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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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Gambaran Pengetahuan dan Sikap Pasien Post Bedah Elektif tentang Informed Consent di RS X Tahun 2024 Nurfadhilatussifah, Dela; Sugiarti, Ida
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Vol. 9 No. 2 (2024): 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.v9i2.1675

Abstract

Informed consent is giving consent after obtaining complete information. The patient has the right to accept or reject some or all of the assistance measures that will be provided. This decision depends on the patient's knowledge and attitude regarding consent to medical treatment. Several cases of medical malpractice in Indonesia actually started with the failure to implement informed consent properly. The aim of this research is to analyze the knowledge and attitudes of post-elective surgery patients regarding informed consent at Hospital X. This type of research is descriptive quantitative. The sampling technique uses accidental sampling. The population in this study was 42 patients after elective surgery in December 2023. The research instrument used a questionnaire sheet. The results of the study showed that of the 42 post-elective surgical patients regarding informed consent at Hospital Efforts are needed to simplify explanations in language that is easy for patients to understand and use certain media to improve patient understanding.
Tinjauan Pengisian Formulir Informed Consent Pasien Dengan Tindakan Hecting di Puskesmas X Kabupaten Tasikmalaya Gunawan, Reza Maulana; Sugiarti, Ida
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Vol. 9 No. 2 (2024): 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.v9i2.1681

Abstract

Approval for medical action or Informed Consent is required to ensure that the patient has understood all the information provided to make a decision and the patient gives consent or refusal. Informed consent is useful as legal evidence to reduce the risk of problems or claims against doctors or health care facilities for actions taken on patients. So the completeness of filling out the informed consent form is very important in community health centers. The X Health Center, Tasikmalaya Regency, has not fully complied with the completeness of filling out the informed consent form.Knowing the completeness of filling out the Informed Consent Form for Patients with Hectating Actions at the X Community Health Center, Tasikmalaya Regency. The research method used was a quantitative descriptive design with a sample of 44 Informed Consent patients with Hecting procedures based on the total sampling of patient visits in the 2023 treatment room. The results of the research on the completeness of filling out informed consent in the Patient Identification review were 78% complete, the Important Report review was 67% complete, the Authentication review was 63% complete, the Good Documentation review was 81.2% complete and from the four components of the recording review the results were 69% complete and 31% incomplete. The completeness of filling out informed consent has an important role in supporting the quality of service aspects as well as the legal aspects of the form as legal evidence for patients and health service facilities.
Kelengkapan Pengisian Rekam Medis Elektronik Pasien di Poli Umum Puskesmas Surabaya Timur Masyfufah, Lilis; Listiawan, Nadhila; Yulianita, Novi Eka; Wahyuni, Titin; Sutha, Diah Wijayanti; Pribadi, Maylina Surya Wirawati
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Vol. 9 No. 2 (2024): 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.v9i2.1689

Abstract

The digital transformation of health is one proof of technological developments in health services. The implementation of health digitalization in the Surabaya City environment has started on November 10 2014 and in 2020 it will be ready to transform into an Electronic Health Record (EHR). The implementation of EHR began with the implementation of RME at Surabaya City Health Centers since March 2022. However, RME implementation is still not optimal, so research needs to be carried out on the completeness of RME at East Surabaya Regional Health Centers. This research method uses a type of quantitative research that collects data in the form of numbers using an observational approach. The population used is RME patients at Community Health Centers in the East Surabaya Region, namely Menur Health Center and Keputih Health Center, while the research sample will be taken using the Cochran Formula. The results of the identified data will be processed using Microsoft Excel for quantitative analysis and will be presented in table form to describe the object. The results of the research show that incomplete filling in of patients' RME at the East Surabaya Community Health Center General Polyclinic is found in the Identity, Important Reports and Authentication components, while the Documentation component is 100% complete. It can be concluded that the incompleteness of RME filling at the East Surabaya Community Health Center reaches 70%, the data is not complete.
Analisis Kepuasan Pengguna Sistem Rekam Medis Elektronik Menggunakan Metode EUCS di RS Hermina Kota Padang Kamal, Syamsul; Mayasari, Nila; Khairani, Dila
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Vol. 9 No. 2 (2024): 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.v9i2.1691

