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All Journal Jurnal Manajemen Pendidikan Jurnal Manajemen Informasi dan Administrasi Kesehatan Journal of Multidisciplinary Academic Jurnal Manajemen Informasi Kesehatan Indonesia (JMIKI) Surya Medika: Jurnal Ilmiah Ilmu Keperawatan dan Ilmu Kesehatan Masyarakat Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Jurnal Ilmiah Wahana Pendidikan Nusantara Hasana Journal Arkus Indonesian Journal of Health Information Management (IJHIM) Jurnal Ilmiah Kesehatan Masyarakat Sehat Rakyat: Jurnal Kesehatan Masyarakat Jurnal Rumpun Ilmu Kesehatan Jurnal Sosial dan Sains Journal of Hospital Management Cerdika: Jurnal Ilmiah Indonesia MEDICORDHIF Jurnal Rekam Medis Journal of Educational Innovation and Public Health Jurnal Medika Nusantara Vitamedica: Jurnal Rumpun Kesehatan Umum Vitalitas Medis : Jurnal Kesehatan Dan Kedokteran Vitamin: Jurnal Ilmu Kesehatan Umum Obat: Jurnal Riset Ilmu Farmasi dan Kesehatan Jurnal Rekam Medic
Widjaja, Lily
Universitas Esa Unggul, Jakarta
Religion Agriculture, Biological Sciences & Forestry Humanities Astronomy Computer Science & IT Dentistry Economics, Econometrics & Finance Education Engineering Environmental Science Health Professions Law, Crime, Criminology & Criminal Justice Library & Information Science Medicine & Pharmacology Nursing Physics Public Health Social Sciences Veterinary Other

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Tinjauan Sistem Penjajaran Rekam Medis di RSU Bhakti Asih Tangerang Putri, Alifatul Aulia Sagita; Dewi, Deasy Rosmala; Indawati, Laela; Widjaja, Lily
Jurnal Rekam Medic Vol 5, No 1 (2022): Edisi Februari
Publisher : LPPM Institut Kesehatan Helvetia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33085/jrm.v5i1.5163

Abstract

Pendahuluan:Penyimpanan rekam medis bertujuan untuk mempermudah dan mempercepat ditemukan kembali dokumen rekam medis yang disimpan dalam rak filing. Pada sistem penjajaran adalah penyimpanan rekam medis di rak,maka kita menjajar dengan cara tertentu di rak penyimpanan. Rumah Sakit ini beralamat di Jl. Raden Saleh No.10, RT.001/RW.004, Karang Tengah, Kec.Karang Tengah, Kota Tangerang, Banten. Populasi dalam penelitian ini adalah keseluruhan rekam medis pasien yang dibutuhkan di Rumah Sakit Umum Bhakti Asih pada bulan Januari 2021 berjumlah 17,572 rekam medis. Tujuan: Tujuan penelitian ini adalah untuk mengetahuo bagaimana sistem penjajaran rekam medis di RSU Bhakti Asih Tanggerang. Metode: Penelitian ini menggunakan metode deskriptif dengan teknik analisis kualitatif yaitu dengan cara observasi langsung dan menjelaskan hasil yang didapat secara lengkap mengenai pelaksanaan sistem penjajaran di Rumah Sakit Umum Bhakti Asih. Teknik pengumpulan data dalam penelitian ini menggunakan teknik Observasi dan wawancara. Hasil: Berdasarkan hasil penelitian menggunakan sistem penjajaran Terminal Digit Filling (TDF) dan penyimpanan secara sentralisasi. Kesimpulan: Berdasarkan penelitian pada bulan Januari 2021 jumlah kunjungan pasien rawat jalan 18,444 dengan rata-rata 594,9 pasien,rekam medis yang terkirim pada bulan Januari 2020 sebanyak 18,377 dengan rata-rata 592,8. Rekam medis yang ditemukan sebanyak 99,6% (18.377 dokumen rekam medis), tidak ditemukan dengan persentase 0,4 % (67 dokumen rekam medis) yang disebabkan oleh beberapa faktor sepertim faktor man (petugas), faktor money, faktor matherial, faktor mechine, dan faktor methode.
Ketepatan Kodefikasi Sebab Dasar Kematian pada Sertifikat Kematian di Rumah Sakit Pusat Angkatan Darat Gatot Soebroto Dwijayanti, Risma Mei; Indawati, Laela; Dewi, Deasy Rosmala; Widjaja, Lily
Jurnal Rekam Medic Vol 5, No 2 (2022): Edisi Agustus
Publisher : LPPM Institut Kesehatan Helvetia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33085/jrm.v5i2.5191

