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All Journal Indonesian of Health Information Management Journal (INOHIM) Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI)
Pribadi, Maylina Surya Wirawati
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Health Professions Public Health

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Kelengkapan Pengisian Rekam Medis Elektronik Pasien di Poli Umum Puskesmas Surabaya Timur Masyfufah, Lilis; Listiawan, Nadhila; Yulianita, Novi Eka; Wahyuni, Titin; Sutha, Diah Wijayanti; Pribadi, Maylina Surya Wirawati
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Vol. 9 No. 2 (2024): 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.v9i2.1689

Abstract

The digital transformation of health is one proof of technological developments in health services. The implementation of health digitalization in the Surabaya City environment has started on November 10 2014 and in 2020 it will be ready to transform into an Electronic Health Record (EHR). The implementation of EHR began with the implementation of RME at Surabaya City Health Centers since March 2022. However, RME implementation is still not optimal, so research needs to be carried out on the completeness of RME at East Surabaya Regional Health Centers. This research method uses a type of quantitative research that collects data in the form of numbers using an observational approach. The population used is RME patients at Community Health Centers in the East Surabaya Region, namely Menur Health Center and Keputih Health Center, while the research sample will be taken using the Cochran Formula. The results of the identified data will be processed using Microsoft Excel for quantitative analysis and will be presented in table form to describe the object. The results of the research show that incomplete filling in of patients' RME at the East Surabaya Community Health Center General Polyclinic is found in the Identity, Important Reports and Authentication components, while the Documentation component is 100% complete. It can be concluded that the incompleteness of RME filling at the East Surabaya Community Health Center reaches 70%, the data is not complete.
Analisis Penerapan Rekam Medis Elektronik Berdasarkan Kebijakan Permenkes No. 24 Tahun 2022 di RS Bantuan 05.08.03 Sidoarjo Pribadi, Maylina Surya Wirawati; Masyfufah, Lilis; Astuti, Widi; Ajrina, Arij
Indonesian of Health Information Management Journal (INOHIM) Vol 12, No 2 (2024): INOHIM
Publisher : Lembaga Penerbitan Universitas Esa Unggul

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.47007/inohim.v12i2.575

Abstract

AbstractThe advancement of science and technology has significantly improved and streamlined the work of healthcare professionals. One example of this progress is the transition from manual medical records to Electronic Medical Records (EMR). At Bantuan 05.08.03 Hospital in Sidoarjo, the implementation of EMR remains in a hybrid system, combining manual and electronic methods, which does not align with Minister of Health Regulation Number 24 of 2022. This research aimed to analyze the implementation of EMR at the hospital based on the specified regulation. A qualitative descriptive method was employed, with observations conducted using a checklist to evaluate the Medify application. Research subjects included doctors, nurses, nutritionists, IT personnel, and medical record staff, each represented by one participant. The results revealed that clinical information entry, data input for financing claims, and EMR storage processes met the required standards. However, inconsistencies were identified in patient registration, data distribution, information processing, quality assurance, and content transfer. These discrepancies indicate that the hospital's EMR implementation is not fully compliant with the regulation. Addressing these gaps requires focused efforts to enhance technical systems and staff training, ensuring full compliance with the regulation and optimizing EMR functionality.Keyword: conformity, confirmation, observation AbstrakKemajuan ilmu pengetahuan dan teknologi telah secara signifikan meningkatkan dan mempermudah pekerjaan para profesional kesehatan. Salah satu contohnya adalah transisi dari rekam medis manual ke Rekam Medis Elektronik (RME). Di Rumah Sakit Bantuan 05.08.03 Sidoarjo, penerapan RME masih menggunakan sistem hybrid yang menggabungkan metode manual dan elektronik, sehingga belum sesuai dengan Peraturan Menteri Kesehatan Nomor 24 Tahun 2022. Penelitian ini bertujuan untuk menganalisis pelaksanaan RME di rumah sakit tersebut berdasarkan peraturan tersebut. Metode penelitian yang digunakan adalah deskriptif kualitatif, dengan observasi yang dilakukan menggunakan lembar cek untuk mengevaluasi aplikasi Medify. Subjek penelitian meliputi dokter, perawat, ahli gizi, petugas IT, dan petugas rekam medis, masing-masing diwakili oleh satu peserta. Hasil penelitian menunjukkan bahwa proses pengisian informasi klinis, input data untuk klaim pembiayaan, dan penyimpanan RME sudah sesuai dengan standar yang ditentukan. Namun, ditemukan ketidaksesuaian dalam proses pendaftaran pasien, distribusi data RME, pengolahan informasi, jaminan mutu, dan transfer isi RME. Ketidaksesuaian ini menunjukkan bahwa implementasi RME di rumah sakit tersebut belum sepenuhnya sesuai dengan peraturan. Untuk mengatasi kesenjangan ini, diperlukan upaya khusus untuk meningkatkan sistem teknis dan pelatihan staf, sehingga dapat memastikan kepatuhan penuh terhadap peraturan dan mengoptimalkan fungsi RME.Kata Kunci: kesesuaian, konfirmasi, observasi
Co-Authors Ajrina, Arij Listiawan, Nadhila Masyfufah, Lilis Sutha, Diah Wijayanti Wahyuni, Titin Widi Astuti Yulianita, Novi Eka