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Muhammad Yunus
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m.yunus@polije.ac.id
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+628123413933
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j-remi@polije.ac.id
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Program Studi Rekam Medik Politeknik Negeri Jember Jl. Mastrip PO Box 164, Jember, Jawa Timur
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Kab. jember,
Jawa timur
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J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan
Published by Politeknik Negeri Jember
ISSN : -     EISSN : 2721866X     DOI : https://doi.org/10.25047/jremi
Core Subject : Health,
Health Professions Public Health
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan is a scientific journal that is managed and published by the Program Studi Rekam Medik, Jurusan Kesehatan, Politeknik Negeri Jember. J-REMI contains the publication of research results from students, lecturers and or other practitioners in the field of medical records and health information with coverage and focus on the fields of Health Information Management, Health Information Systems, Health Information Technology, Health Quality Information Management and Classification, Coding of Diseases and Problems. Health and Action.
Arjuna Subject : Profesi Kesehatan - Menejmen Informasi Kesehatan
Articles 30 Documents
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Search results for , issue "Vol 1 No 3 (2020): June" : 30 Documents clear
Evaluasi Kinerja Petugas Distribusi Berkas Rekam Medis Rawat Jalan di RSUD dr. Saiful Anwar Malang Najla Kamil; Novita Nuraini; Maya Weka Santi
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 3 (2020): June
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v1i3.2076

Abstract

Provision of outpatient medical record documents is the time required to provide medical recorddocuments from the patient registering to the examination. According to Minister of Health Decree No. 129of 2008 which states that the provision of outpatient medical record files is less than 10 minutes. Based onthe observation time of providing medical record documents at Dr. Hospital. Saiful Anwar Malang for morethan 10 minutes. The longest time for providing medical record documents is in the process of distributingmedical record documents from the distribution rack to the clinic for 14.84 minutes. To find the factors thatcause delays in the distribution of food, an evaluation of the performance of the distribution officers iscarried out with the performance theory of Motivation, Opportunity, and Ability. The aim is to determine thedelay factor in the distribution of medical record documents which causes the quality of hospital services todecrease. Based on observations, interviews and documentation, it is known that the factors causingdelays in distribution are lack of motivation and sanctions, lack of discipline among officers and no clearSOP regarding the distribution of medical records. Then there is a need for clear performance monitoringand preparation of SOPs related to the distribution of medical record documents.
Analisis Kebutuhan Electronic Medical Record (EMR) Pasien Rawat Jalan Dewasa Menggunakan Metode UCD di RSCM Evi Novitasari; Maya Weka Santi; Atma Deharja
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 3 (2020): June
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v1i3.2079

Abstract

RSUPN Dr. Cipto Mangunkusumo is a government hospital in Central Jakarta, Indonesia. The hospital hasnot used an electronic medical record with a land area of 12,1409 hectares and is still using manualmedical records, causing the length of documents to be distributed to each unit that needs it. Besides thedistance traveled causes the loss of files in it. The target achievement of medical record response time isstill very far from what has been set, which is equal to 90% of medical records reaching poly at <25minutes. Implementation of electronic medical records at RSUPN Dr. Cipto Mangunkusumo has not beenimplemented yet because the needs of the implementation of electronic medical records have not beenmet, so it is necessary to analyze the electronic medical records needs of adult outpatients. The researchmethod used is the user centered design method which is a design method that puts the user at the centerof a system design process. The process in the UCD method is to understand and determine the user'scontext, determine the needs of users and organizations, design solutions produced, and designevaluation of user needs. The results of the study are end-users of electronic medical records of adultoutpatients, namely doctors, nurses, medical recorders, and pharmacists. There are 3 needs for users andorganizations namely information needs, functional needs and non-functional needs. There are 13interface designs and interface design evaluation results, namely the design produced according to userneeds
Desain Formulir Pengkajian Awal Neonatus di Rumah Sakit Tingkat III Baladhika Husada Jember Rizky Farah Dilla; Dony Setiawan Hendyca Putra
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 3 (2020): June
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v1i3.2083

Abstract

The neonatal preliminary assessment form is one of the important forms, because it includes informationabout newborns. Baladhika Husada Hospital in Jember is one of the hospitals which still does not have apreliminary assessment form specifically for newborns or neonates, there still uses initial assessment formsfor general patients. The purpose of this study was to design a neonatal initial assessment form at BaladhikaHusada Hospital Level III Jember. This type of research is a qualitative study with research subjects includingSp.A doctors, midwives, nurses, chief medical records, and medical records officers. Data collectiontechniques in this study used interviews, observation, brainstorming. The results of this study were seen fromthe physical aspects of the neonatal initial assessment form using white paper with a size of 70 grams F4 (33cm and 21.5 cm) in portrait form. Viewed from the anatomical aspects of the neonatal heading assessmentform, the logo, the name of the agency, the address of the agency, and the title of the form, for theintroduction, are represented by the title. Viewed from the aspect of the contents of the neonatal preliminaryassessment form, the data added consisted of obstetric status, anthropometric vital signs, apgar scoreassessment, and physical examination starting from B1 - B7. Suggestions from researchers on the results ofthe neonatal initial assessment form design are expected to be implemented at Baladhika Husada HospitalLevel III Jember.
Tinjauan Pelaksanaan General Consent pada Pasien Baru Rawat Jalan RSUP dr. Sardjito Bhre Diansyah; Gamasiano Alfiansyah; Sustin Farlinda
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 3 (2020): June
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v1i3.2084

