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All Journal Jurnal ABDIMAS Budi Darma 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
Lubis, Siti Permata Sari
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RANCANGAN KARTU INDEKS UTAMA PASIEN (KIUP) DI UPT PUSKESMAS SEI AGUL Simanjuntak, Esraida; Simanjuntak, Marta; Valentina, Valentina; Lubis, Siti Permata Sari
Jurnal Ilmiah Pengabdian Kepada Masyarakat (Ji-SOMBA) Vol. 2 No. 2 (2023): Jurnal Ilmiah Pengabdian Kepada Masyarakat (Ji-SOMBA)
Publisher : Universitas Imelda Medan

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (354.47 KB) | DOI: 10.52943/ji-somba.v2i2.1317

Abstract

KIUP bermanfaat untuk mencari nomor rekam medis apabila pasien tidak membawa KIB, memudahkan pencarian nomor rekam medis untuk keperluan retensi DRM, dan sebagai alat bantu penyusutan laporan kunjungan pasien. Kegiatan pengabdian kepada masyarakat ini dilaksanakan di Puskemas Sei Agul yang bertujuan memberikan penyuluhan tentang penggunaan KIUP untuk memudahkan petugas pendaftaran yang sulit untuk mencari rekam medis pasien jika pasien tidak membawa kartu berobat di puskesmas. Metode yang digunakan dalam kegiatan ini adalah dengan memberikan penyuluhan secara langsung, demonstrasi dan pendampingan dalam pengimplemantasian KIUP di bagian pendaftaran rekam medis. Hasil dari kegiatan pengabdian kepada masyarakat ini adalah bertambahnya pengetahuan dan keterampilan petugas penyimpanan dalam menggunakan KIUP untuk memudahkan pencarian rekam medis pada saat pasien datang berobat dan membantu keperluan penyusutan dan retensi. Kegiatan ini dilaksanakan dengan baik berkat dukungan dan kerja sama dari semua pihak baik tim pelaksana, mahasiswa, petugas dan Kepala Puskesmas Sei Agul serta Dinas Kesehatan Kota Medan.
PENYULUHAN PENGISIAN INFORMASI KLINIS REKAM MEDIS BERDASARKAN AKREDITASI PUSKESMAS EDISI 2 VERSI 2019 SUB STANDAR 3.8.3 DI PUSKESMAS GLUGUR DARAT KOTA MEDAN Valentina, Valentina; Simanjuntak, Esraida; Lubis, Siti Permata Sari; Ritonga, Zulham Andi; Hasibuan, Ali Sabela
Jurnal Ilmiah Pengabdian Kepada Masyarakat (Ji-SOMBA) Vol. 3 No. 1 (2023): Jurnal Ilmiah Pengabdian Kepada Masyarakat (Ji-SOMBA)
Publisher : Universitas Imelda Medan

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/ji-somba.v3i1.1528

Abstract

Penilaian akreditasi menjadi hal yang sangat penting untuk pembinaan peningkatan mutu dan kinerja melalui perbaikan yang berkesinambungan di puskesmas. Kegiatan pengabdian kepada masyarakat dilaksanakan di Puskemas Glugur Darat bertujuan memberikan penyuluhan tentang pengisian informasi klinis rekam medis berdasarkan Akreditasi Puskesmas sub standar 3.8.3. Metode yang digunakan dalam pengabdian kepada masyarakat ini adalah dengan memberikan penyuluhan secara langsung, demonstrasi dan pendampingan dalam pelaksanaan proses pengisian informasi klinis rekam medis untuk menurunkan ketidaklengkapan pengisian rekam medis di puskemas. Hasil dari kegiatan pengabdian kepada masyarakat ini adalah meningkatnya pengetahuan, keterampilan dan komitmen bersama petugas untuk mengisi informasi klinis secara lengkap dan jelas di dalam rekam medis sesuai sub Standar 3.8.3 Akreditasi Puskesmas, ditetapkannya petugas analisa, serta penambahan ketentuan pengkoreksian dan penambahan data rekam medis pada SOP. Kegiatan ini berhasil dilaksanakan atas dukungan dan kerja sama yang baik dari semua pihak baik tim pelaksana, mahasiswa, petugas dan Kepala Puskesmas Glugur Darat serta Dinas Kesehatan Kota Medan.
REDESAIN MAP REKAM MEDIS DI UPT PUSKESMAS PEKAN LABUHAN KOTA MEDAN Andi Ritonga, Zulham; Valentina, Valentina; Lubis, Siti Permata Sari; Simanjuntak, Esraida; Karo Karo, Siddik; Hasibuan, Ali Sabela
Jurnal Ilmiah Pengabdian Kepada Masyarakat (Ji-SOMBA) Vol. 3 No. 2 (2024): Jurnal Ilmiah Pengabdian Kepada Masyarakat (Ji-SOMBA)
Publisher : Universitas Imelda Medan

