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All Journal Jurnal Manajemen Informasi dan Administrasi Kesehatan JURNAL PENDIDIKAN TAMBUSAI Jurnal Manajemen Informasi Kesehatan Indonesia (JMIKI) Health Sciences and Pharmacy Journal Surya Medika: Jurnal Ilmiah Ilmu Keperawatan dan Ilmu Kesehatan Masyarakat Abdi Dosen : Jurnal Pengabdian Pada Masyarakat Jurnal Untuk Masyarakat Sehat (JUKMAS) Infokes : Jurnal Ilmiah Rekam Medis dan Informasi Kesehatan Intan Husada : Jurnal Ilmiah Keperawatan J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Jurnal Ilmiah Kesehatan Masyarakat Jurnal Rekam Medis dan Manajemen Informasi Kesehatan Malcom: Indonesian Journal of Machine Learning and Computer Science Journal of Artificial Intelligence and Digital Business Jurnal Pengabdian Kepada Masyarakat: Kesehatan (JPKMK) Jurnal An-Najat: Jurnal Ilmu Farmasi dan Kesehatan Jurnal Medika Nusantara Antigen: Jurnal Kesehatan Masyarakat dan Ilmu Gizi Vitamedica: Jurnal Rumpun Kesehatan Umum Vitalitas Medis : Jurnal Kesehatan Dan Kedokteran Inovasi Kesehatan Global Vitamin: Jurnal Ilmu Kesehatan Umum
Iqbal, Muhammad Fuad
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Analisis Kelengkapan Pengisian Catatan Perkembangan Pasien Terintegrasi Dokter Pada Rekam Medis Elektronik Assesmen IGD Di RSUD Tarakan Tahun 2024 Arif Ibnu Fadillah; Bangga Agung Satrya; Noor Yulia; Muhammad Fuad Iqbal
Jurnal Medika Nusantara Vol. 3 No. 2 (2025): Jurnal Medika Nusantara
Publisher : Stikes Kesdam IV/Diponegoro Semarang, Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.59680/medika.v3i2.1786

Abstract

Integrated Patient Progress Notes (CPPT) are activities of health workers (doctors, nurses, pharmacists, nutritionists, and other officers) in recording the results of their activities, in one format together in the patient's medical record related to the patient's care process. This sheet contains the patient's identity, date of examination, examination time, notes from the treating doctor, notes from other clinical staff, and is verified with the initials and name of the officer who filled it in. All actions taken are recorded at the time, date and type of action given and must be signed by the examining doctor. This study aims to see the completeness of the doctor's integrated patient progress notes in the electronic medical record of the IGD assessment at Tarakan Hospital, Jakarta. This study uses a descriptive methodology with a quantitative approach. A sample of 77 electronic medical records of the IGD assessment used random sampling. Research results: from the analysis, the completeness was 90%, not reaching the minimum standard set by the Ministry of Health, which is 100%. Of the 4 components analyzed, the highest level of completeness is in the patient identification, authentication, good recording components of 100%, while the lowest percentage of completeness is in the important report content component of 93%. Several factors that cause poor doctor CPPT are when the doctor has filled in the Doctor CPPT but the system does not save it because an error occurs. It is recommended that the system be monitored consistently to prevent such errors during data entry, and that a special computer unit for doctors be created to minimize waiting time when interacting with other nursing staff.
Identifikasi Faktor Risiko Fisik di Ruang Penyimpanan Rekam Medis Rumah Sakit Islam Jakarta Pondok Kopi Vickriyal Nadith; Muhammad Rezal; Nanda Aula Rumana; Muhammad Fuad Iqbal
SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat Vol. 4 No. 2 (2025): April 2025
Publisher : Yayasan Literasi Sains Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.55123/sehatmas.v4i2.5067