Abstract

One of the accreditation instruments is Patient and Family Rights (HPK) 6.3 which states that patients andtheir families were provided with an explanation of the scope of the general consent. Based on preliminaryresearch at the outpatient registration unit at RSUP dr. Sardjito Yogyakarta, the average new registeredpatients reached 43.25 patients per day and 89% of them did not receive an explanation about thecontents of the general consent form. This research aims to identify the current general consent form foroutpatients in 2020, identify the procedure applied in delivering information of the general consent foroutpatients, and identify factors obstructing the application of the general consent. This research wasqualitative. The data were collected through interviews and observations. The subjects of the researchinvolved officers of the inpatient registration unit at RSUP dr. Sardjito Yogyakarta and the head of themedical record and health information department. The results of this research show that the registrationofficers do not inform the general consent information for new patients because they have more concernon the speed of registration process without telling the content of general consent and unavailability ofSOP in providing general consent information that cause less proper work implementation.
Analisis Penyebab Ketidaksesuaian SPO Pengisian General Consent di Rumah Sakit Universitas Airlangga Nuril Amalia; Novita Nuraini; Andri Permana Wicaksono; Rosita Prananingtias
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 3 (2020): June
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v1i3.2090

Abstract

The incompatibility of SPO (Standart Operational Procedure) for General Consent completion was one ofmany problems that exist in the implementation of medical record activities at Airlangga UniversityHospital. SPO incompatibility in General Consent Completion could be seen from incorrect answer inGeneral Consent form for each indicator. From 21 samples of General Consent forms, there wasunsuitable answers in such as the identity of the person in charge (62%), the identity of the patient (71%),the approval for information release, privacy, personal values and patient confidence as well as thesignature and name of the witness (100%), the signature and the name of the patient person in charge(24%) and the date (43%). The purpose of this study was to analyze the cause of the SPO incompatibilityfor General Consent completion in Airlangga University Hospital. This type of research was qualitativeresearch and data collection obtained through interview. The subjects in this study were 5 registrationofficers at Airlangga University Hospital. The result of this study showed the causes of the GeneralConsent Completion SPO incompatibility were no specific training about medical records, the GeneralConsent Completion SPO did not explain the procedures to complete the form thoroughly, and there wasno socialization related to the General Consent Completion at Airlangga University Hospital. The solutionsfor this problem are, there should be an effort to improve the General Consent Completion SPO, providetraining for registration officers and conduct socialization on General Consent Completion.
Analisis Tingkat Kepuasan Pasien BPJS Unit Rawat Inap dengan Metode IPA di Rumah Sakit Baladhika Husada Jember Tahun 2019 Mitha Amelia Rahmawati; Atma Deharja
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 3 (2020): June
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v1i3.2092

Abstract

Inpatient services at Baladhika Husada Hospital in Jember still have problem to provide satisfaction to patientssuch as nurses not responsive and less friendly, room cleanliness is not maintained, electricity is oftenextinguished and air conditioners are not lit, toilet cleanliness is not maintained, the room is cramped andtemperature over the standard, inpatient BPJS registration process are complicated and parking space can’taccommodate. The purpose of this study was to determine the level of patient satisfaction of inpatient BPJSunits by the IPA method. Type of the research is quantitative research with descriptive techniques analysis.The IPA analysis method to measure the level of performance and importance based on quality, delivery,security, and morals by identifying the value of the gap and depicted in the Cartesian diagram. The level ofstatisfaction of inpatients based on the IPA method is known that the results of the analysis of the cartesiandiagra m illustrating four quadrans that top priority, maintained, low priority, and considered excessive. Theresults of the gap value based on quality, conductor, security, and morals are <1, but based on security thereis one attribute that has a gap >1. The main improvement efforts for brainstorming results are monitoring theperformance of cleaning services and conducting public speaking training for officers to improvecommunication
Evaluasi Sistem Penomoran Rekam Medis Menggunakan Metode Focus PDCA di RSUP Sanglah Sedyo Pinerdi; Atma Deharja; Ervina Rachmawati
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 3 (2020): June
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v1i3.2095

