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All Journal LINK Jurnal Rekam Medis dan Informasi Kesehatan Jurnal Manajemen Informasi Kesehatan Indonesia (JMIKI) Indonesian of Health Information Management Journal (INOHIM) Indonesian Journal of Global Health research
Irmawati, Irmawati
Jurusan Rekam Medis Dan Informasi Kesehatan Poltekkes Kemenkes Semarang
Computer Science & IT Education Health Professions Languange, Linguistic, Communication & Media Nursing Public Health

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TINJAUAN PENGISIAN RESUME KELUAR RAWAT INAP RUANG TERATAI TRIWULAN IV DI RSUD KABUPATEN CIAMIS TAHUN 2012 Irmawati Irmawati; Lily Kresnowati; Edy Susanto; Teni Ikhsan Nurfalah
Jurnal Manajemen Informasi Kesehatan Indonesia (JMIKI) Vol 2, No 1 (2014)
Publisher : Asosiasi Perguruan Tinggi Rekam Medis dan Informasi Kesehatan Indonesia- APTIRMIKI

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33560/.v2i1.34

Abstract

ABSTRACTThis study aims to review the completeness and incompleteness resume filling out the form in the Lotusroom because it has the largest number of patients. The content of completeness reviewed in this study areidentification, important statement and authentication. Outcome resume has an important role as a meanof communication between physicians and other officers, the underlying planning of patient care, enablingmaterial analysis and evaluating quality of patient care, a legal document as patient needs, hospitals anddoctors, generating clinical data for research and education as well as providing information to the insuranceor any other payments. Therefore, the completeness of filling outcome resume is important. This study usesdescriptive analysis to do observations. Observations made on secondary data then processed to producequantitative data. The results showed that the completeness of outcome resume content identification form asmuch as 97.93%, significant report as much as 89.44% authentication as much as 96.00%and correct reportas much as 97.48%. From these results it can be concluded that the completeness of the whole elements rangefrom 94, 61%. Refers to the minimal standard documents which proposed the health department in 2007,that the documents should be 100%. It can be concluded that outcome resume in Ciamis District Hospital isincomplete filling.Keywords: Completed Outcome Resume
Analisis Dispute Kode Diagnosis Rumah Sakit Dengan Badan Penyelenggara Jaminan Sosial (BPJS) Kesehatan Irmawati Irmawati; Marsum Marsum; Monalisa Monalisa
Jurnal Manajemen Informasi Kesehatan Indonesia (JMIKI) Vol 7, No 2 (2019)
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.v7i2.235

Abstract

Tarif Ina-Cbg's berbentuk paket yang mencangkup seluruh komponen biaya rumah sakit yang berbasis pada data costing dan coding penyakit mengacu pada International Classification of Diseases (ICD) yang disusun oleh WHO yang terdiri dari 14.500 kode diagnosis dan ICD 9 CM 7.500 kode tindakan. Verifikator dari BPJS mencermati diantaranya coding, clinical pathway dan diagnosis penyakit yang harus dilampiri dengan proses pemeriksaan terhadap pasien, apabila tidak sesuai maka akan dikembalikan kepada pihak rumah sakit. Tujuan Penelitian ini adalah untuk mengetahui analisis dispute kode diagnosis rumah sakit dengan BPJS kesehatan. Penelitian survey dengan metode deskriptif secara  kuantitatif  melalui  studi dokumentasi dan ceklist observasi dilengkapi dengan pengambilan data kualitatif di RSUD Ungaran Rumah Sakit Tipe C. Menggunakan Total Sampling pada bulan Agustus 2018 sebanyak 67 berkas klaim dengan dispute kode. Hasil penelitian menunjukkan sebagian besar berkas klaim yang dikembalikan adalah kasus dengan klasifikasi kelompok Case-Mix Main Groups (CMG)  kode A (Infectious and parasitic diseases Groups) sebanyak 35,82%. Gambaran dispute kode diagnosis oleh BPJS dan rumah sakit terjadi pada kondisi kode tidak spesifik, kode DU (Diagnosis Utama) atau kode DS (Diagnosis Sekunder) tidak didukung oleh data pemeriksaan penunjang, kode DS menjadi bagian atau lanjutan dari kode, kode pada kondisi diagnosis suspect. Penyelesaian berkas klaim pengembalian karena dispute kode dengan reseleksi kode rule MB2 sebanyak 59,70%. Penentuan kode hendaknya selalu membaca kembali dan mengikuti kaidah-kaidah. Tenaga medis perlu memahami bahwa kelengkapan dan kekonsistensian dalam pengisian rekam medis sangat dibutuhkan untuk menghasilkan kode yang akurat.
Kesehatan Dan Keselamatan Kerja (K3) Di Bagian Filing Irmawati Irmawati; Lily Kresnowati; Edy Susanto; Teni Ikhsan Nurfalah
Jurnal Manajemen Informasi Kesehatan Indonesia (JMIKI) Vol 7, No 1 (2019)
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.v7i1.215

