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All Journal Abdi-Dharma MEDICORDHIF Jurnal Rekam Medis International Journal of Health and Medicine EDU RMIK Jurnal Edukasi Rekam Medis Informasi Kesehatan Klinik: Jurnal Ilmiah Kedokteran dan Kesehatan
Ima Rusdiana
STIKes Widya Dharma Husada Tangerang
Computer Science & IT Economics, Econometrics & Finance Education Environmental Science Health Professions Industrial & Manufacturing Engineering Materials Science & Nanotechnology Medicine & Pharmacology Nursing Public Health Social Sciences Other

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ANALISIS KOMPETENSI PETUGAS REKAM MEDIS TERHADAP MUTU PELAYANAN REKAM MEDIS DI RSUD BERKAH PANDEGLANG Christin, Rumondang; Rusdiana, Ima; Rahmi, Junaida; Herawati, Aryana
EDU RMIK Jurnal Edukasi Rekam Medis Ilmu Kesehatan Vol 4, No 2 (2025): EDU RMIK: Jurnal Edukasi Rekam Medis Informasi Kesehatan
Publisher : STIKes Widya Dharma Husada Tangerang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52031/erjermik.v4i2.1155

Abstract

This study aims to examine the competence of medical record officers in relation to the quality of medical record services at RSUD Berkah Pandeglang. Officer competence plays a vital role in ensuring the completeness, accuracy, security, confidentiality, and availability of medical records. This research used a descriptive qualitative method with data collection through interviews and observations. The findings showed that most officers did not have an educational background in medical records but had over 10 years of work experience. Performance evaluations are conducted regularly, and most activities follow existing procedures even though a written SOP is still under development. In terms of security, access to electronic medical records (EMR) is regulated through individual accounts and reinforced through regular staff awareness campaigns. Regarding confidentiality, access is limited to healthcare personnel directly involved in patient care. In terms of completeness and accuracy, medical records are generally filled within 24 hours, although some incompleteness still occurs due to staff discipline. For availability, while no formal SOP currently exists, services continue based on existing policies such as internal decrees (SK). Based on these findings, it is recommended that the hospital expedite the development of written SOPs and conduct regular training to improve the quality of medical record services.
TINJAUAN WAKTU TUNGGU PENDAFTARAN RAWAT JALAN POLI PARU DI RUMAH SAKIT BHAYANGKARA LEMDIKLAT POLRI Rusdiana, Ima; Sucipto, Sucipto; Zebua, Amelia Intan Ramadhani
EDU RMIK Jurnal Edukasi Rekam Medis Ilmu Kesehatan Vol 4, No 2 (2025): EDU RMIK: Jurnal Edukasi Rekam Medis Informasi Kesehatan
Publisher : STIKes Widya Dharma Husada Tangerang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52031/erjermik.v4i2.1100

Abstract

Rumah sakit sebagai penyedia layanan kesehatan dituntut memberikan pelayanan yang cepat, tepat, dan sesuai standar, salah satunya melalui pengelolaan waktu tunggu pasien. Waktu tunggu menjadi indikator penting dalam menilai kualitas pelayanan rawat jalan. Standar Pelayanan Minimal (SPM) dari Kementerian Kesehatan menetapkan waktu tunggu ≤60 menit sejak pasien mendaftar hingga mendapat pelayanan dokter. Penelitian ini bertujuan untuk meninjau waktu tunggu pendaftaran rawat jalan Poli Paru di Rumah Sakit Bhayangkara Lemdiklat Polri dan mengidentifikasi faktor-faktor yang memengaruhi lamanya waktu tunggu. Penelitian menggunakan metode kuantitatif dengan pendekatan deskriptif melalui observasi dan wawancara terhadap 183 responden. Hasil menunjukkan bahwa sebanyak 136 pasien (74,31%) mengalami waktu tunggu ≥60 menit, sedangkan 47 pasien (25,68%) sudah sesuai standar. Rata-rata waktu tunggu adalah 81 menit. Ditemukan bahwa rumah sakit belum memiliki kebijakan tertulis yang secara spesifik mengatur waktu tunggu, serta prosedur administrasi seperti pencetakan surat kontrol dilakukan di loket pendaftaran, bukan di poliklinik. Keterlambatan dokter dan keterbatasan jumlah tenaga medis juga turut memengaruhi lamanya waktu tunggu. Kesimpulan dari penelitian ini adalah waktu tunggu pelayanan belum memenuhi standar dan memengaruhi kepuasan pasien. Oleh karena itu, diperlukan kebijakan tertulis, peningkatan jumlah dokter, serta perbaikan alur pelayanan untuk meningkatkan efisiensi dan mutu pelayanan rumah sakit.
Use of Abbreviations in Medical Consent Forms at X Hospital in Indonesia: A Descriptive Analysis Gama Bagus Kuntoadi; Ima Rusdiana; Miftah Parid Firmansyah
International Journal of Health and Medicine Vol. 3 No. 1 (2026): January : International Journal of Health and Medicine
Publisher : Asosiasi Riset Ilmu Kesehatan Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.62951/ijhm.v3i1.575

