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INDONESIA
Jurnal Rekam Medis dan Informasi Kesehatan
ISSN : 26221863     EISSN : 26227614     DOI : https://doi.org/10.31983/jrmik.v2i1.4391
Core Subject : Health,
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.
Articles 120 Documents
Analisis Beban Kerja dan Kebutuhan Sumber Daya Manusia Petugas Rekam Medis Puskesmas Adan-adan Kabupaten Kediri Hikmawan Suryanto
Jurnal Rekam Medis dan Informasi Kesehatan Vol 3, No 1 (2020): Maret 2020
Publisher : Poltekkes Kemenkes Semarang

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (2011.268 KB) | DOI: 10.31983/jrmik.v3i1.5514

Abstract

Human resources are an important and vital component in an organization's operations. Quality health services can not be separated from the organization of a good medical record. In order to run well, sufficient medical records are needed. In the Adan-Adan Health Center, the number of patient visits from July 2018 to July 2019 was 16,828 people. Medical records officer only numbered 1 person. The research objective is to calculate the needs of human resources in the medical record unit using the ABK method. The design of this research is descriptive observational with case study approach. Respondents in this study were medical staff at the Adan-adan Health Center in Kediri Regency with a total of 1 person. The results of the study are that there is a shortage of human resources in the Adan-Adan Health Center medical record unit which should be 3, but totaling 1 person. Suggestions for Adan-Adan Health Center are employee recruitment needs to be done so that the number of medical records officers can be fulfilled. AbstrakSumber daya manusia merupakan komponen penting dan vital dalam operasional sebuah organisasi. Pelayanan kesehatan yang bermutu tidak terlepas dari penyelenggaraan rekam medis yang baik. Agar berjalan dengan baik, maka dibutuhkan sumber daya rekam medis yang cukup. Kunjungan pasien di Puskesmas Adan-adan pada periode Juli 2018 – Juli 2019 sebesar 16.828 orang. Petugas rekam medis hanya berjumlah 1 orang. Tujuan penelitian untuk menghitung kebutuhan sumber daya manusia di unit rekam medis menggunakan metode ABK. Desain penelitian ini yaitu observasional deskriptif dengan pendekatan case study. Responden dalam penelitian ini yaitu petugas rekam medis Puskesmas Adan-adan Kabupaten Kediri yang bejumlah 1 orang. Hasil penelitian yaitu terdapat kekurangan jumlah sumber daya manusia di unit rekam medis Puskesmas Adan-adan yang seharusnya berjumlah 3, namun saat ini berjumlah 1. Saran bagi Puskesmas Adan-adan yaitu perlu dilakukan rekrutmen pegawai agar jumlah petugas rekam medis dapat terpenuhi.
Identifikasi Prioritas Masalah Unit Rekam Medis di Puskesmas Nusukan Puguh Ika Listyorini
Jurnal Rekam Medis dan Informasi Kesehatan Vol 3, No 1 (2020): Maret 2020
Publisher : Poltekkes Kemenkes Semarang

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (1337.568 KB) | DOI: 10.31983/jrmik.v3i1.5574