Abstract

ABSTRACTOccupational health and safety is not only important for medical record officers but also can support work productivity. Health and safety of a good medical record worker will have a positive impact on work productivity of medical recorder so that will improve health service and benefit to hospital. Occupational risk can result in the decrease of work productivity, so efforts should be made to minimize the occurrence of the impact of occupational risk. Health and safety is intended to prevent, reduce, protect and even eliminate the risk of work accident (zero accident). Behavior of medical recorder filing section in work is one of the causes of risk of work accident, namely unsafe action and unsafe condition. Therefore it is necessary to conduct research on health and safety of medical records officer. To know health and safety of medical record employee of filing department at RSUD Banyumas based on human factor, work equipment factor, and work environment factor. This research type is case study with qualitative approach and cross sectional research design. The subject of this research is the medical recorder of the filing department of RSUD Banyumas while the object of the research is health and safety. Technique of collecting data by way of division of questioner, interview, observation, and study documentation. Data analysis techniques use reduction, data presentation and conclusion. The technique of data validity by means of technique triangulation.       The results of this study indicate that the health and safety of medical record officer filing section seen from human factors, work equipment factors, and work environment factors. In Human Factors knowledge recorder filing Health and Safety (K3) is good enough. In environmental factors temperature and humidity are in accordance with the standard, while for lighting need to be a contrast setting light so as not too dim and too bright. On the work equipment factor need maintenance, repair, improvement, replacement, and addition as needed, while for shelf filing integrated mental health needs to be replaced so as not to harm filing officer.ABSTRAKKesehatan dan keselamatan kerja tidak hanya penting bagi petugas rekam medis tetapi juga dapat menunjang produktivitas kerja. Kesehatan dan keselamatan kerja petugas rekam medis yang baik akan berdampak positif terhadap produktivitas kerja petugas rekam medis sehingga akan meningkatkan pelayanan kesehatan dan menguntungkan bagi rumah sakit. Risiko kecelakaan kerja dapat menimbulkan turunnya produktivitas kerja, sehingga perlu dilakukan usaha untuk meminimalisasi terjadinya dampak risiko kecelakaan kerja. Kesehatan dan keselamatan kerja dimaksudkan untuk mencegah, mengurangi, melindungi bahkan menghilangkan resiko kecelakaan kerja (zero accident). Perilaku petugas rekam medis bagian filing dalam bekerja merupakan salah satu penyebab risiko terjadinya kecelakaan kerja, yaitu unsafe action dan unsafe condition. Oleh karena itu perlu dilakukan penelitian tentang kesehatan dan keselamatan kerja petugas rekam medis.Tujuan Penelitian adalah Mengetahui kesehatan dan keselamatan kerja petugas rekam medis bagian filing di RSUD Banyumas berdasarkan faktor manusia, faktor peralatan kerja, dan faktor lingkungan kerja. Jenis penelitian ini adalah penelitian deskriptif dan rancangan penelitian secara cross sectional. Subjek penelitian ini adalah petugas rekam medis bagian filing RSUD Banyumas sedangkan objek penelitiannya adalah kesehatan dan keselamatan kerja. Teknik pengambilan data dengan cara pembagian kuisioner, wawancara, observasi, dan studi dokumentasi. Teknik analisis data menggunakan editing, verifikasi organizing, analizing dan tabulasi.Hasil penelitian ini menunjukkan bahwa kesehatan dan keselamatan kerja petugas rekam medis bagian filing berdasarkan faktor manusia, peralatan kerja, dan lingkungan kerja. Pada Faktor manusia pengetahuan petugas rekam medis bagian filing menganai Kesehatan dan Keselamatan Kerja (K3) sudah cukup baik. Pada Faktor lingkungan suhu belum sesuai standar,kelembapan sudah sesuai dengan standar,sedangkan untuk pecahayan perlu adanya pengaturan kontras cahaya agar tidak terlalu redup dan terlalu terang.  Pada faktor peralatan kerja perlu pemeliharaan, perbaikan, peningkatan, penggantian, dan penambahan sesuai kebutuhan ,sedangkan untuk rak filing kesehatan jiwa terpadu perlu dilakukan penggantian agar tidak membahayan petugas filing.
KELENGKAPAN RESUME DALAM PEMENUHANSTANDAR AKSES KE PELAYANAN DAN KONTINUITAS PELAYANAN (APK) PADA STANDAR AKREDITASITAHUN 2012 Irmawati Irmawati; Marsum Marsum; Monalisa Monalisa
Jurnal Manajemen Informasi Kesehatan Indonesia (JMIKI) Vol 4, No 1 (2016)
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.v4i1.93