Abstract

There are 6 Pillars of Health Transformation, one of which is the 6th pillar, namely Health Technology Transformation, which has a role in utilizing information technology so that with health information technology we can make good use of developments in digital technology, so that the process of digitizing health technology can grow better and grow better. developing in the world of health. In Minister of Health Regulation Number 24 of 2022 concerning Electronic Medical Records, it is stipulated that all Health Facilities at the end of December 2023 must implement RME, where the change from Manual Medical Records to Electronic Medical Records (RME). The aim of this research is to look at user satisfaction regarding the content, appearance, data accuracy, timeliness and ease of Hinai application for RME at Hermina Hospital. The method used in this research is the Quantitative Method with a descriptive approach. In carrying out data processing, the EUCS method was used with 18 samples. This research was carried out in May 2024 at Hermina Hospital, Padang City. The results of the research showed that users were very satisfied with the performance of the Hinai application, where the content got a score of 79 and a TCR of 87.78% for the display, a score of 81 and a TCR of 90.89 were obtained, for data accuracy it was 79.2 and the TCR was 80%, for accuracy When we got a score of 80 and a TCR of 88.89%, then for convenience we got a result of 80.4 and a TCR of 89.32, where for all categories it can be said that users of the Hinai application are very satisfied with the presence of this application and can continue using it in the future. . It is recommended that there be a continuation of this research for further development regarding the Hinai Application program in the future.
Sistem Pelepasan Informasi Rekam Medis Dalam Menjamin Aspek Hukum Kerahasiaan Rekam Medis Di RSU. Imelda Pekerja Indonesia Tahun 2023 Ritonga, Abdul Malik; Manurung, Sarida Surya; Nurani , Ramada; Manurung, Jonni Sastra
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Vol. 9 No. 2 (2024): 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.v9i2.1692

Abstract

Privacy, confidentiality and release of information are communications containing certain confidential information provided by patients to their doctors to be kept confidential, unless the patient has given written consent to release the information from their medical records. The aim of this research is to determine the procedures for the medical record information release system in ensuring the legal aspects of confidentiality at RSU. Imelda Indonesian Worker. This type of research is descriptive, namely a research method carried out with the aim of creating an objective picture of a situation. Research time is from January to August 2023 at RSU. Imelda Indonesian Worker. The subjects in this research were medical records officers, the research informant was the head of medical records. From the results of the research, it is known that the procedures for the release of medical record information system run in accordance with SPO number 002/SPO/MRMIK/2022, there is no specific SPO regarding the confidentiality of medical records but confidentiality has been carried out well in accordance with the SPO for the release of medical record information and in line with the 24 year Health Ministerial Regulation. 2022 regarding medical records, at RSU. Imelda, an Indonesian worker, releases a lot of information for insurance. The obstacle in releasing medical information is patients/families who do not bring a power of attorney and identification, where the patient's family does not understand the importance of a power of attorney. It is hoped that hospitals will create special SOPs regarding the confidentiality of medical records and provide information to patients/families about the requirements and procedures for releasing medical information by placing banners or posters in the information section or other strategic places.
Audit Kode Klinis Pasien Rawat Inap Jaminanan BPJS Kesehatan Di Rumah Sakit Tipe C Dan D Wilayah DIY Hosizah, Hosizah; Puspita Ningsih, Kori; Nisak, Umi Khoirun; Widjaja, Lily
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Vol. 9 No. 2 (2024): 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.v9i2.1707

Abstract

The quality of diagnosis codes is an important part of the hospital management level. The impact of a lack of quality diagnosis codes is the potential to reduce hospital income. A clinical coding audit needs to be conducted to review and analyze discovered errors and attempt to trace their source. The purpose of this research is to audit the code. The research approach was carried out through a quantitative descriptive approach. The research population was inpatient medical records of BPJS Health patients. Sample calculations use Slovin, with a margin of error of 10%. In this study, the clinical coding audit involved 3 coders in each hospital, coding experts from senior practitioners from Type B Hospitals and experts from academics. The results of the clinical code audit showed that the timeliness aspect was 100%, accuracy was 92.5%, completeness was 91.0%, relevance, and legitimacy were 87.5% each, while the lowest was in the reliability aspect at 80.0%. The results of the legibility aspect are in line with the results of relevance. This shows that determining clinical codes for case mix purposes must be supported by complete documentation of the patient's medical records.
GAMBARAN PENERAPAN DAN KELENGKAPAN PENGISIAN REKAM MEDIS ELEKTRONIK RAWAT JALAN DI RUMAH SAKIT TK.II UDAYANA DENPASAR Suriawan, I Gde Agus Hendra; Devhy, Ni Luh Putu; Aditya, Made Wahyu
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Vol. 10 No. 1 (2025): 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.v10i1.1500

