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All Journal Jurnal Kesehatan Komunitas PRIMA : Portal Riset dan Inovasi Pengabdian Masyarakat Jurnal Pengabdian Inovasi dan Teknologi Kepada Masyarakat Jurnal Rekam Medis (Medical Record Journal) JUBIDA-Jurnal Kebidanan
Ernaman Putri, Riza Suci
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Aerospace Engineering Arts Automotive Engineering Chemical Engineering, Chemistry & Bioengineering Computer Science & IT Economics, Econometrics & Finance Education Health Professions Languange, Linguistic, Communication & Media Medicine & Pharmacology Nursing Public Health Social Sciences Veterinary Other

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Analisis Kelengkapan Pengisian Informed Consent Di Ruang Rawat Inap Dewasa Rumah Sakit X Batam Ernaman Putri, Riza Suci; Kusumo, Retno; Larasati , Amelya Hanifah
Jurnal Rekam Medis (Medical Record Journal) Vol. 2 No. 3 (2022): Jurnal Rekam Medis (Medical Record Journal)
Publisher : Universitas Hang Tuah Pekanbaru

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25311/jrm.Vol2.Iss3.993

Abstract

Kelengkapan persetujuan tindakan kedokteran (informed consent) sangat penting karena mempengaruhi aspek hukum rekam medis dan mutu rekam medis, sehingga diperlukan pelaksanaan yang maksimal untuk pengisian persetujuan tindakan kedokteran. Dari hasil observasi dan wawancara di Rumah Sakit X Batam bahwa pengisian formulir informed consent ada beberapa yang tidak terisi. Tujuan penelitian ini untuk mengetahui kelengkapan pengisian informed consent di Rumah Sakit X Batam. Metode penelitian yang dipakai di penelitian ini memakai metode deskriptif kuantitatif dengan melakukan checklist. Hasil penelitian menunjukan persentase kelengkapan lembar informed consent di Rumah Sakit X Batam pada identifikasi pasien lengkap sebesar 100 %. Sedangkan pada informed yang lengkap sebesar 70%, tidak lengkap sebesar 30%. Pada consent yang lengkap sebesar 77%, tidak lengkap sebesar 23%. Sedangkan pada keterbacaan lengkap sebesar 100%. Kesimpulan dari penelitian ini yaitu hasil analisis dari kelengkapan pengisian informed consent masih belum terisi lengkap. Jumlah dari persentase kelengkapan sebesar 87%, dan tidak lengkap sebesar 13%.
EDUKASI KEPADA PASIEN PENTINGNYA MEMBAWA KIB SEBAGAI UPAYA PERCEPATAN PELAYANAN KESEHATAN Ernaman Putri, Riza Suci; Putri, Widya; Windharti, Ceriani
PORTAL RISET DAN INOVASI PENGABDIAN MASYARAKAT Vol. 2 No. 1 (2022): DECEMBER
Publisher : Transpublika Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.55047/prima.v2i1.467

Abstract

To speed up the performance of registration officers in health services, education is carried out for patients regarding this medical identity card (KIB) so that patients realize the importance of bringing KIB when going for treatment. This community service activity was carried out at the Batam Botania Health Center, with the aim of providing counseling to patients about the importance of carrying KIB in order to speed up services and make services of a higher quality. The method used in this service is in the form of outreach, where the audience are patients who come to visit at the time of this counseling. Socialization is delivered through lectures with the help of audio-visual media, so that the material can be conveyed properly. The results of the activity show that socialization is going well and it is hoped that patients can receive material and raise awareness of the importance of carrying KIB during treatment.
SOSIALISASI PELAKSANAAN RETENSI DAN PEMUSNAHAN REKAM MEDIS DI RS AWAL BROS BATAM Ernaman Putri, Riza Suci; Putri, Widya; Wulandari, Siti
PORTAL RISET DAN INOVASI PENGABDIAN MASYARAKAT Vol. 2 No. 2 (2023): MARCH
Publisher : Transpublika Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.55047/prima.v2i2.671

