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Jurnal Manajemen Informasi Kesehatan Indonesia (JMIKI)
Published by Asosiasi Perguruan Tinggi Rekam Medis dan Informasi Kesehatan Indonesia
ISSN : 2337585X     EISSN : 23376007     DOI : -
Core Subject : Health, Science,
Computer Science & IT Health Professions Public Health
Jurnal Manajemen Informasi Kesehatan Indonesia (JMIKI) diterbitkan oleh Asosiasi Perguruan Tinggi Rekam Medis dan Manajemen Informasi Kesehatan Indonesia (APTIRMIKI) bekerjasama dengan Perhimpunan Profesional Perekam Medis dan Informasi Kesehatan Indonesia(PORMIKI). JMIKI diterbitkan 2 kali dalam satu tahun ( Maret dan Oktober). Jurnal ini menerbitkan hasil penelitian (original) tentang Rekam Medis dan Manjemen Informasi Kesehatan, terutama dalam studi manajemen informasi kesehatan, Klasifikasi Kodifikasi Penyakit dan Tindakan, Sistem Informasi Kesehatan, Teknologi Informasi Kesehatan, Manajemen Mutu Informasi Kesehatan.
Arjuna Subject : -
Articles 336 Documents
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IMPLEMENTASI PENGISIAN FORMULIR INFORMED CONSENT KASUS BEDAH UMUM SEBAGAI SALAH SATU BUKTI TRANSAKSI TERAPEUTIK DI RSUD DR. SOEKARDJO KOTA TASIKMALAYA TAHUN 2017 Lina Khasanah Khasanah
Jurnal Manajemen Informasi Kesehatan Indonesia (JMIKI) Vol 5, No 2 (2017)
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.v5i2.157

Abstract

 According to the Ministry of Health Decree No. 129 of 2008 concerning Minimum Standards Services in Hospitals, filling Informed Consent (IC) forms must be 100%. Preliminary study addressing 15 IC form of general surgery case in January 2017 wasn’t filled complete. Purpose of the research is for knowing how the implementation filling of the IC form general surgery cases as evidence of therapeutic transactions in Dr. Soekardjo Tasikmalaya city hospital on 2017.The method of research is descriptive with mixed method approach, a total sample is 127 IC form, and the research participant is a general surgeon, chief medical record unit, nurse and patient.The result showed that the average percentage of completeness IC form of the general surgery cases in the first quarter of 2017 was 68.9%. Inhibitory factors are limited time, lack of human resources, priority on BPJS patient, lack of socialization, priority on high risk patients, no follow-up analysis, oral IC is considered easier, and delay in medical record control. The supporting factors are communication, application of accreditation, time lag of action. So average percentage of IC filling still below the SPM standard. Hospital should improve the causal factors that inhibit the incompleteness of IC and  maintain the supporting factor, so IC can be filled completely
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
PERENCANAAN IMPLEMENTASI UNIT KERJA REKAM MEDIS UNTUK KLINIK PRATAMA PANCASILA BATURETNO WONOGIRI Anggia Meianti; Hendra Rohman; Anna Mayretta
Jurnal Manajemen Informasi Kesehatan Indonesia (JMIKI) Vol 6, No 2 (2018)
Publisher : Asosiasi Perguruan Tinggi Rekam Medis dan Informasi Kesehatan Indonesia- APTIRMIKI

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33560/.v6i2.198

Abstract

Health services in Pratama Pancasila Clinic Baturetno City Wonogiri mostly receives post partum and children case patients. Activities of medical record work unit has not been managed optimally. The management has a plan to change the system. In medical record work units, personnel are not qualified, organizing has not yet been established, operational standards are missing, decentralized storage systems, duplicate files, double entry data, and diagnostic coding not avaliable. The purpose of this studywas to design the initial concept of medical record work unit for pratama clinic. Qualitative descriptive research type. Population 25 people, sample 3 people. Data collection using observation and interview guidelines. The results showed that medical record management required qualified personnel with D3 medical recordsbackground, the creation of procedures from registration to reporting, storage systems shifted to centralization, thus minimizing file duplication, access rights to medical records, and coding according to ICD rules. The conclusion is that the initial concept of the medical record work unit for the primary clinic can be started from planning gradually from identification to alternative selection to be implemented according to standards and needs.
ANALISIS KELENGKAPAN PENGISIAN DATA FORMULIR ANAMNESIS DAN PEMERIKSAAN FISIK KASUS BEDAH Rd. Irda Melinda Febriyanti; Ida Sugiarti
Jurnal Manajemen Informasi Kesehatan Indonesia (JMIKI) Vol 3, No 1 (2015)
Publisher : Asosiasi Perguruan Tinggi Rekam Medis dan Informasi Kesehatan Indonesia- APTIRMIKI

