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All Journal Jurnal Informasi Kesehatan Indonesia (JIKI) J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Jurnal Rekam Medis dan Manajemen Informasi Kesehatan Jurnal Abdimas: Pengabdian dan Pengembangan Masyarakat Jurnal Pengabdian Kepada Masyarakat: Kesehatan (JPKMK) Corona: Jurnal Ilmu Kesehatan Umum, Psikolog, Keperawatan dan Kebidanan Vitamin: Jurnal Ilmu Kesehatan Umum Journal of Medical and Health Science Indonesian Journal Health Science and Medicine Journal of Medical Genetics and Clinical Biology (JMGCB) Academia Open
Resta Dwi Yuliani
Universitas Muhammadiyah Sidoarjo
Civil Engineering, Building, Construction & Architecture Computer Science & IT Control & Systems Engineering Decision Sciences, Operations Research & Management Economics, Econometrics & Finance Health Professions Immunology & microbiology Languange, Linguistic, Communication & Media Medicine & Pharmacology Neuroscience Nursing Public Health Veterinary

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Skrining Sebagai Upaya Peningkatan Kesehatan pada Lansia di Dusun Mlagi Kecamatan Tanggulangin Kabupaten Sidoarjo: Screening As An Effort to Improve Health in The Elderly in Mlagi Village, Tanggulangin District, Sidoarjo District Resta Dwi Yuliani
Jurnal Pengabdian Kepada Masyarakat: Kesehatan Vol. 3 No. 3 (2023): September
Publisher : Sekolah Tinggi Ilmu Kesehatan Notokusumo Yogyakarta

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Abstract

Abstrak: Penyakit tidak menular yang sering di derita oleh lansia antara lain adalah hipertensi dan hiperurisemia. Prevalensi hipertensi mencapai 22% dari populasi di dunia, sedangkan hiperurisemia berdasarkan Riskesdas 2018 sebesar 7,3%. Jawa timur dengan presentase 6,72% dari penduduk di atas usia 15 tahun. Tujuan dari pengabdian kepada masyarakat ini adalah sebagai skrining kesehatan dengan melakukan pemeriksaan tekanan darah dan tes kadar asam urat yang dilakukan di masjid Al-Ikhlas Dusun Mlagi Kabupaten Sidoarjo dengan peserta sebanyak 35 orang usia 45 tahun ke atas. Berdasarkan hasil pemeriksaan yang telah dilakukan bahwa lansia di Dusun Mlagi, Kabupaten Sidoarjo menderita hipertensi sebanyak 11,4% memiliki tekanan darah normal, 37,1% menderita prehipertensi, 42,9% hiperetensi tingkat I dan 8,6% menunjukkan hipertensi tingkat II. Berdasarkan observasi dan wawancara kepada peserta mengeluhkan pusing, jantung berdebar-debar, dan mudah lelah. Selain, itu berdasarkan hasil pemeriksaan terdapat 54,3% lansia memiliki kadar asam urat normal dan 45,7% lansia memiliki kadar asam urat tinggi. Berdasarkan hasil pemeriksaan dan observasi yang telah dilakukan peserta mengeluhkan nyeri pada bagian tengkuk leher, jari-jari tangan dan juga pada bagian lutut.   Abstract: Non-communicable diseases that are often suffered by the elderly include hypertension and hyperuricemia. The prevalence of hypertension reaches 22% of the world's population, while hyperuricemia based on Riskesdas 2018 is 7.3%. East Java with a percentage of 6.72% of the population over the age of 15 years. The purpose of this community service is as a health screening by carrying out blood pressure checks and uric acid level tests carried out at the Al-Ikhlas mosque in Mlagi Hamlet, Sidoarjo Regency with 35 participants aged 45 years and over. Based on the results of examinations that have been carried out, 11.4% of the elderly in Mlagi Hamlet, Sidoarjo Regency suffer from hypertension and have normal blood pressure, 37.1% suffer from prehypertension, 42.9% have grade I hypertension and 8.6% have grade II hypertension. Based on observations and interviews, participants complained of dizziness, heart palpitations and fatigue. Apart from that, based on the results of the examination, 54.3% of elderly people had normal uric acid levels and 45.7% of elderly people had high uric acid levels. Based on the results of examinations and observations made, participants complained of pain in the nape of the neck, fingers and also in the knees.
Analisis Kuantitatif Dokumen Rekam Medis Rawat Inap di Rumah Sakit Ibnu Sina Kabupaten Gresik Yuliani, Resta Dwi
Jurnal Informasi Kesehatan Indonesia (JIKI) Vol 9 No 2 (2023): Jurnal Informasi Kesehatan Indonesia
Publisher : Politeknik Kesehatan Kemenkes Malang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31290/jiki.v9i2.4184

