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Muhammad Yunus
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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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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 4 (2020): September" : 30 Documents clear
Analisis Faktor Penyebab Pending Klaim Akibat Koding Berkas Rekam Medis Pasien Rawat Inap di RSUPN Dr. Cipto Mangunkusumo Salma Firyal Nabila; Maya Weka Santi; Yusirwan Tabrani; Atma Deharja
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 4 (2020): September
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v1i4.2157

Abstract

Klaim BPJS Kesehatan adalah pengajuan biaya perawatan pasien peserta BPJS oleh pihak rumah sakit kepada pihak BPJS Kesehatan yang dilakukan secara kolektif dan ditagihkan kepada pihak BPJS Kesehatan setiap bulannya. Setelah itu BPJS Kesehatan akan melakukan persetujuan klaim dan melakukan pembayaran untuk berkas yang layak, namun untuk berkas yang tidak layak klaim atau pending (unclaimed) harus dikembalikan ke rumah sakit untuk diperiksa kembali. Kejadian pending klaim di RSUPN Dr. Cipto Mangunkusumo disebabkan oleh beberapa hal diantaranya administrasi, medis, koding, tidak layak dan lainnya. Berdasarkan studi pendahuluan ditemukan berkas pending klaim pada bulan januari 2020 sebanyak 788 dari 2539 pasien rawat inap yang menggunakan Jaminan Kesehatan Nasional. Dari permasalahan tersebut maka dilakukan analisis terkait faktor penyebab pending klaim akibat koding melalui pendekatan fenomenologi yang meliputi input dan proses pada bagian Koding di RSUPN dr. Cipto Mangunkusumo. Hasil penelitian terkait SDM diperlukan penambahan jumlah sumber daya manusia serta sosialisasi pembaharuan dari aturan koding. Terkait Sarana dan Prasarana yaitu keterbatasan ruangan petugas koding diperlukan pertemuan secara rutin. Terkait Teknologi yaitu mendukung proses klaim berkas rekam medis pasien diintegrasikan dengan proses manajemen lain yang terdapat di SIMRS. Berdasarkan analisis proses terkait Perencanaan yaitu telah memiliki SOP penyelesaian permasalahan pending klaim. Terkait Pengorganisasian yaitu perlu dibuat job description khususnya pada petugas bagian coding. Terkait Pelaksanaan yaitu proses pengklaiman dilihat dari alur yang ada telah sesuai dengan SOP yang berlaku serta pada analisis proses terkait Evaluasi yaitu mengadakan pertemuan rutin atau rapat bulanan.
Analisis Faktor Penyebab Keterlambatan Pengembalian Berkas Rekam Medis Rawat Inap di RS Universitas Airlangga Abdul Haqqi; Novita Nur Aini; Andri Permana Wicaksono
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 4 (2020): September
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v1i4.2158

Abstract

One of the hospital's obligations is to organize a medical record. Good or bad medical record-up is a description of the quality of the hospital. The minimum service standard for the patient's return of the patient's medical record is completed by obtaining medical services until the medical record file returns to the medical record room within 2x24 hours. The return of an inpatient medical record in Universitas Airlangga Hospital takes more than 2 X 24 hours, even up to 1 week is calculated since the patient returned home and the file has not been completed 100%. Such problems will result in delayed reporting, provision of old patient medical record files should still be sought in the last location of the borrower's medical record file if not found in the filing rack. There is still an unrecorded return time in the expedition book. There is a problem with the delay in the return of an inpatient medical record so that it is necessary to identify the problem that aims to correct or minimize potential problems. The identification methods used are observation and interview methods. Observations are performed on data sources collected either primary data or secondary data related to the cause of the return of the medical record file. The interview is conducted by the researcher to the officer related to the late return of the inpatient medical record file. The study uses the 5M method (Man, Machine, Method, Material, and Money) by Harrington Emerson.
Identifikasi Faktor Penyebab Penumpukan Berkas Rekam Medis Aktif di RS Husada Utama Nurul Kamilia; Rossalina Adi Wijayanti; Ida Nurmawati
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 4 (2020): September
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v1i4.2160

