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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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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

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

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.
KLASIFIKASI PENGKODINGAN PENYAKIT DAN TINDAKAN DENGAN DIAGNOSA DIABETES MELITUS PADA TN. A DI UPT PUSKESMAS SERING TAHUN 2023 Sabela Hasibuan, Ali; Valentina, Valentina; Lubis, Siti Permata Sari; Simanjuntak, Esraida; Karo Karo, Siddik; Ritonga , Zuham Andi
Jurnal Ilmiah Pengabdian Kepada Masyarakat (Ji-SOMBA) Vol. 4 No. 1 (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.v4i1.1790

Abstract

Koding merupakan kegiatan menetapkan kode penyakit dan tindakan dengan tepat sesuai klasifikasi yang diberlakukan di Indonesia International Statistical Classification of Diseases, Tenth Revision (ICD-10) dan tentang Penyakit dan Tindakan Medis yaitu International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) dalam pelayanan dan manajemen kesehatan. Klasifikasi dan kodefikasi penyakit, masalah- masalah yang berkaitan dengan kesehatan dan tindakan medis merupakan kompetensi pertama Profesi Perekam Medis dan Informasi Kesehatan. Kegiatan pengabdian kepada masyarakat dilaksanakan di Puskemas Sering bertujuan memberikan penyuluhan tentang Pengkodingan penyakit dan tindakan DM. Metode yang digunakan dalam pengabdian kepada masyarakat ini adalah dengan memberikan penyuluhan secara langsung, demonstrasi dan pendampingan dalam pelaksanaan proses pengkodingan rekam medis untuk menurunkan ketidaktepatan penentuan kode penyakit dan tindakan DM di puskemas. Hasil dari kegiatan pengabdian kepada masyarakat ini adalah meningkatnya pengetahuan dan keterampilan dalam menentukan kode penyakit dan tindakan. Kegiatan ini berhasil dilaksanakan atas dukungan dan kerja sama yang baik dari semua pihak baik tim pelaksana, mahasiswa, petugas dan Kepala Puskesmas Sering serta Dinas Kesehatan Kota Medan.
ANALISIS PENERAPAN MANAJEMEN RESIKO PADA REKAM MEDIS ELEKTRONIK DI UPT PUSKESMAS KOTA MATSUM Simanjuntak, Esraida; Hasibuan, Ali Sabela; Lubis, Siti Permata Sari; Karo Karo, Siddik; Ritonga, ZuhamAndi; Hulu, Delisman
Jurnal Ilmiah Pengabdian Kepada Masyarakat (Ji-SOMBA) Vol. 4 No. 2 (2025): Jurnal Ilmiah Pengabdian Kepada Masyarakat (Ji-SOMBA)
Publisher : Universitas Imelda Medan

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jisomba.v4i2.1901

Abstract

Penerapan Rekam Medis Elektronik (RME) di fasilitas pelayanan kesehatan tingkat pertama, seperti Puskesmas, merupakan langkah strategis untuk meningkatkan mutu pelayanan kesehatan. Penelitian ini bertujuan untuk menganalisis penerapan manajemen risiko pada sistem RME di UPT Puskesmas Kota Matsum. Metode yang digunakan melibatkan observasi langsung dan analisis risiko terhadap berbagai permasalahan yang berpotensi mengganggu efektivitas sistem RME. Hasil menunjukkan bahwa risiko-risiko yang teridentifikasi, antara lain kelalaian input data, kebocoran informasi pasien, pemadaman listrik, gangguan server, dan infeksi virus komputer, termasuk dalam kategori risiko rendah. Kendati demikian, risiko tersebut tetap memerlukan pengendalian melalui pelatihan petugas, penguatan keamanan data, serta penyusunan SOP yang jelas. Kesimpulan dari penelitian ini menegaskan bahwa penerapan manajemen risiko yang baik pada sistem RME dapat meningkatkan efisiensi, akurasi, serta keamanan data medis, sehingga mendukung pencapaian pelayanan kesehatan yang optimal di Puskesmas
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.
Implementasi Teknologi V`Oice Recognition Dalam Dokumentasi Elektronic Health Record (EHR): Studi Kasus Implementasi Sistem Informasi Klinik Bunda Medical Center Pekan Baru Wahab, Bachtiyar; Lubis, Siti Permata Sari
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.v10i2.1953

Abstract

Digital transformation in healthcare services demands efficiency and accuracy in patient medical record documentation. One promising innovation is the implementation of voice recognition technology to support the automatic recording of medical data. This study aims to design and implement a voice recognition system within the Electronic Health Record (EHR) application at Klinik Bunda Medical Center in Pekanbaru. The research was conducted from May to July 2025, involving 15 active healthcare professionals as the primary users of the system. The method used was a software engineering approach employing the Rapid Application Development (RAD) model, which included interface design, voice recording feature integration, and limited user testing. The implementation results showed a significant improvement in documentation efficiency, with the average documentation time reduced from 6–8 minutes to 4–6 minutes. Additionally, the completeness of SOAP data increased from 73% to 90%. Most healthcare professionals stated that the system made it easier for them to document data without interrupting patient interaction. However, several challenges were identified, such as reduced accuracy in noisy environments and limitations in recognizing local medical vocabulary. In conclusion, the voice recognition system can be effectively applied to improve the quality of medical record documentation at the clinic level, provided that there is adequate infrastructure support, user training, and continuous evaluation. These findings are expected to serve as a foundation for developing similar systems in other healthcare facilities to accelerate the digitalization of health services in Indonesia.
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