Abstract

Medical records are data for compiling health information for both outpatient and inpatient visits. Based on the Minister of Health's decision number 129 of 2008 concerning minimum hospital service standards, recording medical record documents must be 100% complete and correct. The aim of this research is to analyze the incompleteness of inpatient medical records at Ibnu Sina Hospital, Gresik Regency based on 4 aspects, namely, the social data identification aspect, the important report aspect, the authentication aspect, and the correct documentation aspect. The population in this study is the number of inpatient medical record documents that have been deposited for the period June and July 2023, amounting to 1400 sample files obtained using random sampling techniques. Determining the sample size using the Slovin formula resulted in 100 medical record documents. This research is descriptive quantitative research. Based on the results of the analysis, identification reviews were on average complete 51%, incomplete 49%, reviews of important reports were on average complete 82.83%, incomplete 61%, authentication reviews were on average complete 66%, incomplete 34%, and On average, the correct documentation review was 61% complete, 31% incomplete. There needs to be outreach about the importance of patient identification to registration officers and all patient care providers. As well as the formation of a medical records committee and activeness of the room in monitoring the completeness of medical records Keywords: Authentication review, correct documentation review, identification review, important report review
ANALISIS FAKTOR PENGHAMBAT IMPLEMENTASI SISTEM INFORMASI KESEHATAN UNTUK SENSUS HARIAN RAWAT INAP DI RSUD MUNTILAN Yuliani, Resta Dwi
Jurnal Informasi Kesehatan Indonesia (JIKI) Vol 9 No 1 (2023): Jurnal Informasi Kesehatan Indonesia
Publisher : Politeknik Kesehatan Kemenkes Malang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31290/jiki.v9i1.3781

Abstract

Background: Release of medical record information must be accompanied by a written permission of the patient and presentation of the contents must be signed by the treating doctor. Based on a preliminary study on April 2nd, 2018 in Bhayangkara Hospital Lumajang showed that, the patient’s waiting time in the release of the medical record information was 7 days. The purpose of this research is to analyze the obstacle factors for the release of information to third parties in Bhayangkara Lumajang Hospital. Subjects and Method: The method is qualitative with data collection techniques through interviews, observation, documentation and brainstorming. Results: The results of this research showed that there were factors that obstacle the release of information namely attitudes, behavior and expertise of health workers. The conditions of the registration room and medical record room, layout medical record room. Patient waiting time, physical evidence and patient perceptions that did not accordance. Conclusion: The obstacle factor for information release was the patient responsible doctor (DPJP) who is a partner doctor and doctor who was not in the place. The recommend effort to improve the release of information to third parties, Bhayangkara Hospital Lumajang must have permanent patient responsible doctor, and held a special rooms for information release. Suggestions from this research were making expedition book, socializing SOP and making information release information systems.
a IMPLEMENTASI PROFIL PELAJAR PANCASILA MELALUI PELATIHAN PEMBUATAN ECOBRICK SISWA TINGKATAN SEKOLAH DASAR DESA WOTANMAS JEDONG Amirulloh, Fahmi; Auwalina, Roudlotul; Yulianah, Laila; Aini, Aisha Nur; Nabilah, Alivioni Aizzatin; Rahmawati, Amanda Dwi; Yuliani, Resta Dwi
Jurnal Abdimas: Pengabdian dan Pengembangan Masyarakat Vol 6 No 2 (2024)
Publisher : Pusat Penelitian dan Pengabdian Kepada Masyarakat