Abstract

Based on the results of a preliminary study conducted at the Husada Utama Hospital it is known that in 2018 there was an accumulation of active medical record files which were 310 files. The impact of the accumulation of medical record files is the provision of medical record files will take longer so that patients often complain, officers become fatigued quickly in doing their work so that it will also have an impact on the depreciation process that should be done every day, and officers also feel uncomfortable and disturbed because the accumulation of medical record files also interferes with access to filing officers when retrieving and returning medical record files. This study aims to identify the factors causing the accumulation of active medical record files in Husada Utama Hospital. This type of research uses qualitative and data collection by interview, observation, and documentation. The results obtained that the results showed that the cause of the accumulation of medical record files that affect from the Man side is that the officer has never attended medical records training, from the Money side that is still not getting a budget for storage shelves, from the Material side there is a medical record file that is not using a map, in terms of Machine that is the number of storage racks not according to needs and in terms of Method which is the implementation of a storage system, alignment, and retention that is not in accordance with the Standard Operating Procedure (SOP).
Analisis Pelaksanaan Sensus Harian Rawat Inap di RSUD Dr. Saiful Anwar Malang Ferly Ferly; Rossalina Adi Wijayanti; Novita Nuraini
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 4 (2020): September
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v1i4.2163

Abstract

Abstract Information obtained from the daily inpatient census in the form of data that will be processed into information needed by the hospital, so that the daily inpatient census activities must be carried out correctly in accordance with procedures so that the data generated is accurate and can be used as a basis for decision making for management. This study aims to analyze the factors causing the inactivity of inpatient daily census activities correctly using a fishbone diagram. This research is a qualitative descriptive study conducted at Dr. Saiful Anwar Malang in February - March 2020. The subjects of this study were the daily census officer of the inpatient room, and the daily census officer of the medical record section. Data was taken by interview and observation methods. Data were analyzed using fishbone diagrams. The results of this study indicate that the factors that cause the inability of the inpatient daily census to be conducted correctly are Man (misperception of the inpatient census daily officer between the understanding day of care with the length of stay, educational background of the officer not from the medical record, and the officer has never attended training on the census), Money (there is no funding budget for training implementation, Materials (census information system on billing system is not implemented, census recapitulation is still manual using paper forms and Microsoft excel), Method (Daily SOP for inpatient census has not been revised), Machine (census application on billing system is not implemented) Fishbone diagrams where the in-patient census daily activities are carried out correctly are mostly caused by Man factors and Materials factors.
Evaluasi Rekam Medis Elektronik Bagian Coding Rawat Inap RSUD K.R.M.T Wongsonegoro Kota Semarang Septina Dwi Indrawati; Ida Nurmawati; Indah Muflihatin; Syaifuddin Syaifuddin
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 4 (2020): September
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v1i4.2164

Abstract

RSUD K.R.M. T Wongsonegoro The city of Semarang became one of the type B hospitals in the city of Semarang, which have applied the electronic medical record gradually the application of electronic medical records assessed as an effort to improve the quality of services increasing patient satisfaction improves the documentation accuracy reduces clinical error and speeds up patient data access. (Billy Maria in Andriani DKK 2017). One of the service units that require the speed, accuracy and accuracy of access to patient data is the coding part of the hospitalization of the person who handled the medical record and coding (PJRM). In its implementation, there were constraints that made the officers less satisfied with RME. The purpose of this research is to evaluate RME implementation using the PIECES method (performance, information, economic, control, efficiency, service). This type of research is qualitative research, by conducting observation methods and interviews to PJRM officers. The results of RME evaluation conducted using the PIECES method on the performance/performance aspect, RME has already produced a good performance. Based on information/information aspect, RME can provide accurate information quality, according to user needs, and easy to understand. Based on Economy/economy, RME has the value to be integrated with one hospital and have qualified resource. Based on Control/control aspect, RME has good integrity and security because it comes with username and password, has different permissions. Based on the Efficiency/data efficiency aspects of RME can be easily learned, operated, and processed. Based on the Service/service aspect: RME users feel that RME provides convenience for RME users. In conclusion, RME in the coding part of inpatient is good enough in terms of Performance, Information, Economy, Control, Efficiency and Control. The advice that can be given is to make improvements and development on RME to avoid errors, regulatory or regulation regarding steps when errors occur, as well as conducting socialization or training to RME users.
Tinjauan Pelepasan Informasi Rekam Medis Berdasarkan Aspek Hukum Keamanan dan Kerahasiaan Rekam Medis untuk Pendidikan di RSUD Sleman Futari Ayu Istikomah; Feby Erawantini; Dony Setiawan Hendyca Putra
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 4 (2020): September
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v1i4.2169

