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Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI)
Published by Universitas Imelda Medan
ISSN : 25027786     EISSN : 25977156     DOI : https://doi.org/10.2411/jipiki
Core Subject : Health,
Health Professions Public Health
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) (p-ISSN : 2502-7786 ) (e-ISSN : 2597-7156) is a national, peer-reviewed journal. It publishes original papers, reviews and short reports on all aspects of the medical record and health information. 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 - Menejmen Informasi Kesehatan
Articles 241 Documents
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Pelaksanaan Penyimpanan Rekam Medis Berdasarkan Unsur Manjemen 5M di Puskesmas Medan Johor Valentina; Winda Andryani Sinaga
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Vol. 6 No. 2 (2021): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Agustus
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v6i2.590

Abstract

The implementation of medical records carried out at the puskesmas requires management in managing all existing activities with the aim of creating good health services, in accordance with procedures and guidelines. To achieve the goal of processing medical records, 5 elements of management are needed, namely man, money, material, machine, and method. The purpose of this study was to determine the management elements of man, money, material, machine, and method in the implementation of medical records carried out at the Medan Johor Health Center. This type of research uses qualitative research methods with a phenomenological approach. The study was conducted from May to July 2020. The population was all medical record officers at the Medan Johor Health Center. The research sample amounted to 5 people who were taken by saturated sampling. The research instrument is an interview guide and recorded using an audio recorder and a check list sheet for observation. The results showed that the man element was 5 people and none of them had a medical record background and had never received training, the money element was the funding obtained from JKN and APBD, the material element was that a family folder was used to store all patient forms, while the use of tracers and register books has not been used to control the borrowed files out of the storage rack, and the filling cabinet is used as a tool to store medical record files, the machine element is a primary care application to register patients, the SIMPUS application is used for reporting, the method element is Not all SOPs in medical records exist. The advice given is to provide training to medical record officers so that their officers better understand the importance of medical records.
Upaya Meningkatkan Kepatuhan Profesional Pemberi Asuhan Pasien Dalam Dokumentasi Rekam Medis Zakharias Kurnia Purbobinuko; Ratna Prahesti; Kori Puspita Ningsih
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Vol. 6 No. 2 (2021): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Agustus
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v6i2.607

Abstract

Adanya tuntutan rumah sakit untuk menjamin kelengkapan rekam medis, perlu didukung dengan upaya rumah sakit melalui suatu regulasi dan edukasi kepada para PPA dalam proses pendokumentasian rekam medis. Lebih lanjut bahwa paradigma faktor manusia, dalam hal ini adalah PPA dalam menjaga kualitas rekam medis cukup berpengaruh langsung dalam keselamatan pasien. Tujuan dari penelitian ini adalah mengeksplorasi upaya rumah sakit dalam meningkatkan kepatuhan PPA pada dokumentasi rekam medis Penelitian ini merupakan penelitian deskriptif dengan pendekatan kualitatif. Rancangan penelitian menggunakan metode cross sectional. Penelitian ini dilaksanakan di RSUD Panembahan Senopati Bantul. Hasil penelitian menunjuukan RSUD Panembahan Senopati Bantul telah berupaya meningkatkan kepatuhan PPA dengan menetapkan regulasi berupa Pedoman Pelayanan Rekam Medis dan SPO Pengisian Rekam Medis. Upaya dari aspek material dilakukan dengan menyediakan formulir rekam medis berbahan kertas ukuran A4 berat 80 gram berbentuk persegi panjang dengan beberapa warna sesuai kebutuhan pengguna dan diberikan nomor formulir rekam medis. RSUD Panembahan Senopati Bantul telah melakukan penilaian kinerja setiap tahun sekali di akhir tahun, akan tetapi penilai kinerja berkaitan dengan kepatuhan PPA dalam dokumentasi rekam medis belum tertuang dalam SKP. Dalam upaya meningkatkan kepatuhan PPA dalam dokumentasi rekam medis, maka Tim KMKP menetapkan angka ketidaklengkapan assesmen awal medis dalam 24 jam pada pasien rawat inap melalui Instalasi Gawat Darurat (IGD) sebagai indikator mutu prioritas di RSUD Panembahan Senopati Bantul. Sebaiknya dalam upaya meningkatkan motivasi, budaya kerja dan kepatuhan PPA dalam dokumentasi medis, maka RSUD Panembahan Senopati Bantul dapat menerapkan reward dan punishment, sehingga tercapai kepuasan kerja karyawan
Rekam Medis Elektronik sebagai Pendukung Manajemen Pelayanan Pasien di RS Universitas Gadjah Mada Rika Andriani; Dewi Septiana Wulandari; Rizka Siwi Margianti
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Vol. 7 No. 1 (2022): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Februari
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v7i1.599