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.30630/jppm.v6i2.1317

Abstract

Pada dasarnya, kemasan plastik dapat didaur ulang dan dimanfaatkan menjadi sesuatu hal yang bermanfaat. Salah satu upaya dalam penanggulangan sampah yakni melalui pemanfaatan ecobrick. Pengenalan dan pelatihan ecobrick bagi siswa Sekolah Dasar Wotanmas Jedong merupakan bentuk pelatihan pembuatan kerajinan dengan memanfaatkan sampah plastik yang terdapat di lingkungan sekitar. Kegiatan ini bertujuan untuk menanamkan kesadaran sejak dini mengenai penanggulangan sampah plastik yang sulit terurai dan dapat mewujudkan generasi yang sadar akan kondisi lingkungan yang bersih dan sehat sekaligus sebagai bemtuk implementasi penerapan profil pelajar Pancasila (P5). Proses pelaksanaan program dilakukan selama dua minggu di dua sekolah. Hasilnya para peserta didik mampu dalam membuat kerajinan ecobrick berupa kursi pendek/dingklik dan memahami mengenai pengolahan sampah plastik. Melalui kegiatan ini menjadi upaya menumbuhkan sikap-sikap profil pelajar Pancasila seperti bergotong royong, berkebhinekaan global, bernalar kritis, kreatif, mandiri, dan berakhlak mulia dapat diterapkan. Pelatihan kegiatan ecobrick ini dapat menjadi sebuah gerakan yang dapat mengurangi limbah sampah plastik menjadi barang nilai guna dan estetika
Tantangan dalam Integrasi Data Kesehatan dari Berbagai Sistem Electronic Health Record dalam Sistem Kesehatan Nasional Suci Ariani; Resta Dwi Yuliani
Vitamin : Jurnal ilmu Kesehatan Umum Vol. 3 No. 1 (2025): Jurnal ilmu Kesehatan Umum
Publisher : Asosiasi Riset Ilmu Kesehatan Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.61132/vitamin.v3i1.996

Abstract

Electronic Health Records (EHRs) have become an important component in the digital transformation of the healthcare system in Indonesia. However, EHR implementation in many health facilities in Indonesia is still fragmentary and not fully integrated. The main challenges in integrating health data into the national health system are issues of interoperability, data security, and inter-institutional coordination. This study aims to identify and analyze the main challenges in integrating health data from various EHR systems into Indonesia's national health system and its impact on the quality of health services, operational efficiency, and data security. The research method used was a descriptive qualitative approach, which combined literature study and in-depth interviews with experts in the field of health information technology and health policy. A literature study was conducted to identify technical, operational, and policy challenges faced in EHR implementation in Indonesia. Expert interviews were used to validate the findings obtained from the literature and provide additional insights into the local context. Thematic analysis techniques were used to organize and interpret the data. The results showed that the lack of common data standards is a major obstacle in the integration of EHR systems in Indonesia.A total of 45% of healthcare facilities adopt HL7 standards, 30% adopt FHIR, and 25% use proprietary systems, leading to the inability to efficiently share data between institutions. In addition, data security issues are also a major concern, with many healthcare facilities yet to implement adequate security protocols. Limited coordination between health institutions also hinders wider integration. Nonetheless, EHR integration has the potential to improve operational efficiency, with up to 25% reduction in administrative time in institutions that have integrated their systems.
Evaluasi Aplikasi E-Visum di Rumah Sakit Muhammadiyah Lamongan Menggunakan Metode HOT-Fit Novitasari, Diah Ayu; Yuliani, Resta Dwi
JOURNAL OF MEDICAL AND HEALTH SCIENCE Vol. 1 No. 1 (2023): Juli
Publisher : Universitas Muhammadiyah Sidaorjo

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.21070/anamnetic.v1i1.1584

Abstract

Visum et Repertum (Visum) merupakan alat bukti laporan tertulis yang digunakan dalam persidangan oleh pihak yang memiliki wewenang seperti penyidik. Rumah Sakit Muhammadiyah Lamongan memiliki aplikasi elektronik visum (e-visum). Tujuan penelitian ini adalah evaluasi e-visum dengan menggunakan metode HOT-Fit. Jenis penelitian kualitatif dengan sampel 9 dokter IGD dan 1 dokter penangung jawab forensik. Hasil penelitian berdasarkan aspek human petugas melakukan double entry pada aplikasi karena belum terintegrasi dengan telegram, berdasarkan aspek organization perlu dilakukan evaluasi dan pengawasan, berdasarkan aspek technology sudah sesuai dengan indikator sistem, berdasarkan net benefit e-visum bermanfaat bagi user di Rumah Sakit Muhammadiyah Lamongan karena dapat meningkatkan pelayanan dan mengurangi tingkat kesalahan. Kata kunci : e-visum, HOT-Fit, evaluasi
Analisis Kualitatif Dan Kuantitatif Dokumen Rekam Medis Rawat Inap Sectio Caesarea: Literature Review Resta Dwi Yuliani
Jurnal Rekam Medis & Manajemen Infomasi Kesehatan Vol. 3 No. 2 (2023): Desember 2023
Publisher : Universitas Nasional Karangturi