Abstract

Complete medical record files can facilitate other health workers in providing patient care or treatment, and can be used as, a useful source of information for hospital management in determining the evaluation and development of health aservices. The impact of incomplete medical records is delays in the process of filing insurance claims and delays in the orderly administration process. The purpose of this study was to determine the completeness of filling out the Outpatient Electronic Medical Record at Tk.II Udayana Hospital Denpasar. The research method used is quantitative descriptive with a sample of 95 electronic medical records from July to September 2022 using the simple random samplingOmethod. The resultsashowed that 95 (100%) filled out identification completeness and 0 (0%) incomplete, 92 (96.8%) important report filling completeness and 3 (3.2%) incomplete filling, 69 (72.6%) authentication filling completeness) and 26 (27.4%) incomplete, 71 (74.7%) complete correct documentation and 24 (25.3%) incomplete. It can be concluded from the four analyses, the highest completeness of filling out outpatient RME at Tk. II Udayana Hospital Denpasar is found in important identification and reports. Based on the research above, the researchers suggest that hospitals should conduct socialization regarding the completeness of filling in RME to all health workers who are responsible for filling out electronic medical Records.
DATA MINING PENYAKIT TERBANYAK BERDASARKAN DECISION TREE ALGORITMA C4.5 DI RSUD PANDAN ARANG BOYOLALI Al Mubarok, Hafiddhudin; Sutrisno, Trismianto Asmo; Sugiarsi, Sri
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Vol. 10 No. 1 (2025): 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.v10i1.1512

Abstract

Top 10 disease data is data on diseases that often appear and occur most often. Data collection of the top 10 diseases is used to determine disease patterns in the community. Decision tree classification method is a model that maps observations of an item so that a conclusion is obtained about the target value of an item described in the form of a tree model. The C4.5 algorithm is method for creating a decision tree based on the training data that has been provided. The purpose of this research is to result in the classification of the most diseases based on the C4.5 decision tree algorithm of Pandan Arang Boyolali Hospital using excel and RapidMiner. This research design is descriptive observational. The data collection technique in this study was observation, with a total net data of 3449 data. The results of this research, there are no differences in results between excel and RapidMiner which results in the classification of the most diseases, which are blocks A00-B99, Z00-Z99, I00-I99, O00-O99, J00-J99, and E00-E90, and 18 rules are obtained. Evaluation of the performance of the C4.5 algorithm decision tree classification model using confusion matrix produces an accuracy value of 25.14%.
Analisis BOR dan Dampaknya Terhadap Faktor 5M di Rumah Sakit Umum Daerah Cilacap Putrilia, Maya; Hakim, Agya Osadawedya; Anggraeni, Okti; Fauzi, Harry
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Vol. 10 No. 1 (2025): 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.v10i1.1669

Abstract

Efficiency is one of the performance parameters/indicators which theoretically underlies all the performance of an organization including in hospitals. One of the services provided in the hospital is hospitalization. To assess the efficiency of the hospital, you can use the Barber Johnson chart. In this graph there is an area called the area of ??efficiency. RSUD Cilacap is one of the hospitals belonging to the Regional Government of Cilacap Regency which in 2022 will still not meet the established Barber-Johnson standards. The purpose of this study was to analyze the efficiency of BOR at Cilacap Hospital in 2022 using the Barber-Johnson standard. This research method uses a descriptive qualitative approach. The variable used in this study in the processing of daily inpatient censuses. The results of the analysis are then linked to the impact of the Man, Method, Money, Machine, Material factors. The risults of the study exspained that the BOR in Cilacap Hospital did not meet the established efficient standars. The impact of BOR on the man factordid not really affect the hospital, the Money factor did not really effect the Cilacap Hosptal. The impact on the Machine factor makes the equipment in the hospital more durable, the impact on the method factor, namely the reporting system becomes not deal and the reduced indicators in regional development programs, the impact on the material factor causes wateful purchases of materials.
Hubungan Pengetahuan Terminologi Medis Petugas Koding Dengan Ketepatan Kode Diagnosis di Puskesmas Dinoyo Zein, Eiska Rohmania Zein; Rahmawati, Nabila Yunita
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Vol. 10 No. 1 (2025): 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.v10i1.1717

Abstract

A coder's lack of knowledge of medical terminology results in inaccuracies in the diagnosis code made on medical record documents. Therefore, this study aims to analyze the relationship between knowledge of coding officers' terminology and the accuracy of the diagnosis code at the Dinoyo Health Center in Malang City. The method used in this research is quantitative with a cross sectional research design. Data processing techniques using statistical software, namely SPSS. The analysis technique used is univariate and bivariate analysis. The test used in this study was the chi-square. The sample was taken using simple random sampling technique with a probability sampling of 99 samples. The results of the relationship between the coding officer's knowledge of medical terminology and the accuracy of the diagnosis code showed a value that was not correlated, namely 0.541, with a value below 0.05, there was only a correlation between the two. The results showed that the accuracy of the diagnosis code was 43.43% incorrect and 56.56% correct, for the percentage of very good knowledge of medical terminology 16.7% and 83.3% good. It is expected to increase the accuracy of the diagnosis code in order to maintain the Dinoyo Health Center coder value.

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