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/ji-somba.v3i2.1677

Abstract

Pelayanan kesehatan di puskesmas tidak terlepas dari dukungan data-data pasien yang semuanya itu harus tercatat dengan baik dan benar di dalam rekam medis. Map rekam medis (folder) merupakan sampul yang berfungsi untuk menjaga semua formulir rekam medis pasien yang ada dalam satu file dan terlindungi dari kerusakan secara fisik serta menjaga kerahasiaan data pasien didalamnya. Tujuan dari pengabdian ini yaitu untuk mendesain ulang sampul rekam medis dilihat dari aspek anatomi, fisik dan isi, serta disesuaikan dengan kebutuhan data pasien yang ada di wilayah kerja UPT Puskesmas Pekan Labuhan Medan. Metode pengabdian yang digunakan adalah dengan melakukan kolaborasi dengan petugas penyimpanan rekam medis di puskesmas yang terdiri dari pemberian edukasi tentang desain rekam medis yang baik, konsultasi dan perancangan map rekam medis sesuai kebutuhan di puskesmas, serta melakukan demonstrasi dan pendampingan penerapan map rekam medis di puskesmas. Kegiatan pengabdian ini dilakukan pada bulan Februari 2024 dengan jumlah partisipan sebanyak 10 orang petugas kesehatan di UPT Puskesmas Pekan Labuhan. Kegiatan pengabdian ini dilakukan selama 3 bulan. Adapun hasil dari kegiatan pengabdian ini adalah meningkatnya pengetahuan dan keterampilan petugas dalam mendesain map rekam medis yang baik serta sebuah desain produk map (folder) rekam medis di UPT Puskesmas Pekan Labuhan Medan. Keberhasilan kegiatan pengabdian ini didukung oleh kerja sama yang baik dari tim pengabdian masyarakat, petugas dan kepala UPT Puskesmas Pekan Labuhan Medan serta Dinas Kesehatan Kota Medan.
Penggunaan Aplikasi Excel Sebagai Aplikasi Pembantu SIMRS Gos Dalam Pencatatan Dan Pelaporan Di Rumah Sakit TNI AU Soewondo RSAU Dr. Abdul Malik Sitorus, Mei Sryendang; Simanjuntak, Esraida; Lubis, Siti Permata Sari; Hutasoit, Theresia; Sihite, Geovani Arta; Harefa, Calvin Natana Eli; Yani, Fitri
Jurnal ABDIMAS Budi Darma Vol 5, No 1 (2024): Agustus 2024
Publisher : Universitas Budi Darma

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.30865/pengabdian.v5i1.8329

Abstract

The Hospital Management Information System (SIMRS) is a vital component in hospital operations to ensure the efficiency of recording and reporting medical and administrative data. This research aims to analyze the use of the Microsoft Excel application as an auxiliary application in supporting SIMRS Gos at the Soewondo TNI AU Hospital RSAU Dr. Abdul Malik. The use of Excel aims to increase the speed and accuracy of recording and reporting hospital data which has not been fully accommodated by SIMRS Gos. The research method used is a qualitative descriptive approach with interviews and direct observation of hospital officers involved in the recording and reporting process. The research results show that the Excel application provides flexibility in processing data, but requires increased integration with SIMRS to minimize data input errors and duplication of work. The recommendation from this research is further development of SIMRS so that it can accommodate the functions currently carried out by Excel, in order to increase work efficiency and data accuracy in hospitals
Analysis Of the Health Services of Tuberculosis Patients Regarding Compliance with Drinking Drugs In Puskesmas Of Medan Nasution, Yulia Afrina; Lubis, Siti Permata Sari; Simanjuntak, Esraida
Benih : Journal of Midwifery Vol. 4 No. 01 (2025): Benih : Journal of Midwifery
Publisher : Cattleya Darmaya Fortuna