Abstract

In hospitals various types of services are provided including medical records management. Every job carries risks, and understanding and managing these risks requires a comprehensive risk identification process. This study focuses on investigating the physical risk factors in the medical storage rooms at Jakarta Islamic Hospital Pondok Kopi. Key aspects evaluated include room size, distance between rooms, temperature, and lighting conditions. The research method consists of direct observations and measurements of physical parameters in three interconnected archive rooms. The results reveal that the size of the storage room is constrained by the room's dimensions and excessive shelving, which limits staff efficiency in managing medical records. Furthermore, the proximity of rooms complicates accessibility for staff, highlighting the need for better spatial arrangements to improve operational efficiency and reduce the risk of accidents. Temperature assessments show a range of 29.0°C to 30.3°C, exceeding the Indonesian Ministry of Health's 2023 standards. The recommended storage temperature is between 22°C to 26°C with a humidity level of 25% to 55%. These elevated temperatures increase the risk of data damage and discomfort for staff. While lighting conditions generally meet standards, further evaluation is required to ensure optimal, consistent lighting. This study aims to improve storage organization, regulate temperature, and enhance lighting to optimize medical record management in hospitals, ensuring a safer, more efficient working environment for staff.
Analisis ketepatan kode hipertensi pasien BPJS rawat jalan berdasarkan ICD-10 di RS Bhakti Mulia Febriyani, Madinah; Iqbal, Muhammad Fuad; Putra, Daniel Happy; Sonia, Dina
Health Sciences and Pharmacy Journal Vol. 9 No. 1 (2025)
Publisher : STIKes Surya Global Yogyakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.32504/hspj.v9i1.1220

Abstract

Ketepatan kode diagnosis sangat bergantung pada informasi yang ditulis dan diverifikasi oleh dokter dan petugas medis. Ketidakakuratan dalam pengodean diagnosis dapat berdampak serius terhadap kualitas pelaporan rumah sakit, khususnya pada laporan RL4B, yaitu laporan yang mencatat 10 besar penyakit terbanyak yang diderita pasien rawat inap berdasarkan klasifikasi ICD-10. Laporan RL4B ini merupakan bagian dari sistem pelaporan rutin rumah sakit kepada Kementerian Kesehatan dan digunakan sebagai salah satu indikator utama dalam menilai kinerja rumah sakit. Selain itu, data dalam RL4B sangat penting dalam penyusunan kebijakan kesehatan, perencanaan program pelayanan, serta pengalokasian sumber daya kesehatan di tingkat nasional. Tujuan penelitian ini untuk mengetahui ketepatan pengodean diagnosis penyakit hipertensi pasien rawat jalan berdasarkan ICD-10 di Rumah Sakit Bhakti Mulia. Penelitian ini menggunakan metode deskriptif dengan pendekatan kuantitatif. Sampel diambil menggunakan teknik simple random sampling atau purposive sampling, yaitu rekam medis pasien rawat jalan yang terdiagnosis hipertensi. Besar sampel dihitung menggunakan rumus Slovin dan diperoleh sebanyak 86 rekam medis sebagai sampel. Hasil penelitian menunjukkan bahwa sebanyak 53 rekam medis (62%) memiliki ketepatan dalam penentuan kode diagnosis hipertensi, sedangkan 33 rekam medis (38%) tidak tepat. Ketidaktepatan tersebut terutama terjadi pada pemberian kode gabungan (kombinasi) dan pengurutan kode diagnosis. Oleh karena itu, disarankan agar petugas coder rawat jalan meningkatkan ketepatan dalam pengodean diagnosis. Pelatihan berkala mengenai penggunaan ICD-10, khususnya terkait penerapan kode gabungan, direkomendasikan sebagai upaya perbaikan.
Ketepatan Pengodean Lanjutan Diagnosis Pasien Rawat Jalan di RSIJ Cempaka Putih Ulhamdiati, Ulhamdiati; Iqbal, Muhammad Fuad
Surya Medika: Jurnal Ilmiah Ilmu Keperawatan dan Ilmu Kesehatan Masyarakat Vol. 20 No. 1 (2025)
Publisher : STIKes Surya Global Yogyakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.32504/sm.v20i1.1159