Abstract

Health services consist of two kinds, namely medical and non-medical services. One of the non-medical services provided by the medical record unit. In providing medical record unit services do not always run well, therefore it is necessary to identify the priority determination of the problem to find out what problems must be solved first. The Multiple Criteria Utility Assessment (MCUA) method is a method of determining priority problems with scoring techniques. The purpose of this study was to determine the priority of problems in the medical record unit of the Nusukan Health Center using the MCUA Method. This research uses descriptive research design with 4 speakers. According to the results of the identification of problems carried out by the Group Group Discussion (FGD) that there are 3 problems in the medical record unit of the Nusukan Public Health Center, namely the lack of resources for medical records, medical record documents, and the availability of rooms for managing medical records that are still limited. The priority problem with the MCUA method shows that the problem with the highest value is the lack of medical record personnel. Before making additional workforce, it is recommended to calculate the workforce needs in the medical record unit according to the workload of the medical record officer so that the additional workforce is in accordance with the workload of the officer.AbstrakPelayanan kesehatan terdiri dari dua macam yaitu pelayanan medis dan non medis. Pelayanan non medis salah satunya diberikan  oleh unit rekam medis.  Dalam memberikan pelayanan unit rekam medis tidak selalu berjalan dengan baik, oleh karena itu perlu dilakukan identifikasi penentuan prioritas masalah untuk mengetahui masalah apa saja yang harus diselesaikan terlebih dahulu. Metode Multiple Criteria Utility Assessment (MCUA) adalah salah satu metode penentuan prioritas masalah dengan tekhnik scoring. Tujuan penelitian ini untuk mengetahui prioritas masalah di unit rekam medis Puskesmas Nusukan menggunakan Metode MCUA. Penelitian ini menggunakan desain penelitian deskriptif dengan 4 orang narasumber. Menurut hasil identifikasi masalah yang dilakukan dengan Forum Group Discussion (FGD) bahwa terdapat 3 masalah di unit rekam medis Puskesmas Nusukan, yaitu kurangnya sumber daya tenaga rekam medis, missfile dokumen rekam medis, dan ketersediaan ruagan untuk penggelolaan rekam medis yang masih terbatas. Prioritas masalah dengan metode MCUA menunjukkan masalah dengan nilai paling tinggi adalah kurangnya sumber daya tenaga rekam medis. Sebelum melakukan penambahan tenaga kerja, maka disarankan agar menghitung kebutuhan tenaga kerja di unit rekam medis menurut beban kerja petugas rekam medis agar penambahan tenaga kerja sesuai dengan beban kerja petugas.
Tinjauan Ketepatan Koding Penyakit Gastroenteritis Pada Pasien BPJS Rawat Inap di UPTD RSUD Kota Salatiga Elise Garmelia; Maulida Sholihah
Jurnal Rekam Medis dan Informasi Kesehatan Vol 2, No 2 (2019): Oktober 2019
Publisher : Poltekkes Kemenkes Semarang

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (417.245 KB) | DOI: 10.31983/jrmik.v2i2.5350

Abstract

One of the factors causing the inaccuracy of writing diagnosis code is sometimes doctors do not write the diagnosis in the complete form so that medical record errors occur in determining the diagnosis code. Based on preliminary studies that researchers have done in UPTD RSUD Salatiga, the researchers found the results of encoding gastroenteritis disease is inappropriate. Researchers took a random sample, from 8 medical records of patients with BPJS gastroenteritis inpatient there were 6 medical records showing the inaccuracy of encoding diagnosis with 75% percentage of incorrect code and there was different writing of gastroenteritis diagnosis on admission discharge form and discharge summary form.The purpose of this study to determine the accuracy of coding disease gastroenteritis. The type of the research is descriptive quantitative research using cross sectional approach. The population in this research is medical record of inpatients of BPJS gastroenteritis case in january 2017 until october 2017, with the sample of 82 medical record by using simple random sampling method.The results showed the percentage of appropriateness of writing diagnosis on the outline forms form outgoing and returning home is 93.9%, the percentage of accuracy of gastroenteritis disease code is 91.5% and the percentage of appropriateness of diagnosis with the result of laboratory examination is 89%. Factors affecting the inaccuracy of coding results are that medical personnel (physicians) write incomplete and incompatible patients' diagnostic diagnosis of the form sheet, the coder does not check the results of the laboratory to determine the correct code, the lack of update activity of the ICD-10 coding latest version.Of these factors can affect the quality of medical records with the results of coding, claims results and analysis of hospital reporting data.
Kelebihan dan Kekurangan Penerapan Family Numbering System di Puskesmas Dinas Kesehatan Kota Surakarta Harjanti Janti; Astri Sri Wariyanti
Jurnal Rekam Medis dan Informasi Kesehatan Vol 3, No 1 (2020): Maret 2020
Publisher : Poltekkes Kemenkes Semarang