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33560/.v3i1.67

Abstract

AbstractQuantitative analysis has conducted in dr. Slamet Garut General Hospital, but there are still anamnesis andphysical examination forms are incomplete both clinical data and demographic data. Based on the highestpreliminary survey of incompleteness on the register component is 83.34%. The aim of this research is toknow the fulfilment procedure, completeness and incompleteness data fulfilment of anamnesis and physicalexamination forms. The method that used in this research is observation quantitative analysis, using instrumentobservation sheet. The population in this research are 1008 medical record documents on semester I in 2013.The magnitude of the sample uses Slovin formula is 90 documents. Slovin formula is used because it refersto large samples which are 90 documents. The result of research showed that complete form anamnesis andphysical examination of the patient identification component is 20%, important report is 31.12%, authenticationis 83.33% dan the register is 3.34%. Refers to the minimum standard of completeness which is submitted bythe department of health (2006), the completeness document must be 100%. It can be conclusion that theanamnesis and physical examination data fulfilment in dr. Slamet Garut General Hospital is not complete.Preferably, socialization is needed in fulfilment medical record document which is adapted to the StandardOperational Procedure (SOP) or The Fixed Procedure (PROTAP) which is adapted to all units related personalhealth such as doctors, nurses, dan medical record officer.Key words : Completeness, Filling up data, Anamnesis and physical examination.AbstrakDi RSUD dr. Slamet Garut sudah dilakukan analisis kuantitatif tetapi masih terdapat formulir anamnesisdan pemeriksaan fisik yang kurang lengkap baik data demografi maupun data klinis. Berdasarkan surveypendahuluan ketidaklengkapan yang tertinggi pada komponen pencatatan 83,34%. Tujuan penelitian ini untukmengetahui prosedur pengisian, kelengkapan dan ketidaklengkapan pengisian data formulir anamnesis danpemeriksaan fisik. Penelitian ini menggunakan metode analisis kuantitatif yaitu observasi, dengan menggunakaninstrumen lembar observasi. Populasi dalam penelitian ini sebanyak 1008 dokumen rekam medis padasemester I tahun 2013. Besarnya sampel menggunakan rumus Slovin sebanyak 90 dokumen. Hasil penelitianmenunjukan kelengkapan formulir anamnesis dan pemeriksaan fisik komponen identifikasi pasien sebanyak20%, laporan penting 31,12%, authentikasi 83,33% dan pencatatan 3,34% . Mengacu pada standar minimalkelengkapan dokumen yang diajukan departemen kesehatan (2006) kelengkapan dokumen harus 100%.Maka dapat disimpulkan pengisian data formulir anamnesis dan pemeriksaan fisik di RSUD dr. Slamet Garuttidak lengkap. Sebaiknya, diadakan sosialisasi dalam pengisian dokumen rekam medis disesuaikan denganStandar Operasional Prosedur (SOP) atau Prosedur Tetap (PROTAP) yang telah ditetapakan pada semua unitpelayanan kepada tenaga kesehatan terkait seperti : dokter, perawat dan petugas rekam medis.Kata Kunci: Kelengkapan, Pengisian data, Anamnesis dan Pemeriksaan Fisik
KONSISTENSI PENGGUNAAN ISTILAH GASTROENTERITIS PADA DOKUMEN REKAM MEDIS RAWAT INAP RSUD DR.SOEKARDJO KOTA TASIKMALAYA Reni Asmaya Lestari; Ida Wahyuni
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.v4i1.91

