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All Journal Jurnal Kesehatan Komunitas Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Jurnal Kesehatan Tambusai Jurnal Media Informatika Jurnal Pengabdian Masyarakat (ABDIRA) Jurnal ABDIMAS Budi Darma PELS (Procedia of Engineering and Life Science) Jurnal Ilmiah Pengabdian Kepada Masyarakat Benih : Journal of Midwifery Pengabdian Kepada Masyarakat Indonesia SEAN (ABDIMAS SEAN) COVID-19 : Journal of Health, Medical Records and Pharmacy
Sitorus, Mei Sryendang
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SOSIALISASI KELENGKAPAN BERKAS REKAM MEDIS TERHADAP PELAPORAN DATA MORBIDITAS (RL 4A) DI RUMAH SAKIT MADANI MEDAN Simanjuntak, Marta; Sitorus, Mei Sryendang; Erlindai, Erlindai; Christy, Johana; Valentina, Valentina; Lubis, Siti Permata Sari; Azhar, Anja
Pengabdian Kepada Masyarakat Indonesia SEAN (ABDIMAS SEAN) Vol. 1 No. 1 (2023): Pengabdian Kepada Masyarakat Indonesia SEAN (ABDIMAS SEAN), Februari 2023
Publisher : SEAN Institute

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.58471/abdimassean.v1i1.564

Abstract

Pelaporan SIRS terdiri dari pelaporan setiap saat (update) dan periodik (berkala). Salah satu pelaporan yang bersifat periodik yaitu Laporan Data Keadaan Morbiditas Dan Mortalitas Pasien Rawat Inap (RL4a) yang wajib dilaporkan setiap tahun. Tujuan pengabdian ini untuk memberi gambaran kepada petugas pengaruh ketidak lengkapan berkas rekam medis terhadap pelaporan RL 4a di Rumah Sakit Madani Medan. Kegiatan dilakukan dengan menjelaskan faktor ketidaklengkapan berkas rekam medis rawat inap yang digunakan untuk pelaporan data morbiditas pasien rawat inap (RL4a) di Rumah Sakit Madani Medan dan meningkatkan pemahaman petugas tentang pentingnya kelengkapan rekam medis terkait data morbiditas. Data yang dianalisis yaitu dokumen rekam medis rawat inap di Rumah Sakit Madani Medan tiga bulan terakhir yaitu bulan Januari sampai Maret tahun 2024 yaitu sebanyak 162 berkas dengan sampel sebanyak 62 berkas rekam medis. Hasil analisis diketahui ketidaklengkapan paling banyak untuk karakteristik pasien kategori jenis pasien 45,2%, pencatatan diagnosa 30,6%, diagnosa akhir 22,6%, dan kode ICD X 59,7%. Untuk ketidaklengkapan pengisian keadaan pasien saat keluar 17,7% dan pencatatan tanggal dan jam keluar 24,2%. Penyebab ketidaklengkapan disebabkan kurangnya pemahaman petugas tentang pentingnya kelengkapan rekam medis untuk klaim dan pelaporan, kegiatan review rekam medis belum maksimal dan SPO juga belum ada di Rumah Sakit Madani Medan. Ketidaklengkapan tersebut berdampak pada keterlambatan pengisian dan pengiriman Formulir RL4a karena petugas pelaporan harus mengecek ulang data yang tidak lengkap sehingga dibutuhkan waktu yang lebih lama dalam pengisian Formulir RL4a. Sosialisasi dilakukan kepada petugas rekam medis untuk meningkatkan pemahaman petugas tentang pentingnya kelengkapan rekam medis terkait data morbiditas. Kegiatan ini terlaksana dengan baik karena dukungan Direktur Rumah Sakit Madani Medan dan seluruh petugas kesehatan khususnya petugas rekam medis Rumah Sakit Madani Medan.
Sosialisasi Identifikasi Manajemen Risiko dalam Penyelenggaraan Rekam Medis Elektronik di UPT Puskesmas Pulo Brayan Sitorus, Mei Sryendang; Simanjuntak, Marta; Daeli, Cosmas Samuel; Hutasoit, Theresia; Erlindai, Erlindai; Sihite, Geovani Arta
Jurnal Pengabdian Masyarakat (ABDIRA) Vol 5, No 3 (2025): Abdira, Juli
Publisher : Universitas Pahlawan Tuanku Tambusai