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.53416/jurmik.v3i2.133

Abstract

Based on the 2018 Riskesdas data, it is stated that delivery is by means of action cesarean sectionreached 17.6%. This event is considered to exceed the standards set by WHO. The purpose of this study was to analyze qualitative and quantitative inpatient medical record documents cesarean section with review literature. The results of this study were based on a qualitative analysis of medical record documents on the 4 articles that were conductedreviews, based on qualitative analysis seen from a review of the completeness and consistency of diagnoses,reviews completeness and consistency of diagnostic records, reviews recording during care and treatment,reviews exists informed consent there are still many medical record documents that are not complete and consistent, one of the factors that influence this incompleteness is the level of awareness of health service workers who lack the importance of completing patient medical record documents. Meanwhile, based on quantitative analysis, from the 4 articles inreviewsthere is only 1 article that states its completeness reaches 100%. Reviews identification of incompleteness on the sex item, reviews authentication is found in the nurse's signature and full name, doctor's name and signature, reviewsreporting of incomplete filling in filling out the main and entry diagnoses and not attaching the results of laboratory examinations, where as on reviews records are in illegible writing in the case of doctors' and nurses' writings that are unclear or illegible, corrections in writing strokes that are not signed. Keywords: qualitative analysis, quantitative analysis, sectio caesarea.
Penilaian Kualitas Data Individu Rekam Medis Elektronik: Assessment of Individual Data Quality in Electronic Medical Records Resta Dwi Yuliani; Umi Khoirun Nisak
Jurnal Pengabdian Kepada Masyarakat: Kesehatan Vol. 5 No. 1 (2025): Maret
Publisher : Sekolah Tinggi Ilmu Kesehatan Notokusumo Yogyakarta

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Abstract

Abstrak: Rekam medis elektronik diharapkan mampu meningkatkan efektivitas dan efisiensi dalam pelayanan pasien. Efektifitas dan efisiensi implementasi sistem informasi dapat dilihat melalui kualitas data dan informasi yang dihasilkan oleh sistem tersebut. Tujuan pengabdian kepada masyarakat ini adalah untuk memberikan sosialisasi kepada staff Rekam Medis dan IT Rumah Sakit mengenai cara penilaian kualitas data rekam medis elektronik berdasarakan dimensi completeness, uniqueness, validity dan accuracy. Metode yang dugunakan dalam kegiatan ini adalah ceramah, diskusi dan penilaian data pada rekam medis elektronik. Berdasarkan hasil pemaparan materi dan diskusi dengan staf rekam medis dan IT RS NU Tuban dimensi kelengkapan sudah sesuai karena dalam melakukan input data sudah dipastikan lengkap. Dimensi keunikan/ unique telah dipastikan bahwa untuk input data pasien dengan variabel data yang unique adalah NIK sudah sesuai, yaitu setiap 1 NIK hanya dimiliki oleh 1 orang pasien saja (tidak terjadi duplikasi) NIK. Dimensi validity dipastikan bahwa tanggal masuk rumah sakit, tanggal perawatan dan keluar rumah sakit sudah sesuai. Dimensi akurasi/ accuracy sudah sesuai dengan type/ format data. Kesimpulan dari kegiatan ini bahwa di Rumah Sakit NU Tuban kualitas data pada rekam medis elektronik sesuai dengan dimensi completeness, uniqueness, validity dan accuracy.   Abstract: Electronic medical records are expected to improve the effectiveness and efficiency of patient care. The effectiveness and efficiency of information system implementation can be seen through the quality of data and information produced by the system. The purpose of this community service is to provide socialization to the Medical Records and Hospital IT staff regarding how to assess the quality of electronic medical record data based on the dimensions of completeness, uniqueness, validity and accuracy. The methods used in this activity are lectures, discussions and data assessments on electronic medical records. Based on the results of the presentation of materials and discussions with the medical records and IT staff of NU Tuban Hospital, the completeness dimension is appropriate because in inputting data it is ensured to be complete. The uniqueness dimension has been ensured that for patient data input with unique data variables, namely NIK, it is appropriate, namely that each 1 NIK is only owned by 1 patient (no duplication) NIK. The validity dimension ensures that the date of hospital admission, date of treatment and discharge from the hospital are appropriate. The accuracy dimension is in accordance with the data type/format. The conclusion of this activity is that at NU Tuban Hospital the quality of data in electronic medical records is in accordance with the dimensions of completeness, uniqueness, validity and accuracy.
Redesain Map Rekam Medis Berdasarkan Aspek Anatomi, Fisik, dan Isi di Klinik Fisioterapi Resta Dwi Yuliani; Suci Ariani; Herista Novia Widanti; Galuh Ratmana Hanum
Corona: Jurnal Ilmu Kesehatan Umum, Psikolog, Keperawatan dan Kebidanan Vol. 3 No. 3 (2025): September : Corona: Jurnal Ilmu Kesehatan Umum, Psikolog, Keperawatan dan Kebid
Publisher : Asosiasi Riset Ilmu Kesehatan Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.61132/corona.v3i3.1620