Abstract

Latar Belakang : Sejak diterapkannya Sistem Jaminan Sosial Nasional pada tahun 2004 yang dikelola oleh Badan Penyelenggara Jaminan Sosial (BPJS), Program Jaminan Kesehatan Nasional bertujuan untuk menyediakan layanan kesehatan yang berkualitas dan dapat diakses oleh seluruh masyarakat Indonesia.. Metode : Penelitian ini dilakukan di Rumah Sakit Islam Jakarta Cempaka Putih pada bulan Juni 2024 dengan menggunakan metode deskriptif kuantitatif untuk mengevaluasi ketepatan pengkodean sekunder pada pasien rawat jalan. Penelitian difokuskan pada rekam medis pasien periode Juli hingga September 2023 dengan total 54.628 kasus, dan 368 kasus diambil sebagai sampel acak. Pengumpulan data dilakukan melalui studi dokumentasi dan wawancara untuk memastikan ketepatan kode sekunder serta mengidentifikasi faktor-faktor penyebab ketidaktepatan. Analisis data menggunakan statistik deskriptif untuk menggambarkan distribusi frekuensi, dengan data sekunder yang diverifikasi melalui aplikasi RSIJ Cempaka Putih dan dikelola dalam format Excel. Hasil : Dari 368 sampel yang dianalisis, sebanyak 196 sampel (53,26%) memiliki kode yang tepat, sedangkan 172 sampel (46,74%) memiliki kode yang tidak tepat. Ketidaktepatan ditemukan pada kode Z09.4 (Pemeriksaan lanjutan setelah pengobatan fraktur tulang), Z09.8 (Pemeriksaan lanjutan setelah pengobatan lain untuk kondisi lain), Z35.8 (Kehamilan risiko tinggi), Z48.8 (Perawatan lanjutan pasca operasi), Z09.3 (Pemeriksaan lanjutan setelah psikoterapi), dan Z49.1 (Dialisis ekstrakorporeal). Kesimpulan : Perbaikan terhadap ketidaktepatan pengkodean pada pasien rawat jalan di Rumah Sakit Islam Jakarta Cempaka Putih sangat penting untuk meningkatkan kualitas layanan kesehatan, efisiensi administrasi, dan integritas keuangan. Penanganan permasalahan ini akan membantu dalam perencanaan layanan kesehatan dan peningkatan mutu pelayanan kepada pasien dalam sistem kesehatan Indonesia yang terus berkembang.
Identifikasi E-Form (Elektronik Formulir) Identitas Pasien Rawat Jalan pada Aplikasi Eti Care di Rumah Sakit Budi Kemuliaan Jakarta Dyah Melisa Setianingrum; Dina Sonia; Muhammad Fuad Iqbal; Daniel Happy Putra
Inovasi Kesehatan Global Vol. 2 No. 2 (2025): Mei : Inovasi Kesehatan Global
Publisher : Lembaga Pengembangan Kinerja Dosen

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.62383/ikg.v2i2.1640

Abstract

Building an effective and efficient health system is an important effort to improve the quality of health services in Indonesia, the implementation of RME is an integral component in the modern health service system. The government issued the One Healthy policy in efforts to implement Health Data governance. In order to achieve this, data variables and data formats/values ​​determined by the Ministry of Health must be used as a reference in the implementation of RME based on Minister of Health Regulation No. 24 of 2022. The aim of this research is to analyze data variables in the ETI Care application for outpatient registration at Budi Kemuliaan Hospital Jakarta according to the applicable guidelines, that is Minister of Health Decree Number HK.01.07/MENKES/1423/2022. This research uses descriptive qualitative methods. Data variables were obtained and their conformity with the existing meta data in the ETI Care application with government meta data, that is in the general identity there were 13 missing data variables and 2 variables that did not exist in the identity of the newborn baby, and 7 data variables that did not match the general identity and 1 data variable whose format/value did not match the identity of the newborn baby. It is necessary to develop the system by involving users in adjusting technical and organizational policies. There are still data variables that do not exist in the ETI Care application in the outpatient registration section, and there is also a discrepancy between the format/value of outpatient registration in the ETI Care application and the format/value of Minister of Health Decree Number HK.01.07/MENKES/1423/2022. This requires further communication with the vendor regarding system development in accordance with applicable guidelines.
Ketentuan Kodefikasi Pneumonia Kasus Rawat Inap pada Pasien Jaminan Kesehatan Nasional (JKN) berdasarkan ICD 10 Iqbal, Muhammad Fuad
Jurnal Rekam Medis & Manajemen Infomasi Kesehatan Vol. 2 No. 1 (2022): Juni 2022
Publisher : Universitas Nasional Karangturi

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (294.041 KB) | DOI: 10.53416/jurmik.v2i1.66