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31004/abdira.v5i3.722

Abstract

Electronic Medical Records are medical records created using an electronic system intended for organizing Medical Records (Permenkes RI, 2022. Health centers are required to have and organize medical records for every patient who receives services (Permenkes RI, 2008). Integrated risk management is the process of identifying, analyzing, evaluating and managing all potential risks and is applied to all units or activities starting from the preparation of strategic plans, program and budget implementation, accountability and monitoring evaluation and reporting (Permenkes RI, 2019). In the Pulo Brayan Health Center Medical Records Unit, factors that influence risk were found, namely: physical, biological, psychological, chemical, and ergonomic factors. Activities were carried out by socializing the Management of Risk Management and SOP for Risk Management in the Medical Records Unit and revisions. Continued with risk identification and assessment. The results of the physical factors showed that medical record officers had the potential to experience eye fatigue due to exposure to computer radiation which can be overcome by using anti-radiation to reduce the risk. Psychological factors include increased emotions due to network disruptions, overcome by increasing network capacity and maintenance. Ergonomic factors Muscle tension is overcome by using a more ergonomic work chair.
Review of the Completeness of the Medical Resume Form Based on the Assessment Elements of Mirm 15 National Hospital Accreditation Standards (SNARS) at Imelda Pekerja Indonesia Hospital Medan 2021 Liem, John Barker; Rifhan, Zanurul; Simanjuntak, Marta; Sitorus, Mei Sryendang; Alna, Jihan
COVID-19 : Journal of Health, Medical Records and Pharmacy Vol. 2 No. 01 (2024): COVID-19 : Journal of Health, Medical Records and Pharmacy
Publisher : CV. Devitara

Show Abstract | Download Original | Original Source | Check in Google Scholar

Abstract

Incompleteness in filling out a medical resume will greatly affect the hospital's accreditation assessment listed in the MIRM 15 SNARS standard sub-group Issue 1.1. This study aims to determine the completeness of filling out the resume form based on the assessment elements of MIRM 15 SNARS Edition 1.1 at Imelda Pekerja Indonesia Hospital in Medan. This study uses quantitative and qualitative methods, with a population of 1,355 medical resume forms at Imelda Pekerja Indonesia Hospital Medan in November-December 2021 and a sample of 93 medical resumes which are completed into 100 medical resume forms. Based on the results of the study, it was found that 76 medical resume forms were filled (70%) and 30 medical resume forms were incomplete (30%). score Based on the assessment of SNARS Edition 1.1, the number of complete medical resume forms was 76% with a score of 5 (partially fulfilled) because the achievement range was 29%-79%. The highest completeness on the medical resume form at Imelda Pekerja Indonesia Hospital is found in the patient history component, diagnostic examination, therapeutic procedures and actions, drugs given and drugs when the patient leaves the hospital, the patient's health condition (current status) and follow-up instructions (100% ) Medical resume forms and the lowest completeness were found on physical examination (15%) indication of patients being treated (6%), comorbidities (12) and patient/family signatures (24%) of medical resume forms. Researchers suggest that there is a need for socialization that continuously increases knowledge to medical officers about filling out the complete medical resume form according to SNARS at Imelda Pekerja Indonesia Hospital in Medan.
FAKTOR – FAKTOR PENENTU KETEPATAN KODE DIAGNOSA CHRONIC KIDNEY DISEASE (CKD) PASIEN RAWAT INAP DI RUMAH SAKIT UMUM IMELDA PEKERJA INDONESIA TAHUN 2023 Hutasoit, Theresia; Sitorus, Mei Sryendang; Erlindai, Erlindai; Christy, Johanna; Syahputri, Melati Adila
Jurnal Kesehatan Tambusai Vol. 5 No. 4 (2024): DESEMBER 2024
Publisher : Universitas Pahlawan Tuanku Tambusai

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31004/jkt.v5i4.37033

Abstract

Ketepatan dalam pemberian kode diagnosis merupakan hal yang harus diperhatikan oleh perekam medis khususnya coder. Salah satu kompetensi yang harus dimiliki oleh seorang perekam medis adalah kodefikasi penyakit dan tindakan medis. Ketepatan kode diagnosis pada penyakit CKD sangat dipengaruhi oleh kelengkapan rekam medis. Berdasarkan hasil survei awal yang dilakukan terdapat 37 rekam medis yang lengkap yaitu (60,65%) kode diagnosis pada penyakit CKD sesuai dengan ICD-10 dan terdapat 24 rekam medis yang tidak lengkap yaitu (39,34%).  Bertujuan untuk mengetahui apa saja faktor penentu ketepatan kode diagnosa CKD pada pasien rawat inap. Jenis penelitian ini adalah deksriptif dengan pendekatan kualitatif yaitu mendeksripsikan dan menggambarkan secara rinci permasalahan yang diteliti dengan mempelajari semaksimal mungkin suatu kejadian. Populasinya yaitu petugas koding rawat inap yang berjumlah 5 orang. Jumlah sampel yang digunakan sebanyak 31 rekam medis CKD rawat inap. Cara pengumpulan data dengan menggunakan observasi dan wawancara. Hasil yang diperoleh dari penelitian ini, dari 31 rekam medis CKD rawat inap terdapat 12 rekam medis yang memiliki kode kurang tepat (38,70%) dan 19 rekam medis yang tepat (61,30%). Faktor penentu ketepatan kode seperti Man kurang telitinya petugas dalam kelengkapan pengisian berkas rekam medis, Material ketidaklengkapan pengisian dan tidak ditulisnya diagnosis penyakit, Method masih ditemukannya petugas yang kurang memahami SPO, dan Machine gangguan jaringan komputer. Berdasarkan hasil penelitian, diharapakan untuk diberikannya pelatihan coding terkait tatacara mengkode yang tepat sesuai panduan SPO, ICD-10 dan perlu ditingkatkan komunikasi antar petugas coding dan dokter yang memberi diagnosis serta melengkapi bagian pemeriksaan penunjang agar dapat menghasilkan kode yang tepat.
Human Resource Placement System for Medical Record Work Unit at Private Hospitals in Medan City in 2024 Nurhaliza, Nurhaliza; Simanjuntak, Esraida; Lubis, Siti Permata Sari; Sitorus, Mei Sryendang
Procedia of Engineering and Life Science Vol. 6 (2024): The 3rd International Scientific Meeting on Health Information Management (3rd ISMoHI
Publisher : Universitas Muhammadiyah Sidoarjo

