J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan
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.
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<![CDATA[Tinjauan Pelaksanaan Pemeliharaan Dokumen Rekam Medis di Ruang Filling RSUP Dr. Sardjito ]]>
<![CDATA[Tias Agustin Ayuningrum]]>;
<![CDATA[Gamasiano Alfiansyah]]>;
<![CDATA[Sugeng Sugeng]]>;
<![CDATA[Sustin Farlinda]]>
<![CDATA[ J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 2 No 1 (2020): December ]]>
Publisher : <![CDATA[Politeknik Negeri Jember ]]>
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DOI: 10.25047/j-remi.v2i1.1983
<![CDATA[The implementation of maintenance medical record documents in RSUP Dr. Sardjito is not optimal. This statement was proven by the damage of medical record documents about 35,05%. The purpose of this research is to review the implementation of maintenance medical record documents uses management elements 5M (man, money, material, machine, and method). The research type is qualitative and the data collection techniques use interviews, observations, and documentations. The subjects of this research are filling officers. The result from man factor shown that filling officers have not received maintenance medical record documents training, meanwhile money factor shown that filling officers did not know about the budget management of maintenance medical record documents. The result from material factor show that the materials for medical records forms and folders have been provided optimally, meanwhile machine factor shown that the type of rack from combination of iron and wood was less suitable because it can made medical record documents were damage. The result from method factor show that standard operational procedure about implementation of maintenance medical record documents was not available. The solutions are giving socialization about implementation of maintenance medical record documents to filling officers, providing standard operational procedure about implementation of maintenance medical record documents, coating around the sharp part of rack using rubber tires that can prevent the damage of medical record folder.]]>
<![CDATA[Faktor Penyebab Ketidaklengkapan Pengisian Kode Diagnosa Rawat Jalan di RS Husada Utama ]]>
<![CDATA[Nabiilah Qurrota A'yun]]>;
<![CDATA[Rossalina Adi Wijayanti]]>;
<![CDATA[Gilang Nur Permana]]>;
<![CDATA[Ida Nurmawati]]>
<![CDATA[ J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 2 No 1 (2020): December ]]>
Publisher : <![CDATA[Politeknik Negeri Jember ]]>
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DOI: 10.25047/j-remi.v2i1.2001
<![CDATA[At present hospitals and paramedics prone to demands that demands the quality of service , lawsuits from a patient and the competitors in the same because of that required to improve the quality and keep the quality of health services at the hospital .One parameter to determine the quality of health services at the hospital is data or information from medical record good and complete , both the contents , accurate , timely and working persayaratan legal aspects .Based on working practices roomy implemented in february to march obtained hasill that incomplete filling out of code diagnose on medical record outpatient husada surabaya hospital main reach 100 % it is not in line with permenkes 269 year 2008 stating that document completeness medical record must be fully 100 %. A journal aims to understand the factors causing the incomplete filling out of the diagnosis code .Incompleteness this researched use the undirected behavior lawrence green with a variable presdiposing factors , enabling options factors , reinforcing factors .Incomplete filling out of the diagnosis code was conducted by interviews is not structured and observation activities directly when performing my roomy .The result of the report is affecting behavior because of the incomplete on charging the diagnosis code outpatient medical record husada hospital as much as the main the hospitals are required to carry out socialization of standard operating procedures aimed at the paramedics to be the remembrance of the content and doing the work of in accordance with the sop.]]>
<![CDATA[Analisis Penyebab Lama Penyediaan Berkas Rekam Medis Rawat Jalan di Puskesmas Mangaran ]]>
<![CDATA[Lutfiatun Nadibah Herman]]>;
<![CDATA[Rossalina Adi Wijayanti]]>;
<![CDATA[Atma Deharja]]>;
<![CDATA[Mochammad Choirur Roziqin]]>
<![CDATA[ J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 2 No 1 (2020): December ]]>
Publisher : <![CDATA[Politeknik Negeri Jember ]]>
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DOI: 10.25047/j-remi.v2i1.2031