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (149.187 KB) | DOI: 10.31983/jrmik.v3i1.5554

Abstract

The numbering system is one of the identification systems used to distinguish one patient's medical record file from another patient. Numbering system in the Surakarta Family Health Service Area Region Health Center Region. The implementation of the numbering system is experiencing problems, if there are patients who move or live separately the Head of the Family takes longer to register the patient, because the Officer will provide a new medical record number, create a new medical record document and a new folder for the patient. The research objective is to identify the strengths and weaknesses of the implementation of the Family Numbering System. A qualitative analysis research method with a case study approach. Sample 16 health centers with saturated sampling techniques. Data collection is done by observation, interview and FGD. The results of the study are the advantages of saving storage space, ease of retrieval and return of documents, ease of access to family-based documents while the weakness of the registration time is longer in the event of separation of the head of the family or moving residence. It is recommended that policies be made for all Puskesmas if there are patients who move house or separate families, maximizing the use of tracers by adding information to the tracer including name, medical record number, date and borrower unit.AbstrakSistem penomoran merupakan salah satu sistem identifikasi yang digunakan untuk membedakan berkas rekam medis satu pasien dengan pasien yang lain. Sistem penomoran di Puskesmas Wilayah Dinas Kesehatan Surakarta Family Numbering System. Pelaksanaan sistem penomoran ini mengalami kendala yaitu jika ada pasien yang pindah tempat tinggal ataupun pisah Kepala Keluarga membutuhkan waktu yang lebih lama dalam mendaftar pasien, dikarenakan Petugas akan memberikan nomor rekam medis baru, membuat dokumen rekam medis baru dan folder yang baru untuk Pasien.  Tujuan penelitian untuk mengidentifikasi kelebihan dan kelemahan penerapan Family Numbering System. Metode penelitian analisis kualitatif dengan pendekatan studi kasus. Sampel 16 puskesmas dengan tehnik sampling jenuh. Pengumpulan data dilakukan dengan observasi, wawancara dan FGD. Hasil penelitian yaitu kelebihan hemat tempat penyimpanan, kemudahan pengambilan dan pengembalian dokumen, kemudahan akses dokumen berbasis keluarga sedangkan kelemahan waktu pendaftaran lebih lama jika terjadi pisah Kepala Keluarga atau pindah tempat tinggal.  Disarankan adanya penentuan kebijakan untuk semua Puskesmas jika ada pasien yang pindah rumah atau pisah KK,  memaksimalkan penggunaan tracer dengan menambahkan informasi pada tracer meliputi nama, nomor rekam medis, tanggal dan unit peminjam.
Gambaran Waktu Penyediaan Dokumen Rekam Medis di Puskesmas Karang Pule Kota Mataram Maria Yovita; Uswatun Hasanah; Reni Chairunnisah
Jurnal Rekam Medis dan Informasi Kesehatan Vol 2, No 2 (2019): Oktober 2019
Publisher : Poltekkes Kemenkes Semarang

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (295.13 KB) | DOI: 10.31983/jrmik.v2i2.5344

Abstract

The time for the provision of medical record documents from when the patient registers until the medical record documents are provided or found by officers with a minimum standard of service is 10 minutes. The purpose of this study was to determine the time description of the supply of medical record documents at the Karang Pule Health Center in Mataram City. The research design used is descriptive. The population in this study was 200 medical record documents with a total sample of 67 documents. The sampling technique used is accidental sampling. The results showed that the frequency distribution of old patient medical record documents 65 and new patient medical record documents 2. The average time needed to provide medical records for old patients is 1 minute 29 seconds and new patients 2 minutes 29 seconds. The average length of time for providing medical records in TPP is 51.65 seconds, Filling 17.64 seconds, 32 seconds distribution. Based on these results it can be concluded that when providing medical record documents at the Karang Pule Puskesmas it has met the minimum service standards, it is recommended to the Karang Pule Puskesmas to maintain and improve service quality.
Prediksi Jumlah Calon Mahasiswa Baru Tahun 2018-2022 di Poltekkes Kemenkes Semarang Adhani Windari; Emi Murniati
Jurnal Rekam Medis dan Informasi Kesehatan Vol 3, No 1 (2020): Maret 2020
Publisher : Poltekkes Kemenkes Semarang