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.21070/pels.v6i0.1980

Abstract

The processing of a quality Medical Record unit requires a very important resource, namely human resources. The first step in producing skilled and reliable human resources requires planning in placing employees/employees who are suitable for their jobs. The process of placing human resources for medical record work units at Imelda Workers' General Hospital Indonesia, Adventist Hospital Medan and Eshmun General Hospital still found that some medical record employees were not in accordance with their qualifications because the employees had a diploma in computers, high school and a bachelor's degree in mechanical engineering. This can certainly lead to a lack of security in maintaining the confidentiality of medical record files, allowing duplication of medical record numbers, lack of quality of data produced and lack of quality of hospital services. The type of research used is descriptive research with a qualitative approach. The subjects of this study are 6 people, namely 1 HRD and 1 head of medical records at each of the Imelda Workers' General Hospital of Indonesia, Adventist Hospital Medan and Eshmun General Hospital. This sampling technique is by purposive sampling method. The results of the research that have been obtained are still medical record work unit officers who are not in accordance with their educational qualifications in the three hospitals, such as the registration section is not included in the medical record unit so that the officers who work are not medical recorder graduates. Work experience and physical health are factors that need to be considered in the placement of human resources and the average placement age of each officer is 25 to 40 years old, this age factor is considered with the intention of avoiding low productivity produced by the employee concerned. To the three hospitals, it is recommended that the placement of human resources in the medical record work unit is adjusted to their educational qualifications, experience, physical health and age.
Hubungan Penggunaan Rekam Medis Elektronik (RME) dengan Kepuasan Petugas Kesehatan di RSU Imelda Pekerja Indonesia Simanjuntak, Esraida; Sitorus, Mei Sryendang; Lubis , Siti Permata Sari; Sihite, Geovani Arta
Jurnal Kesehatan Komunitas Vol 11 No 3 (2025): Jurnal Kesehatan Komunitas
Publisher : Universitas Hang Tuah Pekanbaru

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25311/keskom.Vol11.Iss3.2316

Abstract

The level of feeling experienced by patients as a result of the performance of the health services they receive after comparing it with their expectations is known as patient satisfaction. The purpose of this study was to illuminate how the satisfaction of health workers with the use of Electronic Medical Records (EMR) is poured into the dimensions of content, chimney, format, ease of use, and timeliness at RSU Imelda Buruh Indonesia Medan. Based on the criteria that have been set, this study uses a descriptive method with a quantitative approach. A total sample of 62 people was taken from the population. Observation sheets and questionnaires are research tools. This study found that the use of EMR on the variables of content, precision, ease of use, and timeliness is met with the satisfaction of health workers at RSU Imelda Buruh Indonesia. However, the variable format does not satisfy satisfaction, There is no relationship between the use of EMR in the format variable and the satisfaction of health workers at RSU Imelda Buruh Indonesia. It It is recommended that there are more detailed regulations regarding the use of RME so that the use of RME at the Imelda Buruh Indonesia Hospital can be maximized and that there is a need to re-socialize the regulations on the accuracy of filling in RM so that RM recording by PPA is more complete and accurate so that the quality of reports as RME output can be improved.
Co-Authors Alna, Jihan Anggiani, Rahma Dwi Azhar, Anja Christy, Johana Christy, Johanna Cosmas Samuel Daeli Erlindai, Erlindai Fitri Yani Gusla Nengsih, Yeyi Gusla, Yeyi Harefa, Calvin Natana Eli Hulu, Mery Windhy Kristina Hutauruk, Puput Melati Khairani Lase , Kristalina Liem, John Barker Lubis , Siti Permata Sari Lubis, Siti Permata Sari Nurhaliza, Nurhaliza Olviya , Cicha Rifhan, Zanurul Ritonga, Abdul Malik Ritonga, Sheila Hamdah Hanum Sarida Surya Manurung Sihite, Geovani Arta Simanjuntak, Esraida Simanjuntak, Marta Syahputri, Melati Adila Tanjung, Hizraini Theresia Hutasoit Valentina Valentina, Valentina Widyasari, Savira