Abstract

Pendahuluan: Sebab Dasar Kematian adalah sebab-sebab kematian sebagai segala penyakit, kondisi sakit atau luka yang menyebabkan atau turut menyebabkan kematian jika tidak diderita oleh pasien maka ia tidak akan meninggal. Dalam menentukan kode penyebab dasar kematian, petugas harus memperhatikan prosedur atau aturan yang telah ditetapkan WHO dalam ICD-10 volume 2. Tujuan: Tujuan penelitian adalah untuk mengetahui persentase akurasi kodifikasi penyebab utama kematian di RSPAD Gatot Soebroto. Metode: Penelitian ini dilakukan dengan menggunakan metode deskriptif kuantitatif, yaitu dengan memberikan penjelasan dan deskripsi yang lengkap tentang ketepatan kodifikasi dasar penyebab kematian pada akta kematian di RSPAD Gatot Soebroto. Populasi penelitian adalah 165 rekam medis pasien yang meninggal pada tahun 2019. Jumlah sampel adalah 62 rekam medis kematian yang diambil dengan teknik random sampling. Hasil: Instrumen penelitian berupa pedoman wawancara, pedoman observasi, ICD-10. Persentase akurasi kode penyebab kematian di RSPAD Gatot Soebroto tahun 2019 menunjukkan akurasi kode 82% akurat dalam menentukan penyebab kematian dan 18% tidak akurat karena tidak ada cross check pada tabel MMDS . Lebih baik mengkodekan semua diagnosis dalam sertifikat kematian dan menggunakan aturan kematian, baik Prinsip Umum, Aturan 1, 2 dan 3 dan merujuk ke tabel MMDS untuk memberikan kode yang akurat. Kesimpulan: Faktor faktor yang menyebabkan Ketidaktepatan Kodefikasi sebab dasar Kematian pada Sertifikat Kematian, Petugas Koding kematian mendapatkan file sertifikat medis penyebab kematian salinan ke tiga sehingga tulisan diagnosis dokter kurang jelas. Tulisan dokter yang sering kali tidak terbaca. Tidak adanya SPO khusus untuk koding kematian. Kurangnya SDM khusus koding  kematian.
Gambaran Pelaksanaan Rekam Medis Elektronik Pada Poliklinik di Rumah Sakit Atma Jaya siti Widya Astuti, siti; Muhammad Rezal; Lily Widjaja; Laela Indiawati
Jurnal Manajemen Informasi Kesehatan Indonesia (JMIKI) Vol 13 No 2 (2025)
Publisher : Asosiasi Perguruan Tinggi Rekam Medis dan Informasi Kesehatan Indonesia- APTIRMIKI

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33560/jmiki.v13i2.695

Abstract

Pada era globalisasi, teknologi sangatlah penting untuk menunjang aktivitas kehidupan di dunia kesehatan yang sangat berperan penting dalam menyediakan informasi secara cepat dan akurat. Perkembangan teknologi dalam pelayanan kesehatan menyediakan rekam medis berbasis elektronik. Rekam medis elektronik (RME) adalah dokumen yang menunjukkan penggunaan teknologi informasi untuk mengumpulkan, menyimpan, memproses dan mengakses data dalam bentuk digital. Penelitian ini bertujuan untuk mengetahui proses penerapan rekam medis elektronik di bagian rawat jalan Rumah Sakit Atma Jaya. Metode yang digunakan dalam penelitian adalah metode deskriptif dengan pendekatan kualitatif melalui wawancara dan observasi untuk menggambarkan hasil yang diperoleh secara lengkap dan akurat sesuai fakta. Rumah Sakit Atma Jaya mempunyai standar prosedur operasional (SPO) pelaksanaan rekam medis elektronik yang berbeda-beda di setiap unitnya dan belum ada alur pelaksanaannya dalam bentuk grafik. Software RME yang digunaan bernama Medinfras sudah sesuai dengan SPO terutama dari aspek kerahasiaan dan akses data. Proses implementasi RME dimulai dari registrasi pasien hingga transfer konten di platform Satu Sehat. Kendala yang terjadi berkaitan dengan unsur manusia, material, metode dan mesin.
Tinjauan Ketepatan Penjajaran Rekam Medis Di Rumah Sakit Umum Daerah Kembangan Fauziah Irfany; Lily Widjaja; Laela Indawati; Deasy Rosmala Dewi
Vitamin : Jurnal ilmu Kesehatan Umum Vol. 2 No. 1 (2024): January : Jurnal ilmu Kesehatan Umum
Publisher : Asosiasi Riset Ilmu Kesehatan Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.61132/vitamin.v2i1.188