Abstract

Medical record is a file that contains notes or documents regarding patient identity, examinations, actions, and other services that have been provided to patients. Medical records are said to be of good quality if they are accurate, complete, reliable, valid and timely to return. According to the standard procedure (Protap) regarding the return of medical records no later than 2x24 hours after the patient returns home or after the patient leaves the hospital. This is intended so that medical record officers are ready to provide patient medical records if needed at any time. Awal Bros Batam Hospital has carried out retentions starting from 2016 onwards with vendors. Currently Awal Bros Batam Hospital already has 1 tool for destroying medical record files in the medical record unit. However, the lack of human resources in the medical record unit makes employees in medical records still doing work, not just one job but they do more than one job.
ANALISIS KUANTITATIF DAN KUALITATIF PADA DOKUMEN REKAM MEDIS RAWAT INAP PERIODE JANUARI 2025 DI RSUD EMBUNG FATIMAH BATAM Putri, Widya; Ernaman Putri, Riza Suci; Triani, Melfina
JUBIDA- Jurnal Kebidanan Vol. 4 No. 1 (2025)
Publisher : Yayasan Rahmatan Fidunya Wal Akhirah

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.58794/jubida.v4i1.1491

Abstract

Rekam medis yang lengkap dan akurat sangat penting untuk menjamin mutu pelayanan kesehatan dan perlindungan hukum di rumah sakit. Penelitian ini bertujuan untuk menganalisis kelengkapan dokumen rekam medis secara kuantitatif dan kualitatif. Penelitian ini menggunakan pendekatan deskriptif kuantitatif dan kualitatif terhadap 12 dokumen rekam medis rawat inap dengan riwayat operasi dari total 53 dokumen di ruang rawat inap anak RSUD Embung Fatimah Batam. Teknik pengambilan sampel yang digunakan adalah purposive sampling, dengan kriteria dokumen rekam medis rawat inap pasien anak yang menjalani operasi. Instrumen penelitian menggunakan daftar periksa (checklist) yang dikembangkan berdasarkan standar kelengkapan rekam medis. Analisis kuantitatif mencakup empat komponen utama: identifikasi, laporan penting, autentikasi, dan pendokumentasian yang benar. Analisis kualitatif meninjau kekonsistenan isi dan cara pencatatan untuk memastikan kelengkapan dan keakuratan informasi. Hasil analisis kuantitatif menunjukkan kelengkapan 100% pada komponen identifikasi, autentikasi, dan sebagian besar laporan penting, namun terdapat ketidaklengkapan 8% pada laporan anestesi dan asesmen keperawatan anak. Analisis kualitatif menunjukkan kekonsistenan 100% pada hampir semua aspek, kecuali pada praktik pencatatan (92%) karena ketidaktelitian petugas. disarankan agar pengisian berkas rekam medis sebaiknya dilakukan secara real-time untuk meningkatkan akurasi dan efisiensi pencatatan.
Sosialisasi Pelaksanaan Assembling dalam Meminimalisir Ketidaklengkapan Pengisian Rekam Medis di RS Awal Bros Botania Batam Ernaman Putri, Riza Suci; Putri, Widya; Wahyudi, Wahyudi
PORTAL RISET DAN INOVASI PENGABDIAN MASYARAKAT Vol. 4 No. 3 (2025): JUNE
Publisher : Transpublika Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.55047/prima.v4i3.1814

Abstract

Hospitals play a crucial role in improving public health, therefore hospitals are expected to uphold efficient medical recording practices. The completeness of medical records is vital as it directly impacts the health services provided by medical staff and the overall quality of the hospital's services. When doctors thoroughly fill out medical records, it makes it easier for health workers in the records department to organize data and generate useful information for hospital management. Inadequate communication between doctors and nurses often leads to incomplete medical records. Effective communication between these healthcare professionals within the records department is crucial as it directly affects patient care quality and safety. Negligence by staff also contributes to incomplete medical records, potentially compromising patient care. Medical record officers should consistently educate healthcare providers on the importance of complete medical records, emphasizing the benefits and objectives of maintaining thorough records to ensure high-quality hospital services.
Klasifikasi dan Kodefikasi Diagnosis Infeksi, Parasit, Neoplasma, Cedera, Keracunan, dan Penyebab Luar di RSUD Embung Fatimah Ernaman Putri, Riza Suci; Putri, Widya; Triani, Melfina
Jurnal Kesehatan Komunitas Vol 11 No 2 (2025): Jurnal Kesehatan Komunitas
Publisher : LPPM Hang Tuah Pekanbaru

