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All Journal Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) 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
Lubis, Siti Permata Sari
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Journal : COVID-19 : Journal of Health, Medical Records and Pharmacy

 1 
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

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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

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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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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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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.
Factors Inhibiting the Accuracy of Outpatient Morbidity Reporting Data in SIMRS at Imelda General Hospital Lubis, Siti Permata Sari; Simanjuntak, Esraida; Bancin, Sri Wahyuni
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

The implementation of reporting is very important for hospitals because it can be used as a comparison of visits of old patients or new patients who previously and now reporting in hospitals is divided into 2, namely Internal reporting and External reporting, reporting systems in hospitals will usually be reported monthly, quarterly, and annually. This report aims to produce relevant, accurate and timely information. To be able to produce good and correct, accurate and complete computer output data and can be accounted for is greatly influenced by the discipline of the unit towards patients. Time and place of research May 2023-August 2023 at RSU Imelda, The purpose of this study is to determine the implementation of the management of outpatient morbidity data reporting at SIMRS based on human factors (Man), Method (Method) and Facility (Machine). This type of research is descriptive qualitative. The methods used for data collection are Observation and Interview. The informants in this study amounted to 2 people consisting of 1 SIMRS officer and 1 reporting officer. The result of this study is human resources (Man) where officers still often get errors in writing early diangnosa in patient files, incompleteness of Medical Record files, lack of hospital management preparation, procedure updates and technical instructions in reporting. Facilities (Machine) where the network is often problematic makes officers late in sending reporting data, SOP (Method) where there is no specific SOP in outpatient morbidity reporting but the reporting process still runs well. The suggestion that can be given is to create a special SOP for reporting outpatient morbidity data and improve the network contained in the ruagan so that the processing in reporting can be carried out more optimally.
Co-Authors Andi Ritonga, Zulham Azhar, Anja Bancin, Sri Wahyuni Christy, Johana Erlindai, Erlindai Fitri Yani Gulo, Leli Nurmeida Harefa, Calvin Natana Eli Hulu, Delisman NASUTION, YULIA AFRINA Nurhaliza, Nurhaliza Ritonga , Zuham Andi Ritonga, ZuhamAndi Ritonga, Zulham Andi Sabela Hasibuan, Ali Siddik Karo-Karo Sihite, Geovani Arta Simanjuntak, Esraida Simanjuntak, Marta Sitorus, Mei Sryendang Theresia Hutasoit Valentina Valentina, Valentina Wahab, Bachtiyar