Abstract

Alignment is the process of aligning medical records in the storage room according to the system used. The medical record storage system at Kembangan Hospital uses centralization, the medical record numbering system uses the Unit Numbering System (UNS) and the alignment system uses Terminal Digit Filing (TDF). The aim of this research is to determine the accuracy of medical record alignment. This research used a descriptive method with a quantitative approach, the population was 293 medical records using a saturated sample. From the results of research on the primary digit 07 storage shelf, it was found that there were inaccuracies in the alignment of 162 medical records (55%). This alignment inaccuracy was divided into three digits, namely 34 medical records (21%) had the 1st digit incorrect, 85 medical records (52%) had the 2nd digit incorrect and 43 medical records (27%) had the 3rd digit incorrect. . It was found that the cause of the alignment error was due to human error, the unavailability of a tracer and the map not using color coding. Medical records that cannot be found can be traced by looking at the patient's history of treatment at Simrs Khanza, then looking for the first digit number that is being searched for. When a medical record is not found, a search for the accuracy of the alignment of the medical record is carried out using the medical record tracking method. If a medical record cannot be found, a new medical record will be used temporarily.
Analysis Of The Quality Of Services and Physical Facilities Of The Hospital On Word Of Mouth With Patient Experience As An Intervening Variable At Mekar Sari Hospital Dani Sagitha; Natsir Nugroho; Lily Widjaja
OBAT: Jurnal Riset Ilmu Farmasi dan Kesehatan Vol. 2 No. 2 (2024): March : OBAT: Jurnal Riset Ilmu Farmasi dan Kesehatan
Publisher : Asosiasi Riset Ilmu Kesehatan Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.61132/obat.v2i2.304

Abstract

This research is aimed at analyzing the influence of service quality and physical facilities on WoM (Word of Mouth) with Patient Experience as an intervening variable at Mekar Sari Hospital. The research method used in this research is a correlational quantitative research type with a cross-sectional research design approach by looking at the influence of service quality and physical facilities on WoM with satisfaction as an intervening variable.The sampling technique used purposive sampling, namely a sampling technique using the criteria of internal medicine inpatients at Mekar Sari Hospital. The research sample involved 110 respondents. Path analysis is used as a WoM model analysis tool with patient experience as an intervening variable.The results of this study found a joint positive influence of service quality and physical facilities on WoM with patient experience as an intervening variable. The quality of service and physical facilities have a positive influence on both patient experience and WoM.
Tinjauan Lama Waktu Pendistribusian Rekam Medis Rawat Jalan di Rumah Sakit Umum Bhakti Asih Pratiwi, Adinda; Widjaja, Lily; Muniroh, Muniroh; Putra, Daniel Happy
Cerdika: Jurnal Ilmiah Indonesia Vol. 2 No. 4 (2022): Cerdika: Jurnal Ilmiah Indonesia
Publisher : Publikasi Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.59141/cerdika.v2i4.362

Abstract

Medical record is written or recorded information regarding identity, history taking, physical determination, laboratory, diagnosis of all medical services and actions provided to patients and treatment, whether inpatient, outpatient or receiving emergency services. Distribution in the health sector, especially medical records, has the meaning of a process of distributing medical records to each polyclinic addressed by the patient according to the medical record number. Minimum Service Standards (SPM) are provisions regarding the type and quality of basic services in the speed of providing medical records, the standard time for providing medical records for outpatient services is 10 minutes. This research was conducted at Bhakti Asih Hospital located at Jalan Raden Saleh No. 10, Karang Tengah, Tangerang City, Banten 15157. The purpose of this study was to determine the length of time for the distribution of outpatient medical records at Bhakti Asih General Hospital. This type of research uses descriptive quantitative methods. Data collection techniques used are observation and interviews. In this study, the population was all outpatient medical records in the period June 2021 with a sample of 96 outpatient medical records, using the Incidental/Convenience sampling technique. The results of this study can be seen that 52 medical records (54.16%) have met the SOP 10 minutes, while 44 medical records (45.83%) have not met the SOP 10 minutes. The time of calculating the distribution of outpatient medical records with 96 samples for 10 days with a total time of 984 minutes obtained an average time of distribution of outpatient medical records of 10.25 minutes.
Tinjauan Kebutuhan Rak Penyimpanan Rekam Medis di RSUD Bangka Selatan Ferina, Ferina; Muniroh, Muniroh; Putra, Daniel Happy; Widjaja, Lily
Cerdika: Jurnal Ilmiah Indonesia Vol. 2 No. 4 (2022): Cerdika: Jurnal Ilmiah Indonesia
Publisher : Publikasi Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.59141/cerdika.v2i4.373