<![CDATA[The provision of long-term patient outpatient medical record files in Mangaran Public Health Center is one type of service provided to patients. Based on pre-research survey, it known that the time for providing the medical record files that exceed the established standards is 17.70%. This researched aim is to analyze the caused factors of the long duration for supplying medical file records of long-term patient based on individual and situational factors which will the priority causes of the main problems using the Reinke method. This research is qualitative research. The results showed that long waited for supplying medical record files of long-term patient is the searching process of the medical file records that takes a long time due to the attitude of the officer while handling misfile is not optimal, there is no training related to the medical records, less detailed SOP registration does not contain the standard time to provide the medical file records and the absence of SOP to return the medical records, and also the computers that often error and unavailability of tracers in the storage room. In response to those factors, it is necessary to make an improvement and socialization about the registration SOP’s, requesting propose of the medical record file map/folders and the use of tracers, and also held a training specifically about the medical file records at least 2 or 3 times a year and also doing the computer maintenance at least once a month.]]>
<![CDATA[Analisis Perhitungan Kebutuhan Tenaga Kerja Petugas Rekam Medis Kiara Berdasarkan Teori WISN di RSUPN Dr. Cipto Mangunkusumo ]]>
<![CDATA[Adlien Fadillah]]>;
<![CDATA[Atma Deharja]]>;
<![CDATA[Jalahan Pandiangan]]>
<![CDATA[ J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 2 No 1 (2020): December ]]>
Publisher : <![CDATA[Politeknik Negeri Jember ]]>
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DOI: 10.25047/j-remi.v2i1.2071
<![CDATA[The increasing number of patients required higher of medical record services. It can affect on workload officers. It is known that every day there are 350-400 patients with 20 new patients who come for treatment at RSCM Kiara. One service achievement of 32% in January 2020 with priority KPI (Key Performance Indicator) is the provision of medical record files withput patient agreement up to poluclinic < 30 minutes, of the percentage should be 100%. Based on the pre survey at RSCM showed towards 6 Kiara RSUPN Dr. Cipto Mangunkusumo medical record officers, it can be inferred that the officers having a double job at the same time. The high workload that the officers experienced is a side effect from not having enough numbers of officers. It implies that the officers could have several problems, including physical fatigue. The purpose of this study was to determine the number of labor requirements based on WISN theory for the assembling and filling officer of Kiara RSUPN Dr. Cipto Mangunkusumo. This research using a qualitative method with 6 respondents. Based on the workload calculation using the WISN method, it is known that the number of workers needed in the assembling unit is 2 people and in the filing unit is 15 people. With the results of the calculations of labor needs based on WISN theory, it can be used as an effort to plan the addition of officers numbers in order to improve the quality of hospital services according to the existing workload.]]>
<![CDATA[Analisis Kerahasiaan Rekam Medis Berdasarkan Hak Akses Ruang Filing Rawat Jalan di RSUD Dr.Saiful Anwar Malang ]]>
<![CDATA[Eva Tri Wicahyanti]]>;
<![CDATA[Maya Weka Santi]]>;
<![CDATA[Rossalina Adi Wijayanti]]>
<![CDATA[ J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 2 No 1 (2020): December ]]>
Publisher : <![CDATA[Politeknik Negeri Jember ]]>
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DOI: 10.25047/j-remi.v2i1.2073
<![CDATA[Confidentiality of medical records at RSUD Dr. Saiful Anwar Malang still had several obstacles in implementation, where there were non-medical record officers who enter and exit the outpatient filing room although there was finger prints and written warnings stating that "other than medical record officers are prohibited from entering" in the outpatient filing section. The purpose of this report is to analyze the confidentiality of medical records based on the right of access to outpatient filing rooms at RSUD Dr. Saiful Anwar Malang. This report used qualitative methods, and the analysis method used is 5M management aspects (man, money, material, method, and machine) to identify the problems and look for priority causes use USG (Urgency, Seriousness, Growth) techniques. The results of this report indicate that the management aspects of man, method, material, and machine are the factors causing the lack of secrecy of the medical record based on the right of access to outpatient filing rooms at RSUD Dr. Saiful Anwar Malang. The priority cause of the problem in this report is the ignorance of officers in relation to the existing SOP / Medical Record Services Book. The priority results of the cause of the problem produce a solution, it are necessary to conduct socialization about SOP for storing medical records and Medical Record Services Book relating to the secrecy of medical records to all medical records officers, especially filing officers before being placed in their work units and evaluating every three months by monitoring the implementation of SOP /Medical Record Services Book by an outpatient filing coordinator.]]>
