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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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Tinjauan Pelaksanaan Penyusutan dan Pemusnahan Rekam Medis di RSUD Muntilan Hanifah Shofiarini; Makhrum Irmaningsih; Dyah Megawati Surip Solekhah; Adinda Dwi Nurul ’Ain; Esa Maheswari; Marko Ferdian Salim; Emi Nugroho; Bagus Setyadi
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Vol. 8 No. 1 (2023): 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.v8i1.1136

Abstract

Medical records are crucial documents in a hospital's patient care. Long-term use of paper-based or conventional medical records might result in issues including misfiles, disorganized shelves, and limited storage space. As a result, it's important to implement a procedure for the retention, elimination, and destruction of medical record files in order to eliminate useless files, decrease the growth in the number of files, and maintain the standard of medical record services. This study aims to evaluate the 5 M (Man, Money, Method, Material, and Machine) components of the process of eliminating and destroying medical record files at RSUD Muntilan. The object of research is medical record files, storage facilities, storage, implementation, and destruction of medical files. The method used in this study is a qualitative method through data collection by observation and interviews with medical record officers. The research was carried out at the Muntilan Hospital from June to July 2022. Based on the research that has been done, the process of implementing and destroying medical records is in accordance with applicable procedures and the regulation of the Ministry of Health No. 269 of 2008.
Faktor Yang Mempengaruhi Pelayanan Kesehatan Terhadap Kepuasan Pasien Rawat Inap Di RSUD DR. R.M. Djoelham Binjai Tahun 2022 Erlindai Purba; Angelia Putriana; Afifah Roselini Pasaribu
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Vol. 8 No. 1 (2023): 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.v8i1.1137

Abstract

Patient satisfaction is a level of patient feeling that arises as a result of the performance of health services obtained after the patient compares with what he expects. The purpose of this study is to have a very strategic role in accelerating the improvement of public health status in providing health services. This research method uses quantitative research methods with a cross sectional approach. The population in this study were all inpatients at RSUD Dr. R.M Djoelham Binjai totaled 331 patients. The sample to be studied is 76 respondents. The sampling technique in this study used the accidental sampling technique. Data were analyzed by performing chi-square analysis test. The conclusion of this study is based on hypothesis testing using quantitative methods based on simple linear regression test equipment (F test) it was found that the significance value was 0.0053 or less than 0.05, therefore there was a positive influence between the health service variables (X). Caused by several factors, among others, namely physical evidence (Tangible), reliability (reliability), responsiveness (responsiveness), assurance (assurance), empathy (emphaty) to the satisfaction of inpatients (Y). It is hoped that services that have received a satisfied response from patients will be maintained and improved by measuring the level of patient satisfaction on a regular basis so that they can monitor and maintain the quality of health services.
Review Ketepatan Kode Diagnosis Dan Pending Klaim Rekam Medis Pasien Covid-19 Tahun 2021 Laili Rahmatul Ilmi; Ratna Prahesti; Praptana Pratana; Ayu Wahyuningsih; Chinara Manuela
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Vol. 8 No. 1 (2023): 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.v8i1.1141

Abstract

A complete of medical record and the accuracy of clinical coding is reflect to the quality of medical record documentation. In 2021, the number of pending claim for medical record patient’s covid-19 is 41%, as cause the quality of medical record incomplete. The research aim is to measure the quality of medical records by covid-19 documentation for pending claims and the accuracy of coding Covid-19. The research method is mixed-method sequential explanatory. We used the checklist observation to measure the quality of clinical coding for patient covid-19 and interview guideline to explore the factors of pending claims. The total sampling are 889 of medical records as secondary data was analyze with STATA Version 13. The characteristic of administrative data by gender is man 571 (64,45%), woman 315 (35,35%). the number of classification covid-19 case is probable 25 cases (2,71%), suspected 214(24,15%) and confirmed 648 cases (73,14%). In another hand, the quality of accuracy coding covid-10 use code B34.2 is 377 (42,55%), use code U07.1 is 295(33,30%) and use code Z20.8 is 215 (24.14%). The accuracy of coding covid-19 is 295 (33,30%) and inaccurate 591 (66,70%). we observe the number of pending claims is 222 due to incomplete of signature and full name of physician items in discharge summary form.
Perancangan Ulang Map Rekam Medis Di Puskesmas Glugur Darat Medan 2022 Mei Sryendang Sitorus; Bella Siringo-ringo
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Vol. 8 No. 1 (2023): 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.v8i1.1144