Abstract

AbstractOne of the documentsthat must be metin the accreditation processin 2012is the completenessResume. Based on the Ministry of Health of the Republic of Indonesia (2011) Resumes contain reasons for hospitalization, significant findings, diagnosis has been established, action is given, drugs or medication, and the patient’s condition when transferred. Installation Medical Record at RSUD Slemanwere preparing supporting documents required in the accreditation process. This studywas conducted to determinethe completeness ofthe contentsResumein preparation forcompliance with the standardsof accreditationin 2012.This research uses descriptive research with a qualitative approach. Data collection techniques used by interview, observation and documentation. This study uses triangulation techniques.Percentage of completeness of the content of the Resume for each indicator was 92% on the reason for hospital admission, 79% on the findings of a physical disorder, 49% at diagnosis is made, 37% on drugs or medication, 69% in the patient’s condition when he returned. Average percentage of completeness Resume is 64.5% complete, 16% did not complete, and 19.5% are not filled. Based on the percentage calculation completeness of the Resume content, the compliance APK 3.2.1 at RSUD Sleman get a score of 5 or TercapaiSebagian (TS).Keywords: Analysis ofcompleteness, resumeContent, Standard accreditationin 2012.AbstrakSalah satu dokumen yang harus dipenuhi dalam proses akreditasi 2012 adalah kelengkapan Resume. Berdasarkan Kementrian Kesehatan Republik Indonesia (2011) Resume berisi alasan masuk rawat inap, temuan signifikan, diagnosis yang telah ditegakkan, tindakan yang diberikan, obat-obatan atau pengobatan, dan kondisi pasien saat dipindah. Instalasi Rekam Medis RSUD Sleman sedang menyiapkan dokumen penunjang yang diperlukan pada proses akreditasi. Penelitian ini dilakukan untuk mengetahui kelengkapan isi Resume dalam persiapan pemenuhan standar akreditasi tahun 2012.Jenis penelitian ini menggunakan penelitian deskriptif dengan pendekatan kualitatif. Teknik pengumpulan data yang digunakan dengan wawancara, observasi, dan studi dokumentasi. Penelitian ini menggunakan triangulasi teknik.Persentase kelengkapan isi Resume pada masing-masing indikator adalah 92% pada alasan masuk rumah sakit, 79% pada temuan kelainan fisik, 49% pada diagnosis yang ditegakkan, 37% pada obat-obatan atau pengobatan, 69% pada kondisi pasien saat pulang. Rata-rata persentase kelengkapan Resume adalah 64,5% lengkap, 16% tidak lengkap, dan 19,5% tidak terisi. Berdasarkan kelengkapan persentase perhitungan isi Resume,kepatuhan APK3.2.1di RSUD Sleman mendapatkan skor5 atauTercapaiSebagian(TS).Kata Kunci: Analisis kelengkapan, Isi resume, Standar akreditasi tahun 2012.
Analisis Kemampuan PMIK Terhadap Kelengkapan dan Ketepatan Kode Diagnosis Kasus Persalinan di Rumah Sakit Elise Garmelia; Irmawati Irmawati; Laely Najma Hanifah
Indonesian of Health Information Management Journal (INOHIM) Vol 10, No 2 (2022): INOHIM
Publisher : Lembaga Penerbitan Universitas Esa Unggul