Abstract

Electronic Medical Records (EMR) is a digital repository of administrative and medical data to support integrated health services. EMR can be used to support case management activities such as identification, care coordination, patient progress monitoring, and provide cost-effective interventions. One of main factor in information system implementation is users. Based on users’ perceptions, recommendations can be made. It’s used to maximize the adoption and development of EMR. The purpose of this study to explore the users’ perceived benefits of EMR implementation to support case management. This research is a qualitative research with a case study design. Informants were EMR users, namely doctors, nurse, pharmacist, medical record officer, and laboratory assistant. They were selected through purposive sampling technique. We conducted face-to-face semi-structured interviews and observation. This research used an interview guide with open-ended questions and an observation guide. Results showed benefits of EMR were support patient safety, reduce duplicate examinations, continuity of care, patient care efficiency, and collaboration among health professionals. It is suggested to develop a patient reminder feature and periodic staff training.
Pengaruh Pemberian Tracer Terhadap Ketepatan Penyimpanan Berkas Rekam Medis Di RSU Purbowangi Citra Wiguna Bakti Bakhtiar; Santi Lathifatur Rohmah; Galih Cahya Panuntun
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Vol. 7 No. 1 (2022): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Februari
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v7i1.603

Abstract

Medical record is an inpatient outpatient treatment that stores important data and very important benefits, one of which is as a basis and guidance in planning and analyzing actions and services that will be provided to patients after checking and treatment. Based on the observations that have been made, it turns out that there are several medical record files that are missing and their placements are swapped from other medical record files, this is because too many medical records are accommodated and the lack of medical recording methods in an effort to minimize the occurrence of inaccuracies in storing medical record files. Efforts to solve the problem are to provide a tracer to the medical record file that has just been taken so that when returning the medical recorder it is not confused in finding and placing the correct medical record file. After applying the tracer system, it turns out that there is an effect of giving a tracer on the accuracy of the medical record file.
Studi Kasus Pelayanan Rekam Medis pada Masa Pandemi Covid-19 Di Puskesmas Gondokusuman II Kota Yogyakarta Angga Eko Pramono; Marko Ferdian Salim; Anita Wijayanti
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Vol. 7 No. 1 (2022): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Februari
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v7i1.659

Abstract

The Covid-19 outbreak has been declared as a public health emergency of international concern by the World Health Organization (WHO). The pandemic has also changed the process of health services provided to patients, including medical record services. This study aimed to examine the process of medical record services at the Gondokusuman II Primary Health Center (PHC) in Yogyakarta City during the Covid-19 pandemic. This qualitative research explored medical record services during pandemics. Three staff were recruited as respondents using the purposive sampling technique. Data were collected through observation and interviews. There were differences in patient registration services before and after the pandemic. Before registering, patients will be screened first. If they show Covid-19 symptoms, the patients are directed to the infectious clinic and the provision of medical records will be prioritized. To support the implementation of health protocols, the primary health center provides personnel protective equipment adequately. However, the reference for health protocols related to medical record services at the PHC level is not yet available. So, reference issued by the Ministry of Health is used respectively. Therefore, specific regulations need to be immediately compiled and disseminated to ensure that the prevention of Covid-19 transmission can be carried out more precisely.
Faktor yang Memengaruhi Penggunaan Sistem Informasi Rumah Sakit Berdasarkan Metode Technology Acceptance Model di RSU Advent Kota Medan Arifah Fitriani; Adistia Maulidiah
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Vol. 7 No. 1 (2022): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Februari
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v7i1.680