Abstract

Medical record is a collection of facts or evidence of the patient's condition, past and current medical history and treatment written by the health professional who provides services to the patient. Medical records require sufficient storage shelves and storage space is needed to maintain confidentiality, avoid damage and make it easier for officers to retrieve and return medical records in the long term. If the medical record storage is adequate and meets the standards to support maximum patient care, it is necessary to adjust the need for medical record storage racks at the South Bangka Hospital. The purpose of this study was to determine the need for medical record storage racks for the next 5 years at RSUD South Bangka. This type of research uses a descriptive method with a quantitative approach. Data collection techniques used are observation and interviews. The results of this study are the number of medical record storage racks in the South Bangka Hospital currently amounts to 17 shelves and the South Bangka Hospital currently has a medical record storage area of 25m². It is recommended that the South Bangka Hospital need to provide 49 storage shelves for the next 5 (five) years so that the shelf needs can be met and can accommodate all medical records and it is hoped that the hospital will add an area of medical record room with an additional area of 11.96m² to adjust the addition of medical record racks.
Tinjauan Ketepatan Pengodean Diagnosis Penyebab Dasar Kematian pada Pasien Diabetes Mellitus di RSU UKI Jakarta Nurmalasari, Dinda; Widjaja, Lily; Rosmala Dewi, Deasy; Indawati, Laela
Cerdika: Jurnal Ilmiah Indonesia Vol. 2 No. 4 (2022): Cerdika: Jurnal Ilmiah Indonesia
Publisher : Publikasi Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.59141/cerdika.v2i4.374

Abstract

Determination is a precaution and the accuracy of disease codes can be easily identified into correct and incorrect codes, Correct codes are adjusted in ICD-10 then incorrect codes are inappropriate codes in ICD-0. The cause of death was hospital reporting. The uncertainty of the diagnostic code consists of 5m (man, money, method, machine, material) based on the interview of the coding officer that the precision of the cause of death in the diabetes mellitus diabetes is not optimum because of poor doctors' writing, the use of abbreviations in the diagnosis, the lack of human resources in rmic education, no charge in coding, The method of conducting a death certificate from the medical certificate form is the cause of death at the point of immediate cause, the cause between and the underlying cause and the absence of a specialized chamber. Hence, the authors conducted a study on the correctness of the causes of death in diabetes patients mellitus according to the icd-10. The purpose of this study was to understand the precision of the diagnosis of the causes of death in the diabetes patient mellitus in Jakarta general hospital. Based on a study of the 72 medical records of patients dying of the precision of the cause of death in diabetes patients mellitus in Jakarta general in 2017-2020.
Tinjauan Kebutuhan Rak Penyimpanan Rekam Medis di Rumah Sakit Annisa Bogor Tahun 2022 Salsabila, Annisa Nur; Viatiningsih, Wiwik; Widjaja, Lily; Indawati, Laela
Cerdika: Jurnal Ilmiah Indonesia Vol. 2 No. 7 (2022): Cerdika: Jurnal Ilmiah Indonesia
Publisher : Publikasi Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.59141/cerdika.v2i7.436