Abstract

Medical record folder is a folder that is used to protect the forms in it to facilitate storage, especially patient medical record forms. The medical record folder at the Glugur Darat Health Center in Medan is currently in the form of a landscape and uses pink cardboard which is easy to tear and does not last long. The purpose of this study was to analyze and design a medical record folder in terms of three aspects, namely the physical aspect of the form, the anatomical aspect of the form, and the aspect of form content at the Glugur Darat Health Center in Medan. This research method uses descriptive, qualitative methods with saturated sampling technique, which was carried out at the Glugur Darat Health Center Medan in July-September 2022. The subjects in this study were Medical Record Officers, Filing Officers and Registration Officers at the Glugur Darat Health Center Medan. The result of this study is the design of a medical record folder at the Glugur Darat Health Center in Medan which is viewed from three aspects, namely the physical aspect of the form, a medical record folder made of thin cardboard is easy to tear and not durable. In the anatomical aspect, the form was found to only contain the name of the Family Folder, the name of the Puskesmas and the logo of the Puskesmas in the Heading section. In the aspect of the contents of the form found in the medical record folder at the Glugur Darat Health Center Medan, there is no loading in the medical record folder with the words Confidential.
Tinjauan Perancangan Tracer (Outguide) Pada Unit Penyimpanan Rekam Medis Di RSU Imelda Pekerja Indonesia Tahun 2022 Siddik Karo-Karo; Marjones Hardy H. Sihombing
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Vol. 8 No. 1 (2023): 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.v8i1.1175

Abstract

Tracer (outguide) is a substitute for medical records that will be removed from storage for any purpose. A good tracer should be made of strong and colorful materials. The function of the tracer is to show where medical record documents are when they are not in storage. Tracers can also improve efficiency and accuracy by showing where medical records are stored when they return. The purpose of this study was to redesign the tracer at Imelda Workers' Hospital in Indonesia by replacing materials, shapes, and designs to make it easier for officers to carry out their duties, namely inserting tracers into the shelves between the densely packed medical record files. The research method used is descriptive qualitative research. And the research instruments used are interview guidelines and observation check lists. The tracer (outguide) at Imelda Workers' Hospital in Indonesia has not been used for about a year because all tracers (outguides) have been damaged. The tracer (outguide) was damaged because the material was too stiff and broke easily when the officer inserted the tracer into the storage rack between the dense medical record files. RSU Imelda Workers Indonesia requires a tracer (outguide) made of strong, durable, not easily damaged, torn, broken and researchers have redesigned the tracer (outguide) as the results in the design above, namely by using flexible mica plastic material with a thickness of 0.70 mm , and the color chosen by the researcher in this design is black. The shape and size of the tracer (outguide) in this design is the same as the shape and size of the previous tracer (outguide) in Imelda Workers' Hospital in Indonesia. medical devices with new materials and designs such as the results in this design.
Perancangan Prototype Sistem Informasi Rawat Jalan pada RSU Aisyah Padang Tahun 2022 Syamsul Kamal; Yuli Mardi; Rindy Sakila
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Vol. 8 No. 1 (2023): 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.v8i1.1179