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.47007/inohim.v10i2.432

Abstract

AbstractThe childbirth code according to WHO consists of mother's condition, method, and outcome of delivery. The labor code is used as the basis for making morbidity and mortality reports. The preliminary studies found incompleteness and inaccuracy of labor codes. The research analyzed the ability of PMIK in coding childbirth cases. The research method was a mixed method with a sequential explanatory model. Data collection used documentation studies and interviews. The subjects of the study were the coding officer. The study sample was 95 medical records of childbirth cases in 2021 with a simple random sampling technique. The coding officers in the hospital totaled 5 (five) people with a background of Diploma in Medical Record and Health Information.  The age of the coding officer was between 23 to 28 years old and work experience was one to eight years. There are 5 (five) major maternal diagnoses or conditions, namely long labor, PROM, preeclampsia, pre-term or post-term delivery, and oligohydramnios with a total code completeness of 94.74% and code accuracy of 53.68%. The delivery method based on studies was spontaneous delivery, delivery with breech presentation, and SC with completeness of the code of 92.63% and code accuracy of 1.05%. The delivery result code was not written by the officer so that the completeness and accuracy of the code were 0%. Factors caused incompleteness and inaccuracy of the code were coding officers have never attended training, coding procedures in hospitals have not been in accordance with WHO rules in ICD-10 Volume 2, and the codes have never been evaluated or monitored by hospitals. The conclusion that PMIK has not used the ICD-10 rule according to Volume 2 regarding the outcome of delivery of 0%, the percentage of code completeness, and the percentage of code accuracy were still not optimal.Keyword: maternity case, code completeness, code accuracy, PMIKAbstrakKodefikasi persalinan menurut WHO terdiri atas kode kondisi ibu, metode dan hasil persalinan. Kode persalinan digunakan sebagai dasar pembuatan laporan morbiditas dan mortalitas. Hasil studi pendahuluan ditemukan ketidaklengkapan dan ketidakakuratan kode persalinan. Tujuan penelitian ini untuk menganalisis kemampuan PMIK dalam mengkode kasus persalinan. Metode penelitian yaitu mixed method dengan model sequential explanatory. Pengumpulan data menggunakan studi dokumentasi dan wawancara. Subjek penelitian yaitu petugas koding dan kepala instalasi rekam medis. Sampel penelitian adalah 95 rekam medis kasus persalinan tahun 2021 dengan teknik pengambilan sampel simple random sampling. Petugas koding di rumah sakit berjumlah 5 (lima) orang dengan latar belakang lulusan DIII Rekam Medis. Usia petugas koding antara 23 hingga 28 tahun dengan masa kerja satu hingga delapan tahun. Terdapat 5 (lima) besar diagnosis atau kondisi ibu yaitu long labor, KPD, preeklampsia, pre-term atau post-term delivery, dan oligohidramnion dengan kelengkapan kode total sebesar 94,74% dan ketepatan kode 53,68%. Metode persalinan terdiri dari persalinan spontan, persalinan dengan kondisi janin sungsang, dan cesarean section dengan kelengkapan kode yaitu 92,63% dan ketepatan kode sebesar 1.05%. Kode hasil persalinan tidak dituliskan oleh petugas sehingga kelengkapan dan ketepatan kode adalah 0%. Faktor penyebab ketidaklengkapan dan ketidaktepatan kode yaitu petugas koding belum pernah mengikuti pelatihan, prosedur pengkodean di rumah sakit belum sesuai dengan aturan WHO dalam ICD-10 Volume 2, dan belum pernah dilaksanakan evaluasi maupun monitoring koding. Kesimpulan bahwa PMIK belum menggunakan aturan ICD-10 sesuai Volume 2 tentang hasil persalinan (outcome of delivery) 0%, persentase kelengkapan kode, dan persentase ketepatan kode masih belum optimal.Kata Kunci: kasus persalinan, kelengkapan kode, ketepatan kode, PMIK 
Analisis Kinerja Unit Rekam Medis Berdasarkan Standar Kompetensi PMIK di Rumah Sakit Wilayah Sulawesi Selatan Irmawati Irmawati; Zefan Adiputra Golo; Arief Azhari Ilyas
Jurnal Rekam Medis dan Informasi Kesehatan Vol 7, No 1 (2024): MARET 2024
Publisher : Poltekkes Kemenkes Semarang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31983/jrmik.v7i1.11312