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (344.027 KB) | DOI: 10.31983/jrmik.v3i1.5665

Abstract

Campus managers must be sensitive to consumers in the marketing process, students are importantassets in college life, strategies and regular promotions have a correlation with the number of registrants.Data analysis for 5 years from 2013 to 2017 provides precise accuracy every year and can be used as areference for predicting new student admissions in the following year. The growth in the number of newstudent admissions has an impact on providing lecture halls and improving services. One method forresearch related to the right prediction is to use non linear regression analysis.The results of predictions with non linear regression analysis indicate an increase in the number ofregistrants and decreases each year.AbstrakPengelola kampus harus sensitif terhadap konsumen pada proses pemasaran, mahasiswa adalah asetpenting dalam kehidupan Perguruan Tinggi, strategi dan promosi reguler mempunyai korelasi terhadapjumlah pendaftar. Analisis data selama 5 tahun dari tahun 2013 sampai dengan 2017 memberikan akurasiyang tepat setiap tahunnya dan bisa dijadikan acuan prediksi penerimaan mahasiswa baru pada tahunsetelahnya. Pertumbuhan jumlah penerimaan mahasiswa baru berdampak pada penyediaan ruang kuliahdan peningkatan pelayanan. Salah satu metode untuk penelitian berkaitan dengan prediksi yang tepatadalah menggunakan analisis regresi non linear.Hasil prediksi dengan analisis regresi non linier menunjukkan adanya peningkatan jumlahpendaftar maupun penurunan setiap tahunnya.
Analisis Kelengkapan Rekam Medis Rawat Inap Rumah Sakit Ganesha Di Kota Gianyar Tahun 2019 Ni Luh Putu Devhy; Anak Agung Gede Oka Widana
Jurnal Rekam Medis dan Informasi Kesehatan Vol 2, No 2 (2019): Oktober 2019
Publisher : Poltekkes Kemenkes Semarang

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (193.407 KB) | DOI: 10.31983/jrmik.v2i2.5353

Abstract

Hospital is an organization engaged in services, therefore it is obliged to hold a medical record for the achievement of good administration. Registration, data filling, processing and analysis as well as documentation, this is the process of organizing medical records. Filling in the medical record is said to be good if each item on the medical record sheet is filled with complete data. A complete medical record is a quality image of a hospital.Based on the above background, the researcher wants to find out the percentage of completeness of medical record filling in the inpatients of Ganesa hospital in the city of Gianyar. This type of research is a descriptive study with a cross-sectional design. The sample in this study was 95 inpatient medical record files. Percentage of completeness for RM Patient identity is 100%, doctor's identity is 96.8%, nurse's identity is 85.3%, informed consent is 95.8%, anesthesia is 43.2%, resume is 100%, diagnosis is 100%, abbreviations of 66.3%, readability of 76.8%, rectification of 23.2% and structuring of 100%. The incompleteness in filling the inpatient medical record at the Ganesha Gianyar Hospital was highest in the correction item.
Capaian Indikator Kapitasi Berbasis Komitmen Pelayanan pada Puskesmas di Kota Semarang Anton Kristijono
Jurnal Rekam Medis dan Informasi Kesehatan Vol 3, No 1 (2020): Maret 2020
Publisher : Poltekkes Kemenkes Semarang

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (338.767 KB) | DOI: 10.31983/jrmik.v3i1.5666