Abstract

Prototype design is a software development method that uses an approach to make designs quickly and gradually so that potential users can immediately evaluate the advantages and disadvantages of the designed prototype. With this prototyping method, developers and users can interact and communicate with each other during the process of making prorotypes. In the design of an outpatient information system prototype it is very necessary and needed is supporting data so that the design can be further developed and aligned with existing systems in hospitals. “Aisyiyah Padang. The design of the outpatient medical record information system in the hospital already exists and needs to be analyzed again whether it is relevant for the future or not. In designing the outpatient information prototype used DFD (Data Flow Diagram), ERD (Entity Relation Diagram), direct interview method with hospital medical record staff and IT to retrieve the information needed in the design and completion. The purpose of this research is to see and analyze how far the information system design is currently running, especially the outpatient department and see the weaknesses in designing this system and whether the current system design is useful for hospitals or is it still relevant today and what needs to be developed more specifically, analyzing the specifications of the requirements and system design, designing the system interface, and evaluating the results of the system analysis and design. The results obtained after conducting research at the Aisyiyah General Hospital are the need to develop a prototype outpatient information system that is currently running because there are still deficiencies and weaknesses in the design of the old system, which is no longer relevant to the current condition of the information system.
Comparison of Community Satisfaction with Health Services at Accredited Health Centers in North Sumatra Bintang Rizki Angeli; Susilawati Susilawati
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Vol. 8 No. 1 (2023): 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.v8i1.1197

Abstract

Puskesmas harus dikelola dengan baik serta dapat menjalankan fungsinya secara maksimal mulai dari sumber daya yang digunakan, proses pelayanan hingga kinerja pelayanan. Dengan demikian, menghasilkan pelayanan kesehatan yang aman dan bermutu, serta sesuai kebutuhan masyarakat. Peneliitian ini bertujuan untuk mengetahui hubungan kepuasan masyarakat terhadap pelayanan kesehatan di puskesmas yang terakreditasi di Sumatera Utara. Penelitian ini menggunakan metode kuantitatif dengan desain cross sectional. Hasil uji statistic dengan uji t yang dilakukan oleh peneliti menunjukkan p value 0,000 (p < 0,05) sehingga Ho ditolak dan Ha diterima, hal ini berarti terdapat komparasi antara tingkat kepuasan masyarakat dengan akreditasi dari puskesmas. Dari penelitian yang dilakukan oleh peneliti, dapat disimpulkan bahwa terdapat hubungan kepuasan masyarakat terhadap pelayanan kesehatan di Puskesmas Terakreditasi di Sumatera Utara. Diharapkan kepada puskesmas-puskesmas yang telah mendapatkan akreditasi, agar tetap menjaga kualitas mutunya.
Analisis Faktor Penyebab Pending Klaim Rawat Inap Akibat Koding Rekam Medis Di Rumah Sakit Umum Daerah (RSUD) Dr. Soedirman Kebumen Aldi Pratama; Harry Fauzi; Zahrasita Nur Indira; Prisai Purnama Adi
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Vol. 8 No. 1 (2023): 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.v8i1.1225

Abstract

Klaim Jaminan Kesehatan Nasional (JKN) adalah pengajuan biaya perawatan pasien peserta BPJS Kesehatan oleh pihak rumah sakit kepada pihak BPJS Kesehatan yang dilakukan secara kolektif dan ditagihkan kepada BPJS Kesehatan setiap bulannya. Setelah itu BPJS Kesehatan akan melakukan persetujuan klaim dan melakukan pembayaran untuk berkas yang layak, namun untuk berkas yang belum layak klaim atau pending (unclaimed) harus dikembalikan ke rumah sakit untuk diperiksa kembali. RSUD Dr. Soedirman Kebumen adalah rumah sakit yang bekerja sama dengan BPJS untuk memberikan pelayanan kepada pasien melalui sistem pembiayaan, dimana pada pelaksanaannya masih ditemukan masalah-masalah terutama terkait pending klaim. Kejadian pemding klaim di RSUD Dr. Soedirman Kebumen disebabkan oleh beberapa hal diantaranya administrasi, medis, koding, berkas tidak layak dan lainnya. Berdasarkan studi pendahuluan ditemukan berkas pending klaim pada bulan September 2022 sebanyak 163 dari 1041 berkas pasien rawat inap yang menggunakan Jaminan Kesehatan Nasional. Dari permasalahan tersebut maka dilakukan analisis faktor penyebab pending klaim akibat koding melalui penelitian kuantitatif dengan pendekatan fenomenologi. Hasil analisis menunjukan pengembalian berkas klaim pasien rawat inap BPJS Kesehatan di RSUD Dr. Soedirman Kebumen terjadi karena faktor perbedaan presepsi kode diagnosis dalam berkas klaim antara pihak koder rumah sakit dengan pihak verifikator BPJS Kesehatan. Selain itu kekurangan data pendukung sebagai penegakan diagnosis juga mempengaruhi keakuratan kode diagnosis yang mengakibatkan pending klaim. Berdasarkan permasalahan tersebut perlu adanya upaya yang harus dilakukan rumah sakit seperti kegiatan evaluasi terkait kinerja petugas sesuai job description yang ada dan peningkatan kualitas SDM khususnya petugas koding dengan mengadakan pelatihan serta sosialisasi mengenai pembaharuan kebijakan mengenai klaim. Pengoptimalan kegiatan dengan dibuatnya SPO terkait klaim agar dapat meminimalisir kejadian pending klaim.
Faktor-Faktor Penyebab Keterlambatan Waktu Pengembalian Berkas Rekam Medis Rawat Inap Dirumah Sakit Islam Malahayati Medan Tri Widya Sandika; Akmal Hayati; Sarmaida Siregar
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Vol. 8 No. 1 (2023): 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.v8i1.1227