Abstract

Regional general hospital of sleman (RSUD) is a hospital located in Sleman Regency with type B education. As a teaching education, Sleman District Hospital often borrows medical records for research (Education) related to the release of medical record information with third parties necessary. Because the character of medical record documents and their contents are confidential, the hospital must guarantee the confidentiality of the contents of the medical record file and legal protection for patients and hospitals. This research was aimed to find out how the release of medical record information based on legal aspects of the security and confidentiality of medical records for education in Sleman Hospital. This type of research is qualitative by collecting data using interviews, observation and documentation. The results of research at the Sleman Hospital in the application of releasing medical record information for educational purposes in the Sleman Hospital are still not by existing regulations related to the unavailability of expedition books or medical record file borrowing books where the book is very important in knowing the existence of medical record files that come out. And a special place for researchers when researching medical record files is not yet available due to limited space in the medical record unit of Sleman District Hospital.
Pendekatan Sistem Dalam Pengelolaan Rekam Medis di Rumah Sakit Mitra Sehat Situbondo Tias Agustin Ayuningrum; Rossalina Adi Wijayanti; Atma Deharja; Maya Weka Santi
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 4 (2020): September
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v1i4.2199

Abstract

Pengelolaan rekam medis di Rumah Sakit Mitra Sehat Situbondo kurang optimal. Hal tersebut dibuktikan pada Juni 2019, terjadi ketidaklengkapan pengisian rekam medis di bagian assembling sebesar 66,67%. Selanjutnya, pada bagian coding terjadi pengembalian klaim BPJS pada triwulan 1 tahun 2018 sebanyak 131 berkas. Selain itu, pada bagian filling ditemukan bahwa ruang penyimpanan tidak cukup untuk menampung dokumen rekam medis, sehingga ada dokumen yang ditumpuk di lantai. Tujuan penelitian ini menganalisis pengelolaan rekam medis melalui pendekatan sistem. Jenis penelitian ini adalah kualitatif dengan teknik pengumpulan data wawancara, observasi, dan dokumentasi. Subjek penelitian yaitu kepala rekam medis, petugas assembling, petugas coding, dan petugas filling. Penelitian ini menggunakan metode USG untuk prioritas masalah. Hasil penelitian didapatkan bahwa jumlah petugas rekam medis masih kurang dan ada petugas yang tidak berkualifikasi pendidikan rekam medis, serta ada petugas yang belum mendapatkan pelatihan. Hasil penelitian juga didapatkan bahwa buku ekspedisi rawat inap dan komputer untuk pelaporan belum tersedia. Selain itu, ruang penyimpanan terasa panas dan jumlah rak penyimpanan masih kurang. Standar prosedur operasional rekam medis juga kurang disosialisasikan. Hasil penelitian pada proses assembling ditemukan terjadi ketidaklengkapan pengisian rekam medis. Selain itu, pada proses coding terjadi kekosongan pengisiandiagnosa dan tindakan serta tulisan dokter tidak terbaca. Hasil dari prioritas masalah dapat disimpulkan bahwa yang menjadi masalah utama dalam pengelolaan rekam medis adalah kurang optimalnya fasilitas filling, dimana ruang penyimpanan terasa panas dan rak penyimpanan masih kurang. Saran yang diberikan adalah melakukan pengadaan AC dan pencatatan grafik suhu ruangan secara rutin serta meningkatkan dukungan manajemen dalam penyediaan rak penyimpanan.
Analisis Prioritas Penyebab Belum Terlaksananya Retensi dan Pemusnahan Dokumen Rekam Medis Rawat Inap di RS Mitra Medika Bondowoso Tahun 2019 Futari Ayu Istikomah; Novita Nuraini; Feby Erawantini; Efri Tri Ardianto
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 4 (2020): September
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v1i4.2212

