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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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Pengaruh Akreditasi Untuk Meningkatkan Mutu Pelayanan dan Keselamatan Pasien di Rumah Sakit (Studi Sistematik Review) Raysella Khaulla Miandi; Yuly Peristiowati
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.v7i1.712

Abstract

Hospital accreditation is a government recognition of hospitals that have met the standards that have been set to get an idea of the extent of meeting hospital standards in Indonesia, so that the quality of service can be accounted for. The purpose of review research is systematic to find out the influence of accreditation in improving the quality of service and patient safety in hospitals. The research design used in this study is Systematic Review. The purpose of this method is to help researchers better understand the background of the research that is the subject of the topic sought and understand why and how the results of the study so that it can be a reference for new research. Independent variables are accreditation and variable dependents, namely the quality of hospital services and the safety of hospital patients. Researchers conducted a search for data through the websites of accessible journal portals such as PubMed, Elsevier, Springer, and Google Schoolar. The results showed after the collection of journals using accredited journal sites such as PubMed, Elsevier, Springer, and Google Schoolar. 496 journals were identified and eligibility criteria were carried out. Then after it was filtered obtained 23 journals, then excluded studies were obtained 3 journals met the exclusion criteria, after that based on inclusion criteria so that the total number of articles eligible for review was 20 articles. Quality improvement in all fields, especially in the field of health, one of which is through Hospital Accreditation towards the quality of International services. In the accreditation system that refers to the Standards of the Joint Commission International (JCI) obtained the most relevant standards related to the quality of hospital services International Patient Safety Goals (international targets of patient safety) which includes six hospital patient safety goals.
Analisis Kelengkapan Pengisian Resume Medis Rawat Inap di RS Darurat Covid-19 Wisma Atlet Kemayoran Lutfi Rinaldi Syahbana; Indang Trihandini
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.v7i1.721

Abstract

The completeness of medical records is very important to affect the process of services provided by health workers and impact on the quality of services of a hospital. Preliminary study results conducted at RSDC Wisma Atlet Kemayoran, filling out medical resume form 5 out of 10 files no signature name of medical resume form. Also found, 3 out of 10 files have no outgoing diagnostic information. The purpose of this study is to identify the completeness of the patient's identity, review of important reports, authenticity review and review of the correct completeness of the medical resume form at RSDC Wisma Atlet Kemayoran. This research is qualitative research. The study subject consisted of 2 doctors who filled out a medical resume. The object of the study was a sample of inpatient medical records from June 7-21, 2021 based on slovin formula as many as 98 files. The results of the study on the completeness of filling a medical resume seen from 4 aspects have not been high enough. Incomplete filling of medical resume forms is influenced by several factors, namely man, methode, material, and machine factors.
Tinjauan Peranan Koder Dalam Pengajuan Berkas Klaim BPJS Kesehatan Pasien Rawat Inap Di RSUD DR. R.M. Djoelham Kota Binjai Mordekhai Immanuel Sitorus; Noor Yulia; Puteri Fannya; Nanda Aula Rumana
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.v7i1.722

Abstract

Submission of claim files to BPJS Health is carried out every 10th of the month, BPJS Health will provide information whether the claim file is feasible or not. If the claim file is not feasible, it needs to be corrected. The purpose of the research is to describe the role of the coder in filing claims for BPJS Health inpatients at RSUD Dr. R.M. Djoelham Binjai City. The research method used is descriptive method with a quantitative approach. The sample uses 43 claim files returned by BPJS Health in April and May 2021 and also interviews with two coders. Data is collected by using observation with a checklist instrument and interviews with interview guidelines. The result shows that the hospital does not have standard operating procedures related to the submission of BPJS Health claim files, from 276 files (100%) submitted in April and May 2021, there were 233 files (84,42%) that deserve to be claimed and 43 files (15,58%) that were returned (not eligible). The reasons for the return were due to confirmation of diagnosis (18,60%), medical support (25,58%), indications for hospitalization (16,28%), coding (11,63%), purification failure (6,98%) and other causes (20,93%). The roles of the coder in handling claim files are assembling, determining the primary diagnosis code and secondary diagnosis based on ICD-10, determining the code of action (procedure) based on the ICD-9-CM, and coordinating with various internal parties for the completeness of the BPJS Health claim file. Suggestions for hospital to make standard operating procedures related to claim files submission and coders to be more thorough in preparing the complete claim files.
Desain Formulir Posyandu Lansia Desa Congkrang Kecamatan Muntilan Kabupaten Magelang Jawa Tengah Kuswanto Hardjo; Eniyati; Kori Puspita Ningsih
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.v7i1.733

