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Jurnal Rekam Medis dan Informasi Kesehatan
Published by Poltekkes Kemenkes Semarang
ISSN : 26221863     EISSN : 26227614     DOI : https://doi.org/10.31983/jrmik.v2i1.4391
Core Subject : Health,
Health Professions
It is aimed at all medical record and health information practitioners and researchers and those who manage and deliver medical record and health information services and systems. It will also be of interest to anyone involved in health information management, health information system, and health information technology.
Arjuna Subject : Profesi Kesehatan - Profesi Kesehatan (Lain-Lain)
Articles 8 Documents
 1 
Search results for , issue "Vol 6, No 1 (2023): MARET 2023" : 8 Documents clear
Tinjauan Ketepatan Kode Cedera Multiple Pada Kasus External Cause di RSUP Dr. M. Djamil Padang Oktamianiza Oktamianiza; Diah Salsa Billa; Kalasta Ayunda Putri; Yulfa Yulia; Afridon Afridon
Jurnal Rekam Medis dan Informasi Kesehatan Vol 6, No 1 (2023): MARET 2023
Publisher : Poltekkes Kemenkes Semarang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31983/jrmik.v6i1.9187

Abstract

The accuracy of the code is very necessary so that the information generated from the diagnosis and medical treatment is accurate. However, researchers found in Dr. M. Djamil Padang there are still 29 incorrect codes (76.3%). This is because the determination of multiple injury codes is written separately and fracture diagnosis is not equipped with a fifth character code. The purpose of this study was to determine the accuracy of multiple injury codes in external cause cases at RSUP Dr. M. Djamil Padang. This research was conducted from May to June 2022. The type of research conducted was quantitative with a descriptive approach. The number of samples was 38 using the purposive sampling method, the data collection instrument used a checklist table with univariate analysis. The results of the research that has been carried out found that the frequency of diagnostic accuracy is 27 (71.1%) incorrect diagnoses, the frequency of conformity of primary and secondary diagnoses is 19 (50.0%) incorrect diagnoses, and the frequency of accuracy of diagnostic codes is 29 (76, 3%) code is not correct. So it can be concluded that there are still causes of inaccuracy in coding, which can be seen from the 3 components of the analysis carried out that affects the accuracy of the code. Therefore, researchers suggest that coders should pay attention to the rules and procedures for coding diagnoses based on ICD-10.                                                                                  
Perancangan Aplikasi Child Health Record Berbasis Android Sofia Latifah Fahmi
Jurnal Rekam Medis dan Informasi Kesehatan Vol 6, No 1 (2023): MARET 2023
Publisher : Poltekkes Kemenkes Semarang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31983/jrmik.v6i1.9391

Abstract

According to the results of the Indonesia Nutrition Status Study (SSGI) in 2021, as many as 20.8% Baduta and 24.4% Toddlers were stunted/short. In addition to fulfilling nutrition for children, the immunization sector also shows the same thing. During the last 2 years from 2020-2021 the coverage of complete basic immunization for infants has fallen drastically. Researchers developed this application using the SDLC Waterfall model. The waterfall method has the advantage that when all systems can be fully and correctly defined at the beginning of the project, software engineering can run well without any problems. The data collection technique used was secondary data that had been previously collected by other parties using the internet, library research, and books related to research. The Child Health Record application is expected to be an application that can help parents control their children's health from an early age. The immunization feature in the application is expected to increase complete basic immunization coverage for children, increase parental awareness in fulfilling child nutrition, increase parental awareness of children's nutritional status and explore information related to knowledge about children's health. The use of the Child Health Record application can be used since children are 0 years old so that the monitoring process runs optimally. Application development can be developed into a personal health record that can be used as an adult or a family health record.
Hubungan Kelengkapan Informasi Medis Pada RM A-1, RM I-1 dan RM L-8 dengan Keakuratan Pengkodean Diagnosis Appendic Pada Rekam Medis Rawat Inap di RS. TK. III dr. Reksodiwiryo Padang Tahun 2021 Yulfa Yulia; Oktamianiza Oktamianiza; Kalasta Ayunda Putri; Afridon Afridon; Ayunda Sandony
Jurnal Rekam Medis dan Informasi Kesehatan Vol 6, No 1 (2023): MARET 2023
Publisher : Poltekkes Kemenkes Semarang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31983/jrmik.v6i1.9192