Abstract

AbstractEvery care facilities require special language of communication among officers, in order to achieve an effective and efficient services. The use of the term is the one of the languages in service should provide a common understanding for all officers. The terminology can be diagnostic procedures, surgery or drug therapy. The use of terms that varians in one disease may cause difficulties in the collection of information of morbidity and mortality. The use of terminology gastroenteritis on medical records inpatient in RSUD dr.SoekardjoTasikmalaya City, there are still inconsistent. The purpose of the study to determine the consistency of the use of terminology gastroenteritis in medical records inpatient. This type of research is descriptive with retrospective approach. This research uses simple random sampling from a population of 299 and available a sample of 171. Data collection by observation and review medical records inpatient. The result of the research shows that the use of terminology from 171 documents contained a consistent 43% and 57% were inconsistent. Care workers should improve the result of recording so that the information in the medical record higher quality. The need for cooperation among professional health personnel that established communication and good coordination to fill of medical record.Keywords: Consistency, Terminology, Gastroenteritis.AbstrakSetiap sarana pelayanan kesehatan membutuhkan bahasa khusus sebagai sarana komunikasi antar petugas, agar tercapai pelayanan yang efektif dan efisien. Penggunaan istilah sebagai salah satu bahasa dalam pelayanan harus memberikan pemahaman yang sama bagi semua petugas. Istilah medis tersebut dapat berupa prosedur diagnosis, terapi bedah atau obat.Penggunaan istilah yang bervariasi dalam satu penyakit dapat menimbulkan kesulitan dalam pengumpulan, perolehan informasi morbiditas dan mortalitas.Penggunaan istilah medis gastroenteritis pada dokumen rekam medis rawat inap RSUD dr.Soekardjo Kota Tasikmalaya masih ada yang tidak konsisten.Tujuan penelitian ini untuk mengetahui konsistensi penggunaan istilah medis gastroenteritis pada dokumen rekam medis rawat inap.Jenis penelitian ini adalah deskriptif dengan pendekatan retrosektif.Pengambilan sampel menggunakan Simple Random Sampling dari populasi 299 dan diperoleh sampel sebanyak 171. Pengumpulan data dengan cara observasi dan telaah dokumen rekam medis rawat inap. Hasil penelitian menunjukan bahwa penggunaan istilah medis dari 171 dokumen terdapat 43% yang konsisten dan 57% yang tidak konsisten. Petugas pelayanan hendaknya memperbaiki hasil pencatatan, agar informasi yang ada dalam dokumen rekam medis lebih berkualitas. Perlu adanya kerja sama antar profesi tenaga kerja di rumah sakit, supaya terjalin komunikasi dan koordinasi yang baik dalam mengisi dokumen rekam medis.Kata Kunci: Konsistensi, Istilah Medis, Gastroenteritis
EVALUASI KELENGKAPAN PENGISIAN DOKUMEN REKAM MEDIS INSTALASI RAWAT INAP DENGAN PENDEKATAN ANALISA KUALITATIF DAN KUANTITATIF DI RSIA KENDANGSARI MERR SURABAYA Linda Handayuni
Jurnal Manajemen Informasi Kesehatan Indonesia (JMIKI) Vol 5, No 1 (2017)
Publisher : Asosiasi Perguruan Tinggi Rekam Medis dan Informasi Kesehatan Indonesia- APTIRMIKI

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33560/.v5i1.147

Abstract

Based on the initial survey results indicate that the activity has not done well assembling proven medical records of 10 documents were taken at random showed as much as 34% incomplete and as much as 7% inconsistent. The research purposed to identify the completeness general consent, sign out sheet, initial assessment, and consistency of the general data of patients RSIA Kendangsari Merr Surabaya. This type of research is descriptive using retrospective study which collects data to look back on the causes or variables that influence a result. Conducted in April-July 2016. The sampling technique used purposive non-random sampling, on January until March 2016.The results showed the general consent highest data on incomplete answers is authentication patient / family / responsible (18%), on a sheet in and out of the highest incomplete is the date of authentication (74%), on a prior assessment of the highest data on the answer is incomplete is pain, and the last drug (100%). In the stuffing consistency shows name, date of birth, age, and gender shows the results as a whole (100%) is consistent. So the need to increase awareness and discipline officers assembling in equipping medical records, training, socialization, charging SPO manufacture of medical records
FAKTOR PERAN PERAWAT DALAM PENGISIAN BERKAS REKAM MEDIS DI RUMAH SAKIT HARUM SISMA MEDIKA JAKARTA TIMUR Alpi Cintya; Diana Bersassela
Jurnal Manajemen Informasi Kesehatan Indonesia (JMIKI) Vol 2, No 2 (2014)
Publisher : Asosiasi Perguruan Tinggi Rekam Medis dan Informasi Kesehatan Indonesia- APTIRMIKI

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (332.702 KB) | DOI: 10.33560/.v2i2.24