Abstract

This study identified the use of abbreviations in Medical Treatment Consent Forms (SPTK) at X Hospital Indonesia. A quantitative cross-sectional descriptive approach was applied to 76 SPTKs in September 2024, and questionnaires were administered to 30 patient-responsible physicians (DPJP). The results showed that 75% of SPTKs contained abbreviations, even though 97% of respondents understood the risk of miscommunication to patient safety. The state of the art includes accreditation standards that prohibit the use of abbreviations in informed consent, with global orthopedic studies reporting a decrease from 54% to 22% after educational interventions, as well as Indonesian regulations, namely Peraturan Mentri Kesehatan (Permenkes) Republik Indonesia No. 24/2022, which emphasizes that medical records must be complete. The novelty lies in the first empirical analysis in Indonesian hospitals to reveal the disparity between high physician knowledge and low documentation compliance, contributing to the development of evidence-based monitoring for patient safety. These findings support recommendations for daily review of SPTK, ongoing socialization, and integration of digital checklists to reduce medical errors.
Tinjauan Keamanan Dan Kerahasiaan Data Pasien Terkait Aspek Hukum Rekam Medis Di Rumah Sakit An-Nisa Tangerang Rusdiana, Ima; Holidah, Holidah; Aryani, Sofi Dwi; Kuntoadi, Gama Bagus
EDU RMIK Jurnal Edukasi Rekam Medis Ilmu Kesehatan Vol 5, No 1 (2026): EDU RMIK: Jurnal Edukasi Rekam Medis Informasi Kesehatan
Publisher : STIKes Widya Dharma Husada Tangerang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52031/erjermik.v5i1.1286

Abstract

Latar Belakang: Perkembangan teknologi informasi dalam bidang kesehatan telah mendorong implementasi Rekam Medis Elektronik di berbagai fasilitas pelayanan kesehatan, termasuk Rumah Sakit An-Nisa Tangerang. RME memberikan kemudahan dalam pengelolaan data pasien secara digital, namun di sisi lain juga menimbulkan tantangan terhadap keamanan dan kerahasiaan informasi medis. Tujuan Penelitian: Penelitian ini bertujuan untuk meninjau sejauh mana kebijakan, standar prosedur operasional (SPO), dan pelaksanaan sistem keamanan serta kerahasiaan data pasien di Rumah Sakit An-Nisa Tangerang telah diterapkan sesuai aspek hukum yang berlaku. Metode Penelitian: Penelitian ini menggunakan metode deskriptif dengan pendekatan kualitatif. Data dikumpulkan melalui wawancara terhadap kepala dan staf unit rekam medis serta petugas IT, serta observasi terhadap implementasi sistem. Hasil penelitian: menunjukkan bahwa rumah sakit telah memiliki kebijakan tertulis dan SPO mengenai keamanan dan kerahasiaan data pasien yang disusun berdasarkan regulasi terbaru. Sistem telah menerapkan kontrol akses berbasis akun individual, enkripsi data, dan backup data secara berkala. Namun, ditemukan beberapa kekurangan seperti belum diterapkannya autentikasi dua faktor (2FA), belum adanya prosedur tertulis untuk pemusnahan data setelah masa simpan berakhir, serta belum optimalnya pelatihan formal bagi staf. Kesimpulan: Penelitian ini menyimpulkan bahwa RS An-Nisa telah memiliki kebijakan tertulis sesuai Permenkes, namun implementasinya masih perlu ditingkatkan. Memiliki SPO keamanan data sejak 2019, namun masih diperlukan pelatihan agar implementasi SPO berjalan lebih optimal. Pelaksanaan RME di RS An-Nisa sudah sesuai regulasi dengan kontrol akses dan enkripsi, namun pelatihan teknis bagi staf belum dilakukan secara rutin dan evaluasi lebih bersifat reaktif.
TINJAUAN PELAKSANAAN ASSEMBLING DALAM PENGENDALIAN KELENGKAPAN REKAM MEDIS UNTUK PENINGKATAN MUTU PELAYANAN DI RSUD PONDOK AREN Lestari, Santi; Rahmi, Junaida; Rusdiana, Ima; Berliana, Azzahra; Kuntoadi, Gama Bagus
EDU RMIK Jurnal Edukasi Rekam Medis Ilmu Kesehatan Vol 5, No 1 (2026): EDU RMIK: Jurnal Edukasi Rekam Medis Informasi Kesehatan
Publisher : STIKes Widya Dharma Husada Tangerang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52031/erjermik.v5i1.1294