Abstract

Pneumonia is a disease that attacks the respiratory system due to infection from viral/bacterial aspiration and radiation and other causes, if not treated properly it can worsen the patient's condition, causing an increase in treatment costs. In the era of the National Health Insurance (JKN), the Indonesian Case Base Groups (INA CBG's) system was an important element in the submission and payment of claims for payment of health services that had been carried out by health care facilities, based on the ICD 10 code for diagnosis and ICD 9 CM for the procedure in processing claim. Coder staff must proficient in codification and clinical pathways for each disease because the Health Insurance Administration Agency (BPJS) has rules for every diagnosis. Based on the dispute claim, the INA CBG claim problems in 2018 are determined for the diagnosis of pneumonia as follows: (1) pneumonia whose cause is not specified can be coded J18.9, (2) pneumonia with pulmonary TB must use the join code to A16.2, (3) pneumonia with COPD using the merge code to J44.0, except for acute exacerbations of COPD, coded separately (4) pneumonia with septicemia is coded separately unless medical investigations reveal Streptococcus pneumonia using combined code A40.3, (5) pneumonia with typhoid fever using the combination code A01.0† J17.0* and (6) pneumonia with asthma were coded separately. These provisions must be understood by coders in coding cases of pneumonia to avoid suspension so that the claim process runs smoothly and works efficiently
Tinjauan Sistem Keamanan Rekam Medis Elektronik di Rumah Sakit Al Dr. Mintohardjo Jakarta Aldo Rizky Mahendra; Siswati Siswati; Dina Sonia; Muhammad Fuad Iqbal
VitaMedica : Jurnal Rumpun Kesehatan Umum Vol. 3 No. 3 (2025): Juli : VitaMedica : Jurnal Rumpun Kesehatan Umum
Publisher : STIKES Columbia Asia Medan

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.62027/vitamedica.v3i3.392

Abstract

Medical records are important documents that capture the entire medical history of patients, including identification, diagnosis, treatment, and recovery. With advancements in information technology, electronic medical records (EMR) have emerged as a solution to enhance the efficiency and accuracy of patient data management. However, despite the many benefits of EMR, its implementation at AL dr. Mintohardjo Hospital remains hybrid, combining manual and electronic methods. This indicates challenges in transitioning to a fully digital system. This study aims to identify and analyze issues related to the security of EMR at AL dr. Mintohardjo Hospital. Several issues identified include a lack of training for medical record staff regarding cybersecurity practices and data input errors. The research employs a qualitative approach, with data obtained from observations and interviews with hospital stakeholders. The informants in this study include IT staff, medical staff, and administrative staff. The findings regarding the security of electronic medical records (EMR) at AL dr. Mintohardjo Hospital indicate that, although there are established Standard Operating Procedures (SOP) for EMR security, their implementation is still not fully compliant. In terms of confidentiality, integrity, and availability of data, the study found that AL dr. Mintohardjo Hospital has implemented several security measures, such as user authentication and access management. However, weaknesses remain, such as a lack of user awareness regarding regular password changes and excessive access by administrative staff. Additionally, frequent data input errors can lead to serious consequences for patients, and threats to data confidentiality, integrity, and availability. Although the hospital has implemented measures such as firewalls and audit trail systems to protect data, challenges such as unstable internet connections and reliance on a single resource remain concerns. Overall, while the existing security measures are fairly adequate, this study emphasizes the need for improved staff training and strengthened procedures to minimize risks to the security of electronic medical record data.
Evaluasi Sistem Informasi Manajemen Puskesmas dengan Metode PIECES di Pendaftaran Puskesmas Kemayoran Manullang, Febe Cristiani; Putra, Daniel Happy; Sonia, Dina; Iqbal, Muhammad Fuad
Jurnal Pendidikan Tambusai Vol. 9 No. 2 (2025): Agustus
Publisher : LPPM Universitas Pahlawan Tuanku Tambusai, Riau, Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31004/jptam.v9i2.30352

Abstract

Evaluasi adalah suatu proses untuk menyediakan informasi tentang sejauh mana suatu kegiatan tertentu telah dicapai, bagaimana perbedaan pencapaian itu dengan suatu standar tertentu untuk mengetahui apakah ada selisih di antara keduanya. Tujuan penelitian ini memberikan evaluasi pada penggunaan sistem informasi manajemen dengan baik menggunakan aspek PIECES yang terdiri dari beberapa aspek yaitu performance (kinerja), information (informasi), economy (ekonomi), control (kontrol), sevice (pelayanan). Penelitian ini memakai dekskriptif dengan pendekatan kualitatif. Pada penggunaan sistem ditemukan permasalahan pada variabel data yang tidak ditemukan pada aplikasi simpus yaitu e-puskesmas yang menyebabkan penggunaan e-puskesmas menjadi membutuhkan waktu yang lama dan menganggu pelayanan.
Evaluasi Kepuasan Pengguna Rekam Medis Elektronik dengan Metode EUCS di Rumah Sakit Duta Indah Siti Nur Azizah Jamil; Muhammad Rezal; Noor Yulia; Muhammad Fuad Iqbal
Antigen : Jurnal Kesehatan Masyarakat dan Ilmu Gizi Vol. 3 No. 4 (2025): November: Antigen : Jurnal Kesehatan Masyarakat dan Ilmu Gizi
Publisher : LPPM STIKES KESETIAKAWANAN SOSIAL INDONESIA