Abstract

AbstractMedical Recordis necessarythingtonote, many roles ofmedical personnelwhoare veryinfluentialin theMedicalRecordfilefilling. One of the roleis thenurse’s role, becausenurseismedical professionalwhomoreoftencontactwiththe patientthan doctor. Types ofthis research isquantitative, and subject of research are nurses from theentire roomat RumahSakitHarumSismaMedikaJakartaTimur. Theresearch wasconducted inApril-May2012in Jakarta. TotalPopulationsare 100 people and Samples are117respondents. Resultshowedthat there isno significant relationship between independent and dependent variablesbecausethe knowledgeandskillofrespondents are already good. Incompletedata of 42.91% were found during January-March 2012. TheresultsofMedical RecordsQuality were amounted that56% of respondentsweregood and43% of respondents were notgood. Result of Bivariateanalysis that there are significant relationshipbetweenknowledgeandmedical recordqualitywiththe p-value of 0.027. The assessment resultsforrespondent knowledgeof medical record qualitywereobtained50% good knowledge and50% bad knowledge, theresults ofrespondent skills wereobtained68%good skill and 32% bad skill. Based on theresearch results, medical recordsteam andthe headof nursingatRumahSakitHarumSismaMedikaEast Jakartaare expected toprovidemoretrainingto nurses from entire roomincludedhead room and attending nurse.Key words: quality, medical recordAbstrakRekam Medis merupakan hal yang sangat perlu diperhatikan, banyak peran tenaga medis yang sangatberpengaruh dalam pengisian berkas Rekam Medis. Salah satunya adalah peran perawat, karena perawat adalahtenaga medis yang sangat sering bersentuhan dengan pasien selain dokter. Jenis penelitian kuantitaif dengansubjek penelitian adalah para Perawat seluruh ruangan di RS Harum Sisma Medika Jakarta Timur. Prosespenelitian ini telah dilakukan pada bulan April-Mei 2012 di Kota Jakarta. Jumlah Populasi 117 dan Sampel100 responden. Hasil penelitian menunjukkan antara variabel independen dan dependen tidak terjadi hubunganyang bermakna atau signifikan dikarenakan dari segi pengetahuan dan keterampilan responden diketahui sudahbaik. Didapat angka tidak lengkapnya data selama bulan Januari-Maret tahun 2012 sebesar 42,91%, dan denganhasil Mutu Rekam Medis berjumlah 56% responden yang baik dan 43% responden yang kurangbaik. Dan daripenghitungan Bivariat diperoleh adanya hubungan yang bermakna atau siginifikan antara pengetahuan danmutu rekam medis dengan p-value 0,027. Hasil penilaian dari pengetahuan responden terhadap mutu rekammedis diperoleh hasil 50% berpengetahuan baik dan 50% berpengetahuan buruk, sedangkan pada keterampilandiperoleh hasil sebesar 68% responden memiliki keterampilan baik dan 32% memiliki keterampilan buruk.Berdasarkan hasil penelitian, maka pihak rekam medis dan kepala keperawatan di Rumah Sakit Harum SismaMedika Jakarta Timur diharapkan bisa memberikan pelatihan secara lebih kepada petugas perawat diseluruhruangan termasuk kepala ruangan dan perawat jaga.Kata kunci: mutu, rekam medis
PENGARUH FAKTOR HOT (HUMAN, ORGANISASI, DAN TEKNOLOGI) TERHADAP KEPUASAN PENGGUNA SISTEM INFORMASI PRIMARY CARE DI WILAYAH KOTA SEMARANG Asih Prasetyowati; Roro Kushartanti
Jurnal Manajemen Informasi Kesehatan Indonesia (JMIKI) Vol 6, No 1 (2018)
Publisher : Asosiasi Perguruan Tinggi Rekam Medis dan Informasi Kesehatan Indonesia- APTIRMIKI

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33560/.v6i1.188

Abstract

P-Care application user satisfaction becomes a necessity to ensure reporting service performance to BPJS. The purpose of this study is to look for HOT factors (human, organization, and technology) that affect user satisfaction P-Care applications. Quantitative research type is cross sectional with Primary Care information system object. The research subject is prime care information system operator, amount 61 operators. Data analysis used multivariate regression test. Descriptive analysis of HOT factor shows that human factor is good 100%, as much as 19,7% bad organizational policy, as much as 13,1% quality of service of less good technology. In general, users are satisfied with the p-care information system, but found 9.8% dissatisfaction on the timeliness. Regression test results show that there is influence of HOT factor to user satisfaction (0,829 - 0,222 factor human + 0,131 organizational factor + 0,224 technological factor). All three HOT factors will raise satisfaction by one level. Technological factors provide the greatest influence in increasing user satisfaction
PEMANFAATAN TEKNOLOGI INFORMASI DALAM PEMBELAJARAN KLASIFIKASI& KODEFIKASI PENYAKIT DAN MASALAH TERKAIT Nuryati, administrator
Jurnal Manajemen Informasi Kesehatan Indonesia (JMIKI) Vol 1, No 1 (2013)
Publisher : Asosiasi Perguruan Tinggi Rekam Medis dan Informasi Kesehatan Indonesia- APTIRMIKI