Abstract

Start from 2017, the capitation payment based on the fulfilment of service commitment has been implemented throughout all FKTP in Indonesia. There are three ration indicators of service commitment: contact number (≥150 per mile), ratio of participants of Prolanis who regularly visit (≥50%), and the ratio of non-specialistic outpatient referral (≤5%). The achievement of indicator target shows the service quality and influences the amount of capitation rate obtained by the Community Health Centre from BPJS Kesehatan. The research objective is to identify the glimpse of the achievement of the three indicators and the achievement of capitation number in 37 (thirty seven) Community Health Centres in Semarang City in 2018 and Semester 1 of 2019. The research method is descriptive observational, where during the the research, there has not been any intervention implemented. The data type used is quantitative data obtained from the secondary data of BPJS Kesehatan, Department of Health of Semarang City and Community Health Centres.The research result describes the average achievement of Contact Number of semester 1 and 2 in 2018 which reached 156.43 per mile and 157.08 per mile bigger that the indicator target, semester 1 of 2019 was 144.99 per mile, under the indicator target. Prolanis ratio describes that the Prolanis participants registered in Community Health Centres in Semarang City who regularly pay a visit to the Community Health Centres to obtain the service over chronic diseases they suffer continuously. Non-specialistic outpatient referral ratio suggests that the service quality in Community Health Centres in Semarang city is good. The average achievement of capitation payment based on the service commitment of the same period respectively is: 97,74%; 98,07%; 98,07%. Community Health Centre of Karanganyar has the lowest average achievement of capitation payment in 2018 as well as in Semester 1 of 2019 of 92.50% which shows that in average, there are 2 (two) indicators of capitation payment based on service commitment in Community Health Centres of Karanganyar which is located in unsafe zone during that period.Abstrak        Mulai tahun 2017 pembayaran kapitasi berbasis pemenuhan komitmen pelayanan dilaksanakan di seluruh FKTP di Indonesia. Terdapat tiga rasio indikator komitmen pelayanan : angka kontak (≥150 per mil), rasio peserta prolanis rutin berkunjung (≥50%), dan rasio rujukan rawat jalan non spesialistik (≤5%). Pencapaian target indikator menunjukan kualitas pelayanan dan mempengaruhi besaran tarif kapitasi yang didapat Puskesmas dari BPJS Kesehatan. Tujuan penelitian untuk mengetahui gambaran pencapaian ketiga indikator dan capaian besaran kapitasi pada 37 (tigapuluh tujuh) Puskesmas di Kota Semarang tahun 2018 dan semester 1 tahun 2019. Jenis penelitian adalah observasional deskriptif, dimana selama penelitian berlangsung tidak dilakukan intervensi. Jenis data yang digunakan : data kuantitatif, yang berasal dari data sekunder BPJS Kesehatan, Dinas Kesehatan Kota Semarang.       Hasil penelitian menggambarkan rata-rata capaian Angka Kontak  semester 1 dan semester 2 tahun 2018 mencapai 156,43 per mil dan 157,08 per mil lebih besar dari target indikator, semester 1 tahun 2019 adalah 144,99 per mil, di bawah target indikator. Rata-rata capaian peserta Prolanis rutin berkunjung dan rata-rata capaian rasio rujukan rawat jalan non spesialistik pada periode yang sama, hasilnya di atas target indikator. Rata-rata capaian pembayaran kapitasi pada periode yang sama berturut-turut : 97,74%; 98,07%; 98,07%. Puskesmas Karanganyar rata-rata capaian pembayaran kapitasinya terendah selama tahun 2018 serta semester 1 tahun 2019 sebesar 92,50%.
Identifikasi Penerapan Family Numbering System di Puskesmas Wilayah Dinas Kesehatan Kota Surakarta Harjanti Harjanti; Astri Sri Wariyanti
Jurnal Rekam Medis dan Informasi Kesehatan Vol 2, No 2 (2019): Oktober 2019
Publisher : Poltekkes Kemenkes Semarang

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (293.059 KB) | DOI: 10.31983/jrmik.v2i2.5346