Abstract

Until now, there is no guarantee that every hospital is able to implement a Hospital Information System (SIRS) properly. Medan Adventist General Hospital has organized SIRS since 2018, but its use is still not optimal. This study aims to determine the factors that influence the use of SIRS with a technology acceptance model approach. The data used is primary data. The total respondents obtained in this study were 197 and the statistical tests used were chi-square and structural equation modeling.. The regression weight test showed that perceived usefulness was only significantly influenced by length of work experience (e = 0.173), and computer facilitation (e = 2.235). Meanwhile, perceived ease of use was only significantly influenced by length of work experience (e = -0.223), ability to operate computers (e = 0.439) and computer facilitation (e = 4.842).
Tinjauan Aspek Ergonomi Pada Ruang Penyimpanan Berdasarkan Standart Nasional Akreditasi Rumah Sakit (SNARS) Edisi 1 Di RSU Tere Margareth Medan Tahun 2020 Esraida Simanjuntak; Ermas Estiyana; Septi Anastasya
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Vol. 7 No. 1 (2022): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Februari
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v7i1.693

Abstract

In SNARS edition 1, it is known that medical record documents in paper or electronic form must be kept safe and confidential so they must be stored in a location that is protected from water, fire, heat, and other damage and protected from interference with access and unauthorized use. The purpose of this study was to determine the ergonomics aspect based on the National Standard for Hospital Accreditation (SNARS) Edition 1. The method used was observation and interviews with a descriptive type of research located at Tere Margareth General Hospital Medan in July 2020. The population in this study was the physical aspect. Ergonomics and medical records officers in the storage room as many as 2 people using the total sampling technique. is the storage room for medical record files at the Tere Margareth hospital that does not meet accreditation standards because there are still problems that occur related to room security which can be assessed based on the standard of ergonomic aspects. Ask the hospital to pay more attention to the state of the medical record storage room in order to meet the standard assessment elements of information management and medical records in SNARS Edition 1.
Pelaksanaan Pemeliharaan Dokumen Rekam Medis Di Ruang Penyimpanan Puskesmas Polonia Medan Tahun 2021 Yeyi Gusla Nengsih
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Vol. 7 No. 1 (2022): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Februari
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v7i1.694

Abstract

Dokumen rekam medis merupakan alat untuk mencatat terjadinya transaksi pelayanan sehingga harus dijaga keamanan serta kerahasiaannya dari bahaya kerusakan. Tujuan penelitian ini untuk mengetahui bagaimana pelaksanaan pemeliharaan dokumen rekam medis diruang penyimpanan Puskesmas Polonia Medan. Penelitian bersifat deskriptif dan populasi yang digunakan adalah seluruh dokumen rekam medis diruang penyimpanan Puskesmas Polonia dengan sampel berjumlah 100 berkas. Dari hasil penelitian diperoleh kerusakan dokumen rekam medis diruang penyimpanan Puskesmas Polonia Medan sebesar 56%. Faktor intrinsik yang mempengaruhi yaitu kualitas kertas, tinta dan sampul berkas. Sedangkan faktor ektrinsik yang mempengaruhi yaitu kabel listrik tidak tersusun rapi, rak terlalu penuh dan sempit, kelembapan udara mencapai 16oC, jamur, serangga, debu yang menjadi penyebab kerusakan dokumen rekam medis di ruang penyimpanan Puskesmas Polonia Medan. Disarankan kepada Puskesmas Polonia Medan agar dokumen rekam medis menggunakan sampul plastik dengan rak penyimpanan terbuat dari besi sehingga dokumen rekam medis tidak terkena jamur dan rayap yang dapat merusak dokumen rekam medis.
Tinjauan Penolakan Pada Klaim Pasien BPJS Kesehatan di RSUD Tanjung Pura Valentina; Mita Sari; Tri Widya Sandika
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Vol. 7 No. 1 (2022): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Februari
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v7i1.695