Abstract

Hospital is a health service institution by providing outpatient and inpatient services. Each hospital also has an obligation to have a Medical Record Unit. Medical records are files that contain records or documents such as patient identities, results of diagnoses, actions, and treatments as well as services that have been provided to patients. In the context of administering medical records, health service facilities are required to provide the necessary facilities. One of them is a medical record storage rack to store medical records. Based on the results of research at the Medical Record Unit of the Annisa Hospital, Bogor, it was found that the medical record storage rack was inadequate and some medical records were piled on the floor, making it difficult for officers to find medical records when needed and services at the polyclinic became hampered. The purpose of this study was to determine the need for medical record storage racks for the next 5 years at Annisa Hospital Bogor in 2022. The study was conducted using a quantitative descriptive method, using a non-random sampling method with saturated sampling technique. From the results of the study, the Annisa Bogor Hospital still lacks medical record storage rack facilities which currently have 12 wooden shelves and 3 Roll O'packs, an additional rack of 9 Roll O'packs is needed. The storage area at Annisa Hospital Bogor is sufficient because the area needed for the next 5 years is 61.3 m2. Meanwhile, the current room area is 120 m2 combined with the medical record officer's workspace.
Literature Review Ketepatan Pengodean ICD-10 External Cause di Rumah Sakit Harahap, Maulidiah Rizki; Indawati, Laela; Widjaja, Lily
Cerdika: Jurnal Ilmiah Indonesia Vol. 2 No. 9 (2022): Cerdika: Jurnal Ilmiah Indonesia
Publisher : Publikasi Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.59141/cerdika.v2i9.445

Abstract

External cause is classifying disease with cases of injury, poisoning, and accidents, from external causes. Therefore, medical officers must be competent in coding according to ICD-10 and are required to provide precise and accurate codes. The purpose of this study was to determine the percentage accuracy of the external cause ICD-10 coding and to find out the obstacles to the inaccuracy of external cause coding. using the literature review method. The results of a literature review of 12 journals related to the coding accuracy of ICD-10 external causes in several hospitals found that the highest percentage of code accuracy was 82% with the lowest percentage of code accuracy being 0%, while the highest percentage of coding inaccuracy was 100% and for the percentage of inaccuracy. the lowest code as much as 18 %. The 10 journals above use 5M elements, namely the obstacles that are often obtained from the Man factor which consists of coders who are not careful in determining the code, the competence of medical recorders needs to be honed, and lack of effective communication between coders and officers regarding the contents. medical records. It is recommended for coders who do not understand coding to conduct seminars to learn how to do good coding, so that the percentage of inaccuracies in the hospital is reduced to a lower level.
Co-Authors -, Muniroh Adinda Pratiwi Alex Sander Alfi Shiddiq Syafrian Aliyani Aliyani Angelina Angelina Anggraini, Adelia Annisa Nur Salsabila Arip Budiana Azidah, Mega Puspita Bahlani Bangga Agung Satrya Bangun, Evi Vania Bangun, Gabriella Eviana Bayu Fajar Ilhami Bella Safitri Choirunisa Choirunisa Dani Sagitha Daniel Happy Putra Deasy Rosmala Dewi Deasy Rosmala Dewi Dewi, Deasy Rosmala Dewi, Sisilia Kartika Dian Nur Muslimah Dina Sonia Dwijayanti, Risma Mei Eka Widya Rita P. Fadia Eka Septiawati Fannya, Puteri Fauziah Irfany Ferina Ferina Ferina, Ferina Gabriella Eviana Bangun Gina Sonia Gita, Elsa Chandra Harahap, Maulidiah Rizki Hosizah Hosizah Ilham Abdurohman Indawati, Laela Intan Rusdiana Dewi Khoirunnisa Sabiladina Laela Indiawati Lautsan, Christina M. Fuad Iqbal Mega Puspita Azidah Muhamad Fazriyansah Muhammad Rezal Muniroh - Muniroh Muniroh Muniroh Muniroh Muniroh Muniroh Muniroh Muniroh Muniroh, Muniroh Natsir Nugroho Noor Yulia Noor Yulia Nurmalasari, Dinda Nurmalasari, Mieke Octa Rina Sari Pratiwi, Adinda Puspita, Kori Puteri Fannya Puteri Fannya Putri Nurindahsari Putri, Alifatul Aulia Sagita Rahayu, Ririn Rahelia Putri Ratna Indrawati Regina Yulianti T. S Rezal, Muhammad Risma Sisni Fadilla Rosmala Dewi , Deasy Rosmala Dewi, Deasy Saarah Salsabila Putri Yadita Sabiladina, Khoirunnisa Salsabila, Annisa Nur Sarah Khonsa Satrya, Bangga Agung Siti Rahmawati Handayani siti Widya Astuti, siti Suciyanti Suciyanti Suriyantoro, Suriyantoro Surlialy, Dewi Umi Khoirun Nisak Vania Rachma Putri Viatiningsih, Wiwik Wiranata, Tyansa Eka Sampoerna Wiwik Viatiningsih Yenni Syafitri Yulia, Noor