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.57213/antigen.v3i4.850

Abstract

This study aims to evaluate and identify the obstacles faced and provide recommendations for improvements to the satisfaction of Electronic Medical Records (EMR) users at Duta Indah Hospital using the End User Computing Satisfaction (EUCS) method. At Duta Indah Hospital the EMR system used is Medinfras. EUCS is used to measure user satisfaction with the application system by comparing user expectations with the reality experienced. This evaluation examines seven variables: content, display (format), accuracy, ease of use, timeliness, speed, and flexibility. This research method uses descriptive quantitative with 63 respondents selected as samples. Data were collected through an online questionnaire, processed using Microsoft Excel 2016 software and analyzed using SPSS Version 25 software with a Likert scale to measure the level of satisfaction. The results showed that the majority of users felt "quite satisfied" with all variables, namely: content (57%), display (57%), timeliness (59%), speed (58%), flexibility (56%), accuracy (54%) and ease of use (54%). In conclusion, the RME system is considered quite adequate in supporting user performance, with accurate information, easy-to-understand displays, and efficiency in time and flexibility. The suggestion for the hospital is to conduct an evaluation, improve the appearance of the system menu so that users can access the system more easily and improve regular system maintenance.
Analisis Implementasi Artificial Intelligence dalam Dunia Kesehatan Indonesia: Literature Review: Analysis of Artificial Intelligence Implementation in the Indonesian Healthcare Sector: A Literature Review Avianta, Nur Azizah Syaputri; Putra, Daniel Happy; Satrya, Bangga Agung; Iqbal, Muhammad Fuad
MALCOM: Indonesian Journal of Machine Learning and Computer Science Vol. 5 No. 4 (2025): MALCOM October 2025
Publisher : Institut Riset dan Publikasi Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.57152/malcom.v5i4.2229

Abstract

Artificial Intelligence (AI) diharapkan menjadi kekuatan utama dalam mendukung transformasi digital sektor kesehatan, sesuai visi Kementerian Kesehatan tahun 2023. Namun, implementasi AI di Indonesia masih jauh dari harapan. Meskipun terdapat inisiatif kuat untuk memanfaatkan AI dalam meningkatkan efisiensi dan efektivitas layanan kesehatan, penerapannya masih terbatas dan belum merata. Penelitian ini dilakukan menggunakan metode literature review terhadap 52 artikel ilmiah periode 2021–2024. Dengan pendekatan teori Diffusion of Innovation, penelitian ini mengevaluasi manfaat AI dalam diagnosis, pengambilan keputusan klinis, manajemen data, dan peningkatan akses pelayanan, serta mengidentifikasi model adopsi dan tantangan utama dalam penerapannya. Hasil analisis menunjukkan bahwa tantangan utama dalam implementasi AI di sektor kesehatan Indonesia mencakup belum adanya regulasi spesifik, lemahnya infrastruktur digital, isu etika, dan rendahnya literasi teknologi. Meski demikian, Indonesia memiliki potensi besar dalam pengembangan ekosistem AI yang adaptif dan inklusif. Keberhasilan implementasi sangat bergantung pada kolaborasi lintas sektor, penguatan regulasi, serta peningkatan kompetensi sumber daya manusia dan kapasitas teknologi. Dengan strategi nasional yang terarah dan berkelanjutan, AI berpeluang menjadi pilar transformasi sistem pelayanan kesehatan yang lebih modern, efisien, dan berdaya saing.
Co-Authors Adinda Mentari Nursya’bani Aldo Rizky Mahendra Alifah Irdanti Syakurli Arif Ibnu Fadillah Avianta, Nur Azizah Syaputri Bangga Agung Satrya Daniel Happy Putra Daniel Happy Putra Dewi, Deasy Rosmala Dina Sonia Dyah Melisa Setianingrum Fannya, Puteri Fauziah Apriliani Febriyani, Madinah Hambali, Naira Fazilanisa Hari Dwi Cahya Ida Wahyuni Indawati, Laela Juliandari, Sabilla Junata, Ilfan Laila Ulfa Manullang, Febe Cristiani Nur Fatimah, Gefira Putri, Rula Afrilia Padila Rani Yulistianingsih Revina Purnaningrum Rezal, Muhammad Sadono Hadi Saputro Salsabella, Pradita Siswati Siswati Siti masruroh Siti Nur Azizah Jamil Tarisa Maharani Ulhamdiati, Ulhamdiati Vickriyal Nadith Yulia, Noor