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.54209/benih.v4i01.359

Abstract

Tuberculosis is the second most deadly infectious disease. Indonesia is in the top three countries after India and China. The number of patients in North Sumatra in 2019 was recorded at 37,865 people while in 2020 there were 33,779 cases. Medan has the highest number of cases, which were 12,105 cases in 2020. This research aims to analyze health services such as pharmacy services and nursing services for tuberculosis patients in relation to medication compliance in Puskesmas of Medan. This research uses an observational method with a cross-sectional design. The number of samples is 100 people with purposive sampling technique. The analysis used is univariate, bivariate and multivariate. The pharmaceutical service shows that there is an effect of pharmaceutical service with medication compliance (p= 0.004; 95% CI 1.550-9.309). The OR value is 3.798 meaning that people who experience less effective pharmaceutical service have a risk of 3.798 time to not comply with medication compared to people who experience effective pharmaceutical services. The nursing service shows that there is an effect of nursing service with medication compliance (p= 0.002; 95% CI 1.671-10.602) with an OR value of 4.209, meaning that people who experience ineffective nursing services have a risk of 4.209 times to not comply with medication compared to people who experience effective nursing care. There is an influence of pharmacy services and nursing services with medication compliance in tuberculosis patients in Puskesmas of Medan.
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.
Overview of the Implementation of Incomplete Control of Medical Record Documents at Sentosa Baru Health Center in 2023 Hasibuan, Ali Sabela; Lubis, Siti Permata Sari; Gulo, Leli Nurmeida
COVID-19 : Journal of Health, Medical Records and Pharmacy Vol. 1 No. 01 (2023): COVID-19 : Journal of Health, Medical Records and Pharmacy
Publisher : CV. Devitara

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

Abstract

One of the implementations of controlling medical record documents is by completing medical record documents properly in accordance with SOPs. This study was shown to determine the implementation of medical record document control at Sentosa Baru Health Center. This research is a Quantitative descriptive research. The method used in this study is by Observation. The research was conducted at Sentosa Baru Health Center. The study was conducted from June to August 2023. The population at Sentosa Baru Health Center is 780 medical record documents The sample size in this study was calculated based on the slovin formula so that 80 medical record documents were obtained as research subjects. For the completeness of medical record documents, in the section of writing patient identity, name, time, doctor's signature, there are 80 medical record documents completely (100%). The column of date, month, year, justification for writing medical records there are 40 complete medical record documents (50%) and in the writing section of Assessment, Planning, Screening-vital sign there are 60 complete medical record documents (75%). Thus, the author suggests to the medical record officer at Sentosa Baru Health Center, to re-socialize related to the SOP by filling out medical record documents and then evaluating the suitability between the SOP and the performance of the medical record officer.
Overview of Work Stress of Medical Record Officer of Distribution Section at RSUP H. Adam Malik Medan Lubis, Siti Permata Sari
COVID-19 : Journal of Health, Medical Records and Pharmacy Vol. 1 No. 01 (2023): COVID-19 : Journal of Health, Medical Records and Pharmacy
Publisher : CV. Devitara

