions, discussions on quality indicators and accreditation standards related to clinical documentation, and interactive discussions with resource persons. Evaluation was conducted using a 14-item multiple-choice pre-test and post-test questionnaire. The results demonstrated an increase in participants’ understanding, with a mean pre-test score of 0.911 ± 0.082 and a mean post-test score of 0.990 ± 0.025. Wilcoxon Signed-Rank Test analysis showed a statistically significant difference between pre-test and post-test scores (p < 0.001), with an effect size of 0.913, indicating a very large effect. The program was effective in strengthening participants’ understanding and aligning perceptions regarding medical record and electronic medical record documentation standards. It is expected to improve the quality of clinical documentation, healthcare services, and patient safety, as well as compliance with hospital accreditation standards. medical record documentation, positively impacting service quality and hospital accreditation readiness.
BIMBINGAN TEKNIS VISUALISASI DATA KLAIM INA-CBG’S UNTUK PMIK DI RSIJ PONDOK KOPI Mieke Nurmalasari; Husni Abdul Muchlis; Witri Zuama Qomarania; Muhammad Fuad Iqbal; Nungky Nurkasih Kendrastuti; Yati Maryati; Herliani Florentina Simanjuntak; Amelia Aruni; Syalaisha Nuraini Rachmadiany; Akhmad Tri Arman; Steven Rhinaldi
Indonesian Journal of Health Information Management Services Vol. 6 No. 1 (2026): Indonesian Journal of Health Information Management Services (IJHIMS)
Publisher : APTIRMIKI

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33560/ijhims.v6i1.159

Abstract

Visualisasi data klaim INA-CBG’s memiliki peran strategis dalam meningkatkan efisiensi dan kualitas pelayanan rumah sakit. Unit Rekam Medis dan Informasi Kesehatan (RMIK) RSIJ Pondok Kopi menghadapi keterbatasan kompetensi dalam mengolah dan memvisualisasikan data klaim secara analitis. Tujuan bimbingan teknis ini meningkatkan kompetensi Perekam Medis dan Informasi Kesehatan (PMIK) dalam mengolah dan memvisualisasikan data klaim INA-CBG’s menggunakan Tableau Public untuk mendukung pengambilan keputusan berbasis data. Kegiatan dilaksanakan pada tanggal 12 November 2025 dengan metode pelatihan sistem yang meliputi sosialisasi, pretest, penyajian materi, praktik langsung dalam pembuatan visualisasi data, pengumpulan, dan evaluasi. Sebanyak 14 peserta dari unit Pelatihan, Rekam Medis, Casemix, dan perawat melakukan pelatihan selama 120 menit. Hasil dari kegiatan peserta mampu membuat berbagai jenis visualisasi (pie chart, bar chart, boxplot, dan interactive dashboard) dengan penilaian nilai rata-rata dari 52 (pretest) hingga 73 (evaluasi akhir), menghasilkan penilaian kepuasan sebesar 40,4%. Kegiatan yang dilaksanakan telah meningkatkan kompetensi PMIK dalam visualisasi data klaim INA-CBG’s dan mendorong terbentuknya budaya kerja berbasis data di rumah sakit.
Co-Authors Akhmad Tri Arman Amelia Aruni Anastasia Cyntia Dewi Kurniawati Herliani Florentina Simanjuntak Hosizah Hosizah Husni Abdul Muchlis Husni Abdul Muchlis Imam Sutanto Muhammad Fahmi Nursyabani Muhammad Fuad Iqbal Nurmalasari, Mieke Rubina, Tirzhana Jean Steven Rhinaldi Syalaisha Nuraini Rachmadiany Witri Zuama Qomarania Witri Zuama Qomarania Yati Maryati