Abstract

Efforts to realize the implementation of good medical records require supporting elements in the form of medical record folders with a design that meets standards. Medical record folders protect patient documents and simplify the process of identifying, storing, and managing health data. Based on the results of observations at the UMSIDA Physiotherapy Clinic, the medical record folder used is still simple, only made of ordinary paper without a logo, name, clinic address, or columns for writing patient identity and medical record number. This condition has the potential to cause obstacles in the administration and security of patient data. The purpose of this research is to redesign (redesign) medical record folders based on anatomical, physical, and content aspects to make them more professional and functional. The methods used include needs analysis through interviews with users, evaluation of old designs, and the creation of new designs. The redesign was carried out by adding heading elements in the form of the name and address of the clinic, introduction in the form title or medical record folder, and instructions in the form of the text "Confidential Documents." On the body, the patient's identity is contained such as full name and medical record number. From the physical aspect, the folder is designed in the form of a portrait with a size of 21.5 cm × 33.0 cm, using white 260 grams of ivory paper with a blue background. Meanwhile, the content aspects include the identity of the health service facility, the writing "Confidential Document," the patient's name, medical record number, and year of visit. The results of the study concluded that the redesign of the medical record folder has met the anatomical, physical, and content standards needed to support more organized health services.
Delays in Returning Medical Records: A Factor Analysis: Penundaan dalam Pengembalian Rekam Medis: Analisis Faktor Azizah, Candra Nur; Yuliani, Resta Dwi
Indonesian Journal on Health Science and Medicine Vol. 2 No. 2 (2025): Oktober
Publisher : Universitas Muhammadiyah Sidoarjo

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.21070/ijhsm.v2i2.273

Abstract

General Background: Medical records are a critical component of hospital administration, ensuring accuracy, completeness, reliability, validity, and timeliness for quality healthcare services. Specific Background: However, delays in returning medical record files remain a challenge in inpatient care, disrupting service standards and continuity of care. Knowledge Gap: Limited research has systematically analyzed delay factors using a structured framework in the Indonesian hospital setting. Aim: This study aims to analyze the factors contributing to delays in returning medical record files at Wahidin Sudiro Husodo Hospital using the 5M framework (man, method, machine, material, money). Results: Findings revealed human factors such as high school-level education, limited knowledge, and lack of training; methodological issues where standard operating procedures for inpatient care were not aligned with the 2x24 hours service standard; material shortcomings due to the absence of a tracer; machine factors showing only the use of an expedition book; and financial factors with no incentive or sanction mechanisms. Novelty: This research provides a comprehensive factor-based analysis of medical record return delays by integrating the 5M approach. Implications: The results highlight the need for policy improvements, targeted training, and structured monitoring to achieve timely and reliable medical record management.Highlights: Delays linked to human, procedural, and infrastructural gaps Application of the 5M framework in hospital record analysis Emphasis on policy reform and staff training for improvement Keywords: Delays, Inpatient, Medical Record, Hospital Administration, 5M Framework
Co-Authors Aini, Aisha Nur Amirulloh, Fahmi Apvinia May Savitri Auwalina, Roudlotul Azizah, Candra Nur Bhisma Murti Galuh Ratmana Hanum Herista Novia Widanti Mukarromah, Rizka Aisya Nabilah, Alivioni Aizzatin Novitasari, Diah Ayu Nurul Dwi Andriani Prasetya, Hanung Rahmawati, Amanda Dwi Suci Ariani Umi Khoirun Nisak Widanti, Herista Novia Yulianah, Laila