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25311/keskom.Vol11.Iss2.2263

Abstract

Medical records play an important role in supporting quality health services, one of which is through accurate diagnosis classification and coding. This study aims to analyze the classification and coding of diagnoses of infection, parasites, neoplasms, injuries, poisoning, and external causes for the period of January 2025 at Embung Fatimah Hospital. The type of research used is quantitative research with a descriptive observational research design., conducted on January 20 - February 5, 2025. Data collection techniques were carried out through direct observation and documentation studies from the medical records unit. The number of samples analyzed was 40 out of 391 outpatient diagnosis data. The analysis technique used was descriptive analysis to identify and classify diagnoses. Of the 391 data it was found that, code S (injury) was the most common, with 180 cases, followed by code D (neoplasm), with 132 cases. The ten most common diseases include Vulnus Lacerasi (S31.4), Thalassemia (D56), and Superficial Injury of Head (S00). It was recommended that hospitals conduct routine audits of medical documents to ensure the accuracy of diagnoses.
Pendampingan Ketepatan Diagnosis Komplikasi dan Penyerta Kode Kasus Diabetes Melitus Untuk Percepatan Klaim BPJS di RS Awal Bros Botania Fani Farhansyah; Ernaman Putri, Riza Suci; Nimas Esya Bayazid; Hanifah Cahyani
JDISTIRA - Jurnal Pengabdian Inovasi dan Teknologi Kepada Masyarakat Vol. 6 No. 1 (2026)
Publisher : Yayasan Rahmatan Fidunya Wal Akhirah

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.58794/jdt.v6i1.1836

Abstract

Kegiatan pengabdian ini bertujuan meningkatkan ketepatan pengodean diagnosis Diabetes Melitus (DM) untuk mendukung kelancaran pengajuan klaim BPJS Kesehatan yang menggunakan sistem pembayaran INA-CBG’s. Ketepatan kode sangat menentukan kelompok INA-CBG’s sehingga berdampak pada besaran biaya yang diterima rumah sakit. Pengabdian dilaksanakan di RS Awal Bros Botania melalui kegiatan pendampingan secara langsung yang melibatkan petugas rekam medis dan casemix. Metode yang digunakan meliputi pemaparan materi, latihan pengodean berbasis kasus, posttest, serta diskusi interaktif. Selama kegiatan, peserta mempraktikkan penentuan kode ICD-10 (E10–E14) dengan fokus pada pemilihan karakter keempat sesuai komplikasi dan diagnosis penyerta. Hasil posttest menunjukkan peningkatan signifikan terhadap pemahaman peserta dalam menentukan kode yang tepat. Pada sesi diskusi, peserta mampu mengidentifikasi kendala yang sering muncul, seperti kurangnya informasi pada rekam medis mengenai detail komplikasi dan penggunaan insulin. Kegiatan ini berhasil meningkatkan kompetensi petugas dalam pengodean DM dan memperkuat pemahaman bahwa dokumentasi medis yang lengkap berpengaruh langsung pada keakuratan kode dan kelancaran klaim BPJS. Disarankan agar rumah sakit menyusun SOP pengodean DM dan melaksanakan pendampingan lanjutan untuk keberlanjutan hasil pengabdian
Co-Authors Fani Farhansyah Hanifah Cahyani Kusumo, Retno Larasati , Amelya Hanifah Nimas Esya Bayazid Putri, Widya siti wulandari Triani, Melfina Wahyudi Wahyudi Windharti, Ceriani