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

Abstract

Work stress can be experienced by everyone without exception workers in hospitals and is a consequence of workplace events that demand excessive physical and psychological involvement of employees (Triatna, 2015). Work stress that lasts continuously can cause emotional and behavioral changes such as irritability and difficulty concentrating, which can reduce one's work motivation and result in a decrease in work quality The purpose of this study is to determine the picture of work stress of distribution medical record officers at H. Adam Malik Hospital Medan. The type of research conducted is qualitative descriptive. The sample used by researchers took all 5 distribution officers. Research variables are an attribute or trait of people who have certain variations set by researchers, research instruments in the form of questionnaires given to respondents to see the picture of work stress of medical record officers in the distribution section. Data analysis in this study is presented in the form of a distribution table. The results of research conducted on 5 respondents that the majority of work stress can be concluded that as many as 4 respondents (80%) experience work stress, and the minority work stress as many as 1 respondent (20%). From the results of the study above, it can be concluded that the description of work stress of distribution medical record officers at H. Adam Malik Hospital Medan the majority experience work stress. The researcher's suggestion to the hospital is to provide facilities in the form of goods carriers to medical record officers in the distribution department to facilitate the delivery of medical record files to the polyclinic and this can reduce the workload of medical record officers in lifting heavy items.
Factors Affecting Medical Record Service Quality Activities at Puskesmas Bestari Lubis, Siti Permata Sari
COVID-19 : Journal of Health, Medical Records and Pharmacy Vol. 1 No. 02 (2024): COVID-19 : Journal of Health, Medical Records and Pharmacy
Publisher : CV. Devitara

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Abstract

Factors that affect the quality of medical record services are human resources, facilities and infrastructure and policy monitoring and evaluation. The problem of this study is that there are less medical record officers, causing less fast service. The purpose of the study was to determine the factors that affect the quality of medical record service activities at Puskesmas Bestari. This type of research is a descriptive study where the population and sample are the same, namely 4 general practitioners, 3 dentists, 7 nurses and 2 medical record officers. This research collection technique is a field study technique, namely questionnaires, interviews and observations. The data analysis used in this study was univariate analysis. The results obtained were poor service quality by 12.5%, poor doctor human resources by 28.6%, poor nurse resources by 28.6%, good medical recorder resources by 66.6%, poor facilities and infrastructure by 20%, policy monitoring and evaluation by 40%. Based on these results, it can be concluded that the quality of medical record services, doctor human resources, nurse human resources, medical recorder human resources, facilities and infrastructure and policy monitoring and evaluation are still lacking, so it is expected that the Head of the Puskesmas will conduct training on the importance of the quality of medical record services in improving the performance of officers at the Puskesmas.
Factors for Duplication of Medical Record Numbers at UPT Puskesmas Pasar Merah Simanjuntak, Marta; Lubis, Siti Permata Sari; Simanjuntak, Esraida; Hutasoit, Theresia
COVID-19 : Journal of Health, Medical Records and Pharmacy Vol. 1 No. 02 (2024): COVID-19 : Journal of Health, Medical Records and Pharmacy
Publisher : CV. Devitara

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Abstract

Duplication of medical record numbers is a problem that often occurs in the Integrated Service Unit (UPT) of the Pasar Merah Health Center. This study aims to identify the factors that cause duplication of medical record numbers at UPT Puskesmas Pasar Merah. This research method uses a qualitative approach with in-depth interviews with medical administration officers, patient registration officers, and medical personnel directly involved in managing medical record numbers. In addition, observations were also made to understand the process of managing medical record numbers at UPT Puskesmas Pasar Merah.The results showed that the factors of duplication of medical record numbers involved several aspects, including lack of training of medical administrative officers in database management, recording systems that were not effectively integrated between service units, and the unavailability of medical record number validation when registering new patients. In addition, human error factors such as writing and recording errors are also the cause of duplication of medical record numbers. The recommendations of this study include improving training for medical administrative officers in database management, developing an integrated recording system, implementing direct validation of medical record numbers during patient registration, and strengthening supervision mechanisms to prevent human error in managing medical record numbers. This research is expected to contribute to the improvement of the medical record management system at UPT Puskesmas Pasar Merah, so as to reduce the incidence of duplication of medical record numbers and increase efficiency and accuracy in managing patient data.
Co-Authors Andi Ritonga, Zulham Azhar, Anja Bancin, Sri Wahyuni Christy, Johana Erlindai, Erlindai Fitri Yani Gulo, Leli Nurmeida Harefa, Calvin Natana Eli NASUTION, YULIA AFRINA Ritonga, Zulham Andi Sabela Hasibuan, Ali Siddik Karo-Karo Sihite, Geovani Arta Simanjuntak, Esraida Simanjuntak, Marta Sitorus, Mei Sryendang Theresia Hutasoit Valentina Valentina, Valentina