Abstract

Recording and Reporting are parts of the Medical Record. According to Law No. 29 of 2004 on The Practice of Medicine, Medical Record is a file containing records and documents about the patient's identity, examination, treatment, actions, and other services given to the patient. Good data collection tools can produce accurate and valuable health information. Posyandu elderly Congkrang Village Muntilan District Magelang has been done regularly, but there is no good documentation of examination results. Documentation is written in books, but Posyandu participants can not access it. Forms have not available yet, so participants can not monitor the results of their examinations. The purpose of this study is the creation of health record forms and health examinations documentation of the elderly on an ongoing basis. This research is a development research or Research and Development (R&D) with a qualitative approach. The study results in health record forms in Posyandu elderly "As Syifa" Congkrang Village Muntilan District Magelang Regency based on aspects of form design, namely anatomical aspects, physical aspects, and aspects of content. The final result of creating the health record form is using 80 grams HVS paper size 22 cm x 34 cm with black ink. Based on the validation of the Posyandu elderly that the form design is good and immediately applied because they do not have a health record form.
Tinjauan Faktor-Faktor Penyebab Terjadinya Kerusakan Dokumen Rekam Medis Rawat Inap Di Rumah Sakit Putri Hijau Medan Khairani; Khairannisa Harefa
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Vol. 7 No. 2 (2022): 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.v7i2.702

Abstract

Medical Record is a file containing records and documents regarding patient identity, examination, treatment, actions and other services for patients at health care facilities. The factors that affect archive damage can be divided into two, namely intrinsic factors which are the cause of damage originating from the archive object itself, for example the quality of paper and the influence of ink. extrinsic factors are the causes of damage that come from external factors of archive objects, such as physical, biological and chemical environmental factors. cross-sectional approach, that is, each research subject is only observed once and measurements are made on the status of the character or variable of the subject at the time of examination. Intrinsic factors which include paper, ink and adhesive with the amount of damage to medical record documents caused by ink with a total of 89 (29.5%). Extrinsic factors include physical, biological and chemical factors with 72 (23.9%) damage caused by fungi. The conclusion is that the biggest damage is caused by intrinsic factors, namely chemical damage as many as 89 (29.5%) medical record documents
Tinjauan dan Pelaksanaan Penyusutan Rekam Medis Di RSU Madani Medan Lisa Anggriani Tanjung; Siddik Karo-Karo; Indah Fitri Hartanti
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Vol. 7 No. 2 (2022): 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.v7i2.703

Abstract

Depreciation of medical record documents is an activity to separate documents that are declared active and inactive. If the implementation of depreciation is delayed, there will be a buildup of medical record documents that fill the medical record document storage rack. The accumulation of medical record documents makes storage shelves untidy and prone to misplacement of medical record documents (missfile). In Permenkes No. 269/MENKES/PERIII/2008 concerning medical records, medical records are files containing notes and documents regarding patient identity, examination, treatment, actions and other services provided to patients. The purpose of this study was to determine the implementation of shrinking medical record files at Madani Hospital Medan. This type of research is descriptive qualitative. This method is used to describe the cause of the non-implementation of shrinkage of medical record files at RSU Madani Medan. Collecting data in this study conducted interviews with medical record officers. Based on the results of research at Madani General Hospital in Medan, there were 6 medical record officers and only 4 people with RMIK D-III educational background. The implementation of sorting medical record files at RSU Madani Medan is not in accordance with standard operating procedures because the sorting process is more than 5 years old. Hospitals should provide training for filing officers. For non-medical record officers, medical record education and health information to better understand the implementation of depreciation. Hospitals also need to immediately make a retention schedule so that there is a regular schedule for retention.
Pelaksanaan Program Sistem Pencatatan dan Pelaporan Terpadu (SP2TP) Puskesmas Pesantren II Reny Nugraheni; Ananda Muchamad Syaiful
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Vol. 7 No. 2 (2022): 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.v7i2.719

Abstract

Sistem pencatatan dan pelaporan terpadu puskesmas atau (SP2TP) merupakan kegiatan dan pelaporan data umum, sarana, tenaga dan upaya pelayanan pusat kesehatan di masyarakat. Sistem pencatatan dan pelaporan terpadu puskesmas merupakan sumber pengumpulan data dan informasi ditingkat puskesmas. Tujuan penelitian adalah untuk evaluasi pelaksanaan system pencatatan dan pelaporan terpadu di Puskesmas Pesantren II Kota Kediri Jawa Timur. Desain penelitian menggunakan desain kualitatif dengan pendekatan studi kasus meallui wawancara dan observasi. Kuesioner yang digunakan bertujuan untuk mengetahui input, proses dan output pelaksanaan program puskesmas melalui data primer dan data sekunder. Ketepatan waktu pelaporan adalah penyampaian atau penerimaan menjadi faktor penting dalam arus laporan atas dasar pertimbangan laporan diperlukan untuk bahan pengambilan kebijaksanaan pada saat tertentu atau secara berkala. Keterlambatan penyampaian atau penerimaan laporan akan mengganggu mekanisme pengambilan keputusan.
Visualisasi Pentatalaksanaan Rekam Medis di Masa Pandemi Covid-19 pada Pembelajaran Praktikum Laboratorium Melalui Media Video Tutorial Subinarto Subinarto; Isnaini Qoriatul Fadhilah; Puput Sugiarto
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Vol. 7 No. 2 (2022): 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.v7i2.942