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33560/.v1i1.57

Abstract

ABSTRAKKlasifikasi dan kodefikasi penyakit dan masalah terkait merupakan salah satu kompetensi yangharus dicapai oleh Perekam Medis. Hal tersebut tertuang dalam Kepmenkes RI No 377 tahun 2007tentang Standar Profesi Perekam Medis dan Informasi Kesehatan dengan Deskripsi Kompetensi:Perekam Medis mampu menetapkan kode penyakit dan tindakan dengan tepat sesuai klasifikasiyang diberlakukan di Indonesia (ICD-10) tentang penyakit dan tindakan medis dalam pelayanandan manajemen kesehatan. Permasalahan yang ada pada saat ini adalah masih terbatasnya SDMyang benar-benar terampil dalam menetapkan kode, minimal SDM tersebut telah menempuhpendidikan Diploma 3 Perekam Medis dan Informasi Kesehatan, masih minimnya Dosen/instruktur, alat bantu dan media dalam pembelajaran klasifikasi dan kodefikasi penyakit diperguruan tinggi Perekam Medis dan Informasi Kesehatan.Oleh karena itu dalam penelitian ini akan dibahas mengenai permasalahan dan upaya dalampembelajaran tersebut. Dalam hal ini terkait pemanfaatan teknologi informasi dalam pembelajaranklasifikasi dan kodefikasi penyakit dan masalah terkait.Kata Kunci: Teknologi Informasi, Klasifikasi dan Kodefikasi, Rekam medis
PERANCANGAN SISTEM INFORMASI PENDAFTARAN RAWAT JALAN KLINIK Lily Widjaja; Adi Widodo; Nanda Aula Rumana
Jurnal Manajemen Informasi Kesehatan Indonesia (JMIKI) Vol 3, No 2 (2015)
Publisher : Asosiasi Perguruan Tinggi Rekam Medis dan Informasi Kesehatan Indonesia- APTIRMIKI

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33560/.v3i2.82

Abstract

AbstractClinic is individual health service facilities that provides primary medical services and or specialist, it is held by more than one kind of health workers and presided over by medical workers. In providing health services, clinic needs registration patientmanagement and qualified medical record. Based on it, in the study is done to design registration information system of outpatient clinic that can be used as the basic of service clinic based information system.Registration information system of outpatient clinic is designed by 6 entitiesthey are patients, apothecary, doctor, place registration patients, cash and director clinic. The database used consists of 13 tablesthat are related. The results of systemdesign can be used as a basic of the development of information systems registration outpatient clinic which is able to serve patients fast and accurate and able to present qualifiedinformation medicalrecord.Keywords: Information System, Registration, ClinicAbstrakKlinik adalah fasilitas pelayanan kesehatan perorangan yang menyediakan pelayanan medis dasar dan atau spesialistik, diselenggarakan oleh lebih dari satu jenis tenaga kesehatan dan dipimpin oleh seorang tenaga medis.Dalam memberikan pelayanan kesehatan, klinik membutuhkan pengelolaan pendaftaran pasien dan rekam medis yang berkualitas. Berdasarkan hal tersebut, dalam penelitian ini dilakukan perancangan sistem informasi pendaftaran rawat jalan klinik yang dapat digunakan sebagai dasar pengembangan pelayanan klinik berbasis system informasi.Sistem informasi pendaftaran rawat jalan klinik dirancang dengan 6 entitas yaitu Pasien, Apotek, Dokter,Tempat Pendaftaran Pasien, Kasirdan Direktur Klinik. Basis data yang digunakan terdiri dari 13 tabel yang saling berelasi. Hasil perancangan sIstem ini dapat digunakan sebagai dasar pengembangan sIstem informasi pendaftaran rawat jalan klinik yang mampu melayani pasien dengan cepat dan akurat serta mampu menyajikan informasi rekam medis yang berkualitas.Kata Kunci: SistemInformasi, Pendaftaran, Klini

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