Abstract

Rejection of claims is one of the obstacles in the BPJS Kesehatan claim collection process. The purpose of this study was to determine the description of administrative verification on the rejection of BPJS Kesehatan patient claims at Tanjung Pura Hospital. This type of research is descriptive qualitative. The population is all BPJS patient medical record files that were rejected in June 2021 counted 135 files and BPJS Kesehatan claiming officers at Tanjung Pura Hospital, totaling 2 people. The samples of this study were the medical record files of BPJS patients who were rejected in June 2021 and the BPJS claiming officers who were taken by saturated sampling. The instruments used are check list sheets and interview guidelines. Data was collected by using documentation, observation and interview methods. Data analysis was done descriptively. The results showed that there were 123 claim files (2.9%) which were rejected by BPJS Kesehatan from 4,253 claim files submitted. The reason for the rejection of the claim file was because all of them did not pass the verification of the service administration which consisted of the absence of a DPJP signature on the resume and proof of service, no referral letter attached, no inpatient indication/order sheet, and no indication of anesthesia attached to the operation report. This incompleteness is due to the lack of thorough examination of the completeness of the medical record file by the data analysis section and the absence of SOPs in the implementation of the claim process. It is recommended to the hospital director to make an SOP for claiming BPJS Kesehatan and to the claims officer and data analysis to be more thorough in checking the completeness of the BPJS Kesehatan claim file.
Analisis Dan Perancangan Sistem Informasi Program Kesehatan Ibu Dan Anak Di Puskesmas Lingkar Barat Kota Bengkulu Tahun 2021 Niska Ramadani; Iin Desmiany Duri; Ni Komang Ummi Nur Gayatri; Ismail Arifin
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Vol. 7 No. 1 (2022): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Februari
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v7i1.698

Abstract

Program KIA merupakan salah satu prioritas utama dalam rencana pembangunan jangka panjang nasional (RPJPN) di indonesia tahun 2005 – 2025, di puskesmas lingkar barat pengolahan data KIA masih menggunakan system manual dimana pengolahan data dicatat dibuku registrasi. Pencatatan manual membutuhkan waktu lebih dari 7 menit setiap pelayanan, dan sering terjadinya kesalahan dalam pencatatan dan pendataan serta membutukan waktu yang lama untuk melakukan pengolahan data pelaporan setiap bulannya, oleh karena itu perlu dikembangkannya system informasi KIA secara elektronik sehingga dapat membantu petugas dalam mengolah program KIA secara cepat, tepat, dan akurat. Tujuan dari penelitian ini adalah untuk menganalisis dan Merancang Sistem Informasi Kesehatan Ibu dan anak di Puskesmas Lingkar Barat guna mengatasi permasalahan yang ada pada saat ini Metode yang digunakan dalam perancangan dan membuat desain system aplikasi dengan memanfaatkan metode pengembangan perangkat lunak yaiu metode wartefal. Penelitian yang dilakukan adalah penelitian deskriptif yaitu mengumpulkan data dengan cara melakukan pengamatan secara langsung terhadap objek penelitian. Metode yang digunakan adalah metode wawancara dan observasi. Pengumpulan data menggunakan data primer dan sekunder. Hasil dari penelitian ini sendiri adalah terciptanya sebuah aplikasi untuk mempermudah pengolahan data menjadi sebuah laporan KIA yang dibutuhkan dan mengatasi masalah yang timbul karena sistem Informai Program Kesehatan Ibu dan Anak secara manual. Perancangan dan Pembuatan desain system Informasi dengan menggunakan Pemrograman Visual Basic 6.0 di Puskesmas Lingkar Barat Kota Bengkulu telah dibuat dengan hasil analisis sistem yang sudah ada dan sesuai metode yang digunakan, serta desain perancangan yang elah dibuat sesuai dengan buku registrasi dan formulir pelaporan manual atau kebutuhan pihak rumah sakit dan dapat mempermudah peroses pengolahan sisem KIA. keterbatasan dalam melakukan penelitian ini adalah sulitnya melakukan wawancara secara langsung , dikarenakan situasi pandemic covid 19 Kontribusi : Penelitian ini dapat berguna dan di Puskesmas Lingkar Barat Kota Bengkulu untuk membantu dalam mengolaha data Registrasi dan Pelaporan Kata Kunci : Sistem Informasi, Program kia, EHR

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