Abstract

Regulation of health ministry 2018 number 269 on Medical Record stated that the records of medical patient care inpatient in hospital must be kept at least five (5) years on a period since the date of the last patient treated or discharged. Since the Mitra Medika Bondowoso Hospital was found in 2011 the implementation of retention and destruction of medical record documents has never been carried out. This research was aimed to analyze and know the priority cause unimplementation retention and destruction of documents recording the medical -patient hospitalization by USG (Urgency, Seriousness, and Growth) and brainstorming in Mitra Medika Bondowoso Hospital. Type of this research is that qualitative and the technique collection of data by interviews, observation, documentation, and brainstorming. The results were obtained that the priority of the cause unimplementation of retention and destruction of documents medical record that is the double job of the medical record employees, Retention archive schedule in SOPs, and a lack of understanding of the medical record employees with SOP retention and extermination. The improvement efforts for the problems are to add more medical record employees and to build more teamwork between the employees. Another solutions are to make new SOP recently with the addition of the retention archive schedule as well as involving the employees in the preparation of SOPs.
Pembuatan Sistem Informasi Rekam Medis Bagian Filing di Rumah Sakit Citra Husada Kabupaten Jember Muzaffatul Hasan; Sustin Farlinda; Feby Erawantini; Andri Permana Wicaksono
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 4 (2020): September
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v1i4.2221

Abstract

The  Filing medical records information system is a computerized information that can also be used to help medical records officers in the filing unit when borrowing and returning medical record files and to help them when doing a retention. Filing information system at Citra Husada Hospital, of Jember Regency is still using a manual system for recording the loan file of medical record and also there is no recording date system for returning medical record file. The purpose of this study was to design and create a medical record information system for the filing section at Citra Husada Hospital, Jember Regency using the waterfall method. Data collection uses interviews, observation and FGD (Focus Group Discussion). In the process of designing this system using a Flowchart System, Context Diagrams, Data Flow Diagrams, Entity Relationship. Digram and in implementing programs using Microsoft Visual Basic 2010. The results of this study are the making of a medical record information system for filing to facilitate officers in controlling medical record documents in filing through borrowing, repayment and retention. The next researcher is expected to be able to integrate with the existing SIMRS so that filling in the medical record data can automatically appear when in the filing section
Analisis Beban Kerja Petugas Rekam Medis Dengan Menggunakan Metode Wisn dan Fishbone di Puskesmas Ambulu Tahun 2019 Raisa Putri Ramadhani; Rinda Nurul Karimah; Nugroho Setyo Wibowo; Andri Permana Wicaksono
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 4 (2020): September
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v1i4.2228

Abstract

The existing problem that related to workload of medical records officer in Primary Health Care of Ambulu there are never done the analysis and evaluation, more over since 2018 medical record unit and registration unit splinted into two unit to be on one’s own. This research that intend to do the analysis workload of medical record officers therfore be discovered the level of workload of officer with WISN (workload indicator staff need) methode. If ther is already known the workload of medical record officers the next is an analysis of causative factors of workload was carried out with  fishbone methode with approach of  5M (man, money, methode, material, mechine) and then the next with FGD (focus group discusion) to determine the main priority that caused workload so that improvements of workload can be made. The type of this research is a qualitative with collecting data tecnic in the form of observation, interview, documentation, and FGD. The subject of this research are 3 medical record officer, there are 1 medical recorder and 2 medical recorder helper. The based on this research workload analysis the job description is well done because in the job description there is no division of tasks according to posisition so completion of the task have done together. The result of the calculation of workload is knowing the amount of officer needs the results obtined ideal number of officers there are 4,85 there for be rounded to 5 so the conclusion is the workload in the unit medical record is high with rhe total 0,6. The efforts to improve the workload including addition of human resources and the held of training thus increasing the knowledge and skills of officers.

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