<![CDATA[Evaluasi Kinerja Petugas Distribusi Berkas Rekam Medis Rawat Jalan di RSUD dr. Saiful Anwar Malang ]]>
<![CDATA[Najla Kamil]]>;
<![CDATA[Dony Setiawan Hendyca Putra]]>;
<![CDATA[Feby Erawantini]]>;
<![CDATA[Niyalatul Muna]]>
<![CDATA[ J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 2 No 1 (2020): December ]]>
Publisher : <![CDATA[Politeknik Negeri Jember ]]>
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DOI: 10.25047/j-remi.v2i1.2077
<![CDATA[Patrang Health Center has implemented medical records management, but there are problems in the implementation of medical record management. when duplicating medical record numbers at Patrang Health Center. Duplication in the Patrang Community Health Center results in a decrease in the quality of medical records. The purpose of this study was to analyze the causal factors and determine the priority causes of duplicate medical record numbers at Patrang Health Center. This type of research is qualitative. The technique of collecting data in this study is observation of data duplication of medical records and interviews with respondents based on 7M indicators. Data processing with CARL criteria. The results of this study were found in studies that found the main priority of less useful duplication of the medical record number on the medical record data map with a score of 144. Further problems were officers, filing space was less extensive, filing shelves were inadequate and patients did not carry KIB with a score 108. With the discovery of priorities leading to duplication, the study provides the main solution that discusses the medical record number written on the front and sides of the file as well as other solutions to overcome the problem and made a draft policy to reduce the incidence of duplicate medical record numbers that have been approved.]]>
<![CDATA[Faktor Penyebab Ketidaklengkapan Rekam Medis Rawat Inap di RSUD dr. Saiful Anwar Malang ]]>
<![CDATA[Ana Nafidatul Khoiroh]]>;
<![CDATA[Novita Nuraini]]>;
<![CDATA[Maya Weka Santi]]>
<![CDATA[ J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 2 No 1 (2020): December ]]>
Publisher : <![CDATA[Politeknik Negeri Jember ]]>
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DOI: 10.25047/j-remi.v2i1.2080
<![CDATA[One of efforts to improve the quality of healthcare facilities is to improve the quality of medical record services including completeness, speed and accuracy in providing information for health care needs. A complete and accurate medical record can be used as a reference to health services, legal bases, supporting information to improve medical quality, medical research and be used as a basis to assess the performance of hospitals. The purpose of this research identifies the factors causing the incompleteness of the replenishment of inpatient medical record in the RSUD Dr. Saiful Anwar Malang. The type of research used is qualitative. Data collection techniques by way of document study, interviews and observation. Document studies are conducted on 100 inpatient medical record documents that have not been conducted assembling, while the interview is conducted to the IRNA 2 medical record officer to determine the factors causing the incompleteness of medical record documents. Observation is done to complete the interview data. The results of the analysis on 100 inpatient medical record files were obtained that the incomplete number of medical records was 79%, with the most incompleteness presentation on the responsibilities of the doctor which includes medical resumes, casemix sheets, and surgery reports. The interview and observation results show that the main causation factor for the filing of an inpatient medical record of a surgical ward is from the doctor's awareness and discipline in filling in the medical record documents. As a solution to improve the completeness of medical record filling is by spur motivation and increase the discipline of doctors in filling medical record documents by providing reward and punishment and to repair SOP filling medical record of hospitalizatio.]]>
<![CDATA[Analisis Risiko Kerja pada Petugas Koding Rawat Jalan di RSUP Dr. Kariadi Semarang ]]>
<![CDATA[Irda Nazia Safitri]]>;
<![CDATA[Feby Erawantini]]>;
<![CDATA[Mochammad Choirur Roziqin]]>
<![CDATA[ J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 2 No 1 (2020): December ]]>
Publisher : <![CDATA[Politeknik Negeri Jember ]]>
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DOI: 10.25047/j-remi.v2i1.2106
<![CDATA[Outpatient coding of RSUP Dr. Kariadi has an average of 240 file targets to be coded for each officer, coding activity can trigger work risks such as stress, loss of concentration and illness due to work fatigue. The purpose of this study was to Analyze the occupational risks of