Abstract

Kompetensi yang dimiliki manajer unit kerja rekam medis berdampak pada pengelolaan unit kerja. Masih terdapat manajer unit kerja rekam medis yang tidak memiliki latar belakang pendidikan rekam medis sehingga secara kompetensi tidak memenuhi standar. Penelitian ini bertujuan untuk mengetahui pengaruh kompetensi pengelola unit kerja RMIK terhadap kinerja unit rekam medis dan informasi kesehatan di rumah sakit. Jenis penelitian adalah deskriptif kuantitatif dengan pendekatan cross sectional study. Populasi dalam penelitian ini adalah 113 manajer unit rekam medis di rumah sakit wilayah Sulawesi Selatan dan teknik penarikan sampel yang digunakan adalah convenience sampling. Hasil penelitian menunjukkan bahwa variabel kompetensi memiliki hubungan yang signifikan dengan variabel kinerja unit rekam medis. Kemudian dari hasil uji regresi linear sederhana menunjukkan terdapat pengaruh yang signifikan antara kompetensi pengelola unit kerja terhadap kinerja unit rekam medis di rumah sakit. Pihak manajemen rumah sakit perlu memberikan pelatihan untuk meningkatkan kompetensi manajer unit kerja rekam medis berdasarkan standar nasional akreditasi rumah sakit.
The Effect of African Leaf Tea on Changes in Hematocrit and Blood Pressure Yayan Hartika; Sri Sumarni; Irmawati Irmawati
Indonesian Journal of Global Health Research Vol 6 No S6 (2024): Indonesian Journal of Global Health Research
Publisher : GLOBAL HEALTH SCIENCE GROUP