Abstract

Pengembalian rekam medis adalah sistem yang penting di Unit Rekam Medis karena merupakan awal kegiatan sebelum dimulainya pengolahan rekam medis pasien. Ketepatan waktu pengembalian sesuai dengan kebijakan Rumah sakit Islam Malahayati, yaitu 2x24 jam setelah pasien pulang rawat. Dari observasi pada bulan Juni 2022 sering terjadi keterlambatan pengembalian rekam medis rawat inap. Tujuan penelitian ini untuk mengetahui faktor faktor penyebab keterlambatan pengembalian berkas rekam medis rawat inap. Jenis Penelitian ini bersifat penelitian deskriptif dengan metode pengumpulan data wawancara di Rumah Sakit Islam Malahayati. Faktor faktor penyebab keterlambatan pengembalian berkas rekam medis diantaranya kurangnya informasi dan jelas tentang standar waktu pengembalian berkas rekam medis rawat inap, terdapat petugas yang lupa mencatat berks rekam medis yang dipinjam buku ekspedisi. Saran sebaiknya pihak rumah sakit melakukan sosialisasi SOP (Standar Operasional Prosedure) tentang pengembalian berkas rekam medis rawat inap dan melakukan pelatihan tentang rekam medis, pencatatan dan pengembalian berkas rekam medis.
Analisis Kualitatif Pengisian Rekam Medis Rawat Inap Di Rumah Sakit Umum Daerah Kabupaten Aceh Tamiang Tahun 2022 Zulham Andi Ritonga; Ali Sabela Hasibuan; Tasya Adinda Putri
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Vol. 8 No. 1 (2023): 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.v8i1.1228

Abstract

Completeness of filling out medical records in hospitals is a must for health workers and can be done using qualitative analysis. The purpose of this study was to determine the qualitative analysis of filling in inpatient medical records at the Aceh Tamiang District General Hospital. This research is a descriptive research with a quantitative approach. The research was conducted at the Aceh Tamiang District Hospital. The population in this study was 1,840 and the sample obtained was 95 inpatient medical records. The results showed that the review of the completeness and consistency of the diagnosis was 90 (95%) accurate and 5 (5%) inaccurate, namely in the inpatient doctor's notes. In the notes and nursing care and nursing diagnoses there were 87 (92%) complete and 8 (8%) incomplete. Review of the consistency of recording the diagnosis, there were 85 (89%) complete and 10 (11%) incomplete. There are 83 medical records (87%) accurate and 12 (13%) inaccurate. Incomplete and inaccurate filling of inpatient medical records is found in the consistency of development records and nursing care. There were 82 (86%) complete and 13 (14%) incomplete records of things that were carried out during treatment and treatment, namely on evidence of implementation of treatment plans, instructions and drug changes, and actions taken which were filled out by nurses. Review of informed consent from 16 inpatient medical records, there were 14 (87%) complete and 2 (13%) incomplete, namely the completeness of the contents of the informed consent filled out by nurses. Review of medical methods or practices, there are 84 (88%) complete and 11 (12%) incomplete, namely on the date and time, the signature / initials is easy to read filled in by the doctor

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