Abstract

The Covid-19 pandemic has had an impact on health services in Indonesia. Health workers, especially PMIK, must pay attention to the procedures for handling Covid-19 in providing services to patients. Medical record management procedures need to be taught to students in order to gain knowledge and understanding of medical record management during the Covid-19 pandemic. Visualization of the management of medical records during the Covid-19 pandemic is needed for students in video tutorial media. The purpose of this research is to develop visualization in video tutorial media about the management of medical records during the Covid-19 pandemic in laboratory practicum learning. The study used the research and development method which was carried out in the manual medical record laboratory of Poltekkes Kemenkes Semarang from August to December 2021. The stages in this study began with a needs analysis through FGD, followed by the stages of making video tutorials, testing validity, and ending at the trial stage. . The results of the study obtained visualization in the form of video tutorials which have been declared very valid in the material test by 85% and media testing by 81% by experts. Practicality tests on videos that were conducted on students obtained practical results with a value of 78% so that they were able to provide visualization to students on the management of medical records during the Covid-19 pandemic. It is necessary to measure the effectiveness of video tutorials in increasing students' knowledge and skills regarding the management of medical records during the Covid-19 pandemic.
Tinjauan Penyebab Terjadinya Misfile Dokumen Rekam Medis Rawat Jalan Di RSUD Kabupaten Jombang Tahun 2020 Krisnita Dwi Jayanti; Ratna Frenty Nurkhalim; Ninda Mulya Ike Ardila; Budi Pranoto; Indra Setyawan; Indah Susilowati
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Vol. 7 No. 2 (2022): 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.v7i2.950

Abstract

Medical record outpatient and emergency must be accompanied and completed after service to patiens the same day. This study aims to find out the factors that cause misfile from the management aspects of man, method, machine, and material in Jombang District Hospital. This research is descriptive qualitative with a case study approach. The sample in this study were 11 officers. Data collection techniques used are questionnaires and observation sheets. The results showed that in the man element, it was found that the problem of the absence of medical record officers with a background in medical record education where it is also a trigger for misfile in the filing room, the absence of training for medical record officers due to the lack of programs related to medical record training in Jombang District Hospital, and officers have never been rewarded in any form such as praise or incentives and penalties to be motivated to work better. In the method element found the problem of the absence of the implementation of medical record documents investigation activities every day periodically by officers to prevent the occurrence of misfile. On the machine element found problems of not using tracer and outguide. In the material element found the problem is that the color code in Jombang District Hospital is not applied in its entirety because of the lack of importance of color coding officers to prevent misfiles. It can be suggested that leaders should provide rewards and punishments, participate in training, make policies related to DRM investigation activities, tracer implementation, and color coding on DRM covers.
Tinjauan Manajemen Informasi Dan Rekam Medis (MIRM) 11 Dan 14 Standar Nasional Akreditasi Rumah Sakit (SNARS) Di RSU X Tasikmalaya Tahun 2022 Novi Fidianti; Ida Sugiarti
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Vol. 7 No. 2 (2022): 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.v7i2.986

Abstract

Hospital accreditation is an acknowledgment of service quality. The results of a preliminary study in the filing room, the storage door was not locked because it was the access door to the medical record room, it was found that medical records were stored in cardboard boxes, storage of files stored in an untidy manner made medical records damaged and folded, and no tracer was available. The purpose of this study was to determine the application of security and confidentiality aspects of medical records according to MIRM 11 and 14. This type of research was qualitative with a phenomenological approach. The research subjects were 4 informants with data collection methods using in-depth interviews, observation, and documentation studies. Data analysis used thematic analysis. The results of the study provided SOP and SK for the prevention of unauthorized use of medical records. Protection from loss by recording in the register book. Protection from damage is to replace the cover, adequate facilities, and there are K3 officers. Protection from access interference is with officers always on guard at the storage room. The protection of the storage room against unauthorized access is that the door is always locked. There are SOP on the confidentiality and privacy of information. Regulations are enforced at the time of release of information and when accessing files. Other compliance officers comply with the time of returning medical records

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