Abstract

Medical records are important documents that support the quality of health services, administration, and legal protection in hospitals. One of the important processes in medical record management is assembling, which is the process of collecting, arranging, and reviewing the completeness of medical record documents. This study aims to review the implementation of assembling in controlling the completeness of medical records to improve service quality at Pondok Aren Regional General Hospital.This research used a quantitative descriptive design with purposive sampling. The sample consisted of 127 inpatient medical record files. Data were collected through observation sheets, documentation studies, and interviews with three medical record officers involved in the assembling process.The results showed that the completeness of patient identity such as patient name, gender, and medical record number reached 100%. However, several components were still incomplete, including admission and discharge forms (79%) and medical resume (73%). In addition, the implementation of assembling had not been fully optimal due to limitations in human resources and the still manual medical record system.The study concludes that the implementation of assembling in controlling the completeness of medical records at Pondok Aren Regional General Hospital still needs improvement. Hospitals are expected to conduct periodic evaluations and prepare for the transition to electronic medical record systems to improve the quality of medical record management.
Tinjauan Kelengkapan Pengisian Formulir Permintaan Informasi Medis di Rumah Sakit Permata Pamulang Ima Rusdiana; Holidah Holidah; Tasya Kamila
Jurnal Ilmiah Kedokteran dan Kesehatan Vol. 4 No. 2 (2025): Mei : Jurnal Ilmiah Kedokteran dan Kesehatan
Publisher : Lembaga Pengembangan Kinerja Dosen

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.55606/klinik.v4i2.3966

Abstract

The medical information request form is the consent given by the patient or their closest family after receiving a complete explanation regarding the medical action that will be carried out on the patient. The aim of this study was to analyze the completeness of filling out medical information request forms. The method used in this research is descriptive research using a sample of 50 medical information request forms. The sampling technique used in this research was total sampling. The results of the research showed that filling in the patient's identity at Gem Pamulang Hospital was almost completely complete with a percentage of 98% and almost nothing was incomplete with a percentage of 2%, almost half of the important reports were complete with a percentage of 29.5 and more than half were incomplete with the percentage is 70.5% and the author authentication is partially complete with a percentage of 24%, and most of it is incomplete with a percentage of 76%.
Co-Authors Abdul Haris Muntaha Adi Rivaldi Aida, Mus Aryani, Sofi Dwi AYU SURYANI, AYU Berliana, Azzahra Cahya Maulina, Fresty Chatarina Umbul Wahyuni Gama Bagus Kuntoadi Garis Gemilang Herawati, Aryana Holidah Holidah Holidah, Holidah Indah Kristina Kusumapradja, Rokiah LESTARI, SANTI Meliana Miftah Parid Firmansyah Muhammad, Andre Ravi Mutia Sari Rahmi Junaida Rizkia Larasati Rumondang, Christin Sucipto Sucipto Sucipto Tasya Kamila Zebua, Amelia Intan Ramadhani