Abstract

The duplication of medical record numbers during February 2020 at Sanglah Hospital reachs 7 cases, it iscaused by the mistake of the officer register patients at SIMARS and the handling of duplicate cases that doesnot optimal. The purpose of this study was evaluated the patient's medical record numbering system used theFOCUS PDCA method at Sanglah Hospital. This type of the study is qualitative. The data collecting methodused in this study were observation and interviews. The data analysis stage in this research included aninvestigation stage to find, organized, clarify, understand, select, plan, do, check, dan action. The results ofthis study were duplicate cases that occur because patients were uncooperative when discussed with officers,patient did not register, officers were not thorough, authentication systems for patient search menu was notintegrated, the absence of regulations regarding the handling of cases of duplicate medical record numbers,and duplicate case reporting only limited to merge medical record files. The solutions chosen to solve theproblem were developing SIMARS registration menu, making SOP for handling duplicate cases of SanglahHospital medical records, and making menu recording and reporting of duplicate medical record numbercases in E-PASTI.The planning done is an analys of the needs of emergency room registration officers,discussion of SOP design for handling duplicate medical record number cases, and analys the staff's needsfor the development of E-PASTI that results. The next stage is to give an advice in the IT field to developSIMARS in the patient registration search menu, request SOP authorization for the handling of duplicatemedical record number cases for the head of the medical record, and implement the menu recording andreporting of duplicate medical record number case cases.
Analisis Kepuasan Pengguna Electronic Health Record (EHR) dengan Menggunakan Metode Delone and Mclean di Unit Rekam Medis RSUPN dr. Cipto Mangunkusumo Resti Aprilia Tri Hendaryanti; Atma Deharja
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 3 (2020): June
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v1i3.2102

Abstract

The rapid development of technology requires humans to move forward to compensate for this. Ease thatis obtained along with technological advancements in carrying out all activities so that the time spentbecomes efficient and can reach wider society. RSUPN Dr. Cipto Mangunkusumo has followedtechnological developments by using EHR which is used to facilitate the process of service in the medicalrecord unit from the patient coming to the patient coming out. EHR at RSUPN Dr. Cipto Mangunkusumostill has shortcomings that is loading long enough 5 minutes for 1 file search that inhibits storage officersand agreement officers in providing patient medical records, other conditions are some menus related toreports are not appropriate and still cannot be accessed so officers must process data in advance to beused as a report and the unavailability of EHR learning modules specifically for new users. The study aimsto analyze the satisfaction of users of EHR at RSUPN Dr. Cipto Mangunkusumo using DeLone andMcLean methods with 6 indicators namely system quality, information quality, use, user satisfaction,individual impact and organizational impact. This type of research used qualitative research with 20respondents. Based on the analysis of user satisfaction it is known that the EHR facilitates the work ofofficers, the information provided is of high quality, the functions provided help the work of officers. It isexpected that the analysis of user satisfaction with EHR can be used as an effort to improve electronicmedical records by adding report print menus, updating servers and creating EHR learning modules.
Analisis Faktor Penyebab Kerusakan Berkas Rekam Medis di Rumah Sakit Universitas Airlangga Aulia Nurul Kholifah; Novita Nuraini; Andri Permana Wicaksono
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 3 (2020): June
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v1i3.2104

Abstract

Medical records are files that contain records and documents regarding patient identity, examination results,treatment, actions and other services that have been provided to patients. Management of medical records is oneof medical support services. Based on the results of a preliminary study conducted at Airlangga UniversityHospital Surabaya it is known that in February 2020 amount 104 files were damaged so that the forms containedin them could be torn. This research was aimed to analyze the factors that cause damage to medical record filesat Airlangga University Hospital Surabaya. This type of research uses qualitative and data collection withinterviews and observations by using the analysis of 5M management elements is Man, Machine, Method,Material, Money. The population in this study is the medical records officer filing room section of 5 officers. Theresults obtained are that there are still many medical records officers who have a background not DIII medicalrecords, the lack of socialization of SOPs related to the maintenance of medical record files, limited number ofrack filing, and the less used folder material. So the suggestion made by the researchers is to redesign themedical record file folder by using a color code, and calculate the rack filing needs.
Tinjauan Faktor Penyebab Ketidaktepatan Waktu Pengembalian Sensus Harian Rawat Inap di RSUP dr. Soeradji Tirtonegoro Tahun 2020 Dian Fadilah Ayu Lestari; Andri Permana Wicaksono; Atma Deharja
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 3 (2020): June
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v1i3.2108

Abstract

Based on the results of preliminary studies conducted at the RSUP dr. Soeradji Tirtonegoro is known thehighest delay count is the Anggrek of 95% room and 4th Dahlia room of 80%. The delay has an impactwhich daily census returned is not timely, and be it can increase the work of officers for the next day andsending the recapitulation results to the reporting department is delayed. This study aims to observe theimplementation of the daily census and the factors causing the inaccuracy in returning the daily census ofhospitalization, the determination of the main causes of the problem are using a fishbone diagram. Thistype of research uses qualitative and are collected a data with observation, interview and documentation.The results of the main problem are Man (the work of the recapitulation officer is delayed and ineffective,the employee's indiscipline). Method (there is not written policies of Standard Operating Procedure, theofficer does not know the Standard Operating Procedure). Minutes (The deadline for retuning the dailycensus of hospitalization are not consistent). Machine (there are no features that support the daily censusof hospitalization in SINERGIS, daily inpatient census is manually). Money (there is no rewards).

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