Abstract

Implementation of numbering in the Health District of Dinas Kesehatan Kota Surakarta 1 applies Personal Numbering and 16 health centers implement Family Numbering. The number classification used is 8 digits consisting of 2 initial digits as a regional code, 4 digits as the serial number of the head of the family, 2 digits of the final digit status in the family. However, in the implementation of area code numbering, it has not yet been utilized for the index, but it has not been used for mapping the spread of disease, even if it is used, it helps in making decisions in reducing morbidity. The qualitative analysis research method is a case study approach. Samples of 16 puskesmas with purposive sampling technique. Data collection is done by observation, interview, documentation study and Focus Group Discussion (FGD). The results of the numbering research in the Surakarta City Health Department Area Health Center consists of 8 and 10 digits. Classification of 2 digits area / village / kelurahan code, 4-6 digits sequence number of head of family, final 2 digits of family status code / sequence of visits in one family. The difference in the middle number is due to the different number of patient visits. Utilization of number classification is used to facilitate storage, the percentage of visits, mapping the spread of disease. Policy should be made regarding the implementation of numbering in accordance with the agreement, namely numbering the Unit Numbering Sytem or Family Numbering with personal indexes and the use of 2 digit front numbers and 2 digit final numbers as needed. A tracer is needed to reduce misfolders with data on medical record numbers, patient names, loan dates and borrowing units.
Pengaruh Ketepatan Kodefikasi Penyakit Terhadap Validasi Laporan Morbiditas Rawat Jalan Ivana Putri Risyanti; Syafira Atikah Yudianti
Jurnal Rekam Medis dan Informasi Kesehatan Vol 3, No 1 (2020): Maret 2020
Publisher : Poltekkes Kemenkes Semarang

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (338.65 KB) | DOI: 10.31983/jrmik.v3i1.5667

Abstract

According to the WHO in 2004 the coding implementation must be complete and accurate according to the direction of ICD 10. The accuracy of the code is influenced by the determination or determination of the patient's diagnosis. If the diagnosis is not accurate, it will affect the number of cases in making reports of morbidity, mortality and the calculation of various statistics of the hospital. There is an outpatient coding officer at RS X and also duty to make report morbiditas while making report morbiditas made manually because SIMRS not able to present data needed. In addition, the implementation of codification is performed on the main diagnosis only and outpatient morbidity reports have not been well documented. The objective of this research is to know the effect of the outpatient code on the  validation of outpatient morbidity report in RS X. This type of research uses analytic observation with Cross sectional approach. The population of this study is the number of outpatient cases in daily census outpatient dn report morbidity as many as 573 cases with total sampling technique. Statistical test using chi square on SPSS. The result of the research shows that there is an influence between the accuracy of disease codification on the validation of outpatient morbidity report in RS X with p = 0,000.AbstrakMenurut WHO tahun 2004 pelaksanaan pengkodean harus lengkap dan akurat sesuai arahan ICD 10. Keakuratan kode dipengaruhi oleh penetapan atau penentuan diagnosis pasien. Apabila dalam mengode diagnosis tidak akurat maka akan berpengaruh pada jumlah kasus dalam pembuatan laporan morbiditas, mortalitas serta penghitungan berbagai angka statistik rumah sakit. Petugas koding rawat jalan di RS X berjumlah satu dan bertugas pula membuat laporan morbiditas sedangkan pembuatan laporan morbiditas dibuat secara manual karena SIMRS belum bisa menyajikan data yang dibutuhkan. Selain itu, pelaksanaan kodefikasi dilakukan pada diagnosis utama saja dan laporan morbiditas rawat jalan belum terdokumentasikan dengan baik. Tujuan penelitian adalah mengetahui pengaruh ketepatan kodefikasi penyakit rawat jalan terhadap validasi laporan morbiditas rawat jalan di RS X. Jenis penelitian menggunakan observasi analitik dengan pendekatan Cross sectional. Populasi penelitian ini adalah jumlah kasus rawat jalan pada sensus harian rawat jalan dn laporan morbiditas sebanyak 573 kasus dengan teknik pengambilan total sampling. Uji statistik menggunakan chi square pada SPSS. Hasil penelitian menunjukan ada pengaruh antara ketepatan kodefikasi penyakit terhadap validasi laporan morbiditas rawat jalan di RS X dengan nilai p = 0,000. 

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