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37287/ijghr.v6iS6.5182

Abstract

Hypertension is a non-communicable disease that often presents without symptoms and is one of the leading causes of death worldwide. The prevalence of hypertension is significantly higher in women compared to men. Among women of childbearing age, hypertension increases the risk of complications during pregnancy, such as preeclampsia and bleeding. Elevated hematocrit levels are strongly associated with hypertension in women, contributing to increased vascular resistance and blood pressure. Efforts to manage hypertension include pharmacological and non-pharmacological therapies. In North Maluku, one of the traditional healing practices passed down through generations for lowering blood pressure involves the use of African leaves (Vernonia amygdalina). This study aims to analyze changes in hematocrit levels and blood pressure in women of childbearing age with hypertension before and after consuming 2.4 grams of African leaf tea (Vernonia amygdalina) for 14 days as a companion to antihypertensive medicine. This research employed a true experimental design with a pretest-posttest control group format. The population consisted of 97 hypertensive women of childbearing age in the service area of the Sanana Public Health Center, Sula Islands, North Maluku. A total of 32 participants were randomly selected. The intervention group received Amlodipine 5 mg as an antihypertensive medication along with 2.4 grams of African leaf tea consumed once daily for 14 days. Blood pressure measurements and venous blood sampling for hematocrit level analysis were conducted on days 8 and 15. Data were analyzed using the General Linear Model Repeated Measures (GLM-RM) approach. The findings demonstrated significant reductions in hematocrit levels and blood pressure among hypertensive women of childbearing age in the intervention group, with a p-value of 0.000. The administration of 2.4 grams of African leaf tea (Vernonia amygdalina) daily for 14 days, as a complementary therapy to antihypertensive medication, is effective in reducing hematocrit levels and blood pressure in women of childbearing age with hypertension.
The Effect of Red Spinach Tea (Amaranthus Tricolor L) on Blood Profile in Adolescent Girls with Anemia Annie Cristyana Purba; Sri Sumarni; Irmawati Irmawati
Indonesian Journal of Global Health Research Vol 7 No 3 (2025): Indonesian Journal of Global Health Research
Publisher : GLOBAL HEALTH SCIENCE GROUP

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37287/ijghr.v7i3.6122

Abstract

Anemia continues to be a major nutritional problem in Indonesia, especially among school children and adolescents, which in turn can inhibit growth, reduce learning achievement, and weaken endurance due to reduced concentration and can cause complications during pregnancy, so researchers innovate in preventing these nutritional problems by providing Red Spinach Tea (Amaranthus Tricolor L) and Blood Addition Tablets. Analyzing the effect of Red Spinach Tea (Amaranthus Tricolor L) dose of 2 gr plus 60 mg fe tablets given once a day for 14 days on hemoglobin, hematocrit and erythrocyte levels in adolescent girls with anemia. True Experiment research with pretest-postest design with control group, consisting of 2 groups. The population was female students at Poltekkes Kemenkes Medan with the age of 17-19 years with a total sample of 20 respondents per group. The intervention was given a dose of red spinach tea 2 g given once a day for 14 days and 60 mg blood supplement tablets once a day for 14 days. Bivariate test for paired groups with non-normally distributed data using the Wilcoxon test. Bivariate tests for anpaired groups of pre and post data are not normally distributed, then use the Mann-Whitney test. It was found that the average hemoglobin, hematocrit and erythrocytes in adolescent girls in the intervention group with the administration of Red Spinach Tea and Blood Addition Tablets were higher than the control group with the consumption of Blood Addition Tablets. There is an effect of giving Red Spinach Tea and Blood Addition Tablets on increasing hemoglobin, hematocrit and erythrocyte levels in anemic adolescent girls with p-value = 0,000 (<0.05). Red Spinach Tea (Amaranthus Tricolor L) can potentially be used as a companion to blood supplement tablets to improve anemia status in adolescent girls. Thus, Red Spinach Tea can be utilized as an alternative to complementary therapy in preventing anemia.
Co-Authors Adhani Windari Agustin Ira Krisnanita Ahmad Danuri Annie Cristyana Purba Anton Kristijono Apifah Apifah Arief Azhari Ilyas Bernadeta Riski Kristiyani Dinda Mirtha Melasoffie Edy Susanto Edy Susanto Elise Garmelia Fauzia Rahmawati Golo, Zefan Adiputra Hidayatul Maula Ivana Putri Risyanti Johninda Aulia Akbar Laely Najma Hanifah Lily Kresnowati Marsum Marsum Monalisa Monalisa Nadelia Nazillahtunnisa Nina Dwi Astuti Rizky Febri Nugroho Rozalia Mayasari Sri Lestari Sri Sumarni Subinarto Subinarto Sudiyono Sudiyono Sugiharto Sugiharto Teni Ikhsan Nurfalah Widodo Widodo Yayan Hartika Yela Belia Yogi Teguh Prakoso Yolanda Dinarka Dea