Abstract

Appendix is included in the 20 most diseases in Kindergarten Hospital. III Dr. Reksowidiryo Padang where there are problems in terms of completeness of medical information on RM A-1, RM I-1 and RM L-8 with the level of accuracy of coding disease diagnosis is still low. This study aims to determine the relationship between completeness of medical information and the accuracy of coding appendic diagnoses based on ICD-10 in medical records at the Kindergarten Hospital. III Dr. Reksowidiryo Padang in 2021. The type of research is correlational, the research is carried out at the Kindergarten Hospital. III Dr. Reksowidiryo Padang, the initial survey was carried out in February with field research on 18 to 22 June 2021, the total population in January-December 2021 was 110 along with a sample of 110 appendic medical record files, the study was conducted by direct observation, data analysis used namely bivariate and univariate. With the results of the study, it was found that the completeness of complete medical information was 42 (38.2%), the completeness of incomplete medical information was 68 (61.8%), the accuracy of the accurate diagnosis code was 45 (40.9%), the accuracy of the code was There were 65 (59.1%) inaccurate diagnoses, with p-value = 0.003 (p0.05), which means that there is a relationship between the completeness of medical information and the accuracy of coding for appendic diagnoses. With the results of the study, it is known that the completeness of medical information and the accuracy of the disease diagnosis code is still not good, the researchers suggest that health workers can fill in each item of the medical record sheet completely and write down the diagnosis code accurately and clearly in order to increase efforts to complete the diagnosis and completeness of the diagnosis medical information.
Prototype application of the prolanis service management information online system (SIMPELPRO) to support capitation indicators achievement based on service commitment in first-level of healthcare facilities at the Pratama Clinic, Poltekkes, Ministry of Health, Semarang Setya Wijayanta; Rizal Ginanjar; Isnaini Qoriatul Fadhillah
Jurnal Rekam Medis dan Informasi Kesehatan Vol 6, No 1 (2023): MARET 2023
Publisher : Poltekkes Kemenkes Semarang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31983/jrmik.v6i1.9303

Abstract

Non-communicable diseases (PTM) are catastrophic diseases with the highest causes of death in Indonesia and are still a health problem and a threat to economic growth in Indonesia. The government has established the Social Security Administrative Body (BPJS) for Health through Law Number 24 of 2011 as a form of constitutional commitment to managing the implementation of public health insurance through the National Health Insurance. The lack of information and outreach regarding the Chronic Disease Management Program (Prolanis) in FKTP has resulted in the target of fulfilling the Prolanis Controlled Participant Ratio indicator not being achieved. The RPPB indicator at the Primary Clinic of the Semarang Ministry of Health Poltekkes in 2019 is still 10%. So to overcome this it is necessary to do a number of things, namely by providing information, outreach, and education regarding the types of Prolanis activities and their benefits and objectives. The better the level of information the participants have, the greater the tendency to use Prolanis. The purpose of this study was to develop a Prolanis Service Management Information System Application Prototype (SIMPELPRO) to Support the Achievement of Service Commitment-Based Capitation Indicators at Primary Health Facilities, the Primary Clinic, Poltekkes, Ministry of Health, Semarang. The research method used in this study uses descriptive research methods, with primary data sources, namely using interviews and observations of officers and doctors at the clinic, as well as secondary data from documentation and literature. For system design in this study, researchers will use the prototype method for system development including the stages of needs analysis, implementation, and testing. The results of this study resulted in a system that facilitates officers in terms of data management, data search and presentation of PROLANIS educational materials for participants who have registered as PROLANIS participants at the Primary Clinic of the Health Polytechnic of the Ministry of Health Semarang.
Evaluasi Penerapan Aspek 5M Dalam Penggunaan Tracer di Unit Penyimpanan Rekam Medis RSIA Husada Bunda Malang Nor Mauizzatun Indah F; Eiska Rohmania Zein
Jurnal Rekam Medis dan Informasi Kesehatan Vol 6, No 1 (2023): MARET 2023
Publisher : Poltekkes Kemenkes Semarang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31983/jrmik.v6i1.9621

Abstract

Tracer is an outguide when medical record documents are borrowed or taken by health workers in health services. Tracers at RSIA Husada Bunda is still not appropriate, seen in terms of the design of the marker slip which does not include the destination poly and the use of tracers is still done manually. This study aims to evaluate the use of tracers based on 5M aspects in the medical record unit of RSIA Husada Bunda. This research was conducted using a descriptive qualitative method with instruments in the form of observations and interviews conducted to the head of medical records and medical records officers in the storage section. The results of this study show that in the Man aspect there are discrepancies related to HR criteria in the medical records unit. In the Material aspect, the tracer uses semihard materials, while the use of the tracer refers to a special method, namely the SOP. The application of the tracer in terms of Machine still uses a written manual. In supporting all activities in the medical records unit, it is supported by Money (budget funds) and some are allocated for training activities and seminars. Overall, the use of tracers in the medical records unit of RSIA Husada Bunda has been relatively effective but still needs a stage of improvement in several aspects. Improvements related to the use of tracers can be in the form of updates to tracer materials, redesign of marker slips, and maximizing the use of machines in operational activities using tracers.
Dampak Era Society 5.0 Terhadap Kompetensi Perekam Medis dan Informasi Kesehatan (PMIK) Ade Fatima
Jurnal Rekam Medis dan Informasi Kesehatan Vol 6, No 1 (2023): MARET 2023
Publisher : Poltekkes Kemenkes Semarang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31983/jrmik.v6i1.9298

Abstract

The era of society 5.0 creates new challenges in various sectors of life, one of which is the health sector. Health development is directed at realizing optimal health degrees. To achieve this goal, it is necessary to manage various resources so that efficient, quality, and affordable health services can be available. At this point, a quality medical recorder is needed. In the era of society 5.0 every individual must have knowledge and skills. This relates to the PMIK competency field at number 2, namely Self-Introspection and Self-Development. The influence of the era of society 5.0 on PMIK's competence has led to changes and improvements in knowledge that require PMIK to be able to develop, apply and use technology, one example of its use is Electronic Medical Records (RME) and Hospital Management Information Systems (SIMRS). The purpose of this study was to determine the influence and relationship of the era of society 5.0 on PMIK competence. This study uses a qualitative data interpretation method. This type of method is used to analyze data in qualitative research or also called categorical data. The subject of this research is PMIK and the object is PMIK competence in the era of society 5.0. The potential result of applying the influence of the era of society 5.0 to PMIK competence is a change in competence in line with the demands of the times. This change led to renewal of competencies taught to PMIK candidates.
Gambaran Kepuasan Pasien di Tempat Pendaftaran Pasien Rawat Jalan RSUD Majenang Tahun 2021 Andi Suhenda; Memey Reksi Hanita
Jurnal Rekam Medis dan Informasi Kesehatan Vol 6, No 1 (2023): MARET 2023
Publisher : Poltekkes Kemenkes Semarang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31983/jrmik.v6i1.8909

Abstract

Latarbelakang: berdasarkan wawancara dengan petugas TPPRJ bahwa di RSUD Majenang belum melakukan survei kepuasan terhadap pasien umum dan BPJS tanpa rujukan sehingga tidak diketahui nilai persentase kepuasan, sedangkan berdasarkan SPM RS dari indikator kepuasan dengan nilai standar ≥90%. Tujuan penelitian untuk mengetahui gambaran kepuasan pasien di TPPRJ RSUD Majenang. Jenis penelitian kuantitatif dengan pendekatan deskriptif. Jumlah populasi 4.708, sampel 98 responden, teknik sampel sampling insidental. Cara pengumpulan data membagikan lembar kuesioner, analisis data univariat dengan memaparkan besarnya persentase kepuasan pasien berdasarkan 5 dimensi mutu pelayanan. Persentase kepuasan dimensi mutu reliability 80%, assurance 88%, tangibles 69%, emphaty 85%, dan responsiveness 88%.  Persentase dimensi mutu reliability, assurance, tangibles, emphaty, dan responsiveness didapatkan persentase kepuasan sebesar 82%, tetapi belum sesuai SPM RS karena berdasarkan persentase kepuasan nilai standar ≥90%.
A Scoping Review: Faktor Penyebab Pending Klaim BPJS Kesehatan Rawat Inap di Rumah Sakit Hindun Mursyid; Sri Rahayub; Vican Sefiany Koloic
Jurnal Rekam Medis dan Informasi Kesehatan Vol 6, No 1 (2023): MARET 2023
Publisher : Poltekkes Kemenkes Semarang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31983/jrmik.v6i1.9462

Abstract

Pending claims for Indonesian Universal Health Coverage (BPJS Kesehatan) is a classic issue in the field of health budgeting in the National Health Security (JKN) era. Some studies have examined factors causing pending claims, however, the issue has not been figured out yet because every hospital has different problems. This study was conducted to identify the problems possibly causing pending claims faced by hospitals. The objectives of the study were to find out the factors causing inpatient pending claims for BPJS Health Insurance at the hospital.  The article search method begins by identifying research articles on two databases, Google Scholar and Academia.edu with predetermined keywords. Articles are selected by PRISMA and based on established inclusion and exclusion criteria. The search results obtained 191 articles identified from two database searches, including 151 articles from Google Scholar and 40 articles from Academia.edu, finally, only 9 articles were obtained that matched the criteria. Pending claims for inpatient BPJS Health Insurance at the hospital under study were caused by several problems including inaccuracy in coding, incomplete administrative files, not attaching the results of supporting examinations as a support for the diagnosis, enforcement of diagnoses that did not meet the criteria, different perceptions of standard enforcement of diagnoses between specialist and BPJS, different points of view regarding the diagnosis code between hospital coding officers and BPJS verifiers, the discrepancy between main diagnoses and specialist, incomplete medical resumes, there is no SOP for managing BPJS Health insurance claims, knowledge of claim executors, facilities and infrastructure in the claims section, wrong input on the claim application. Managerial support is tremendously required to solve the issues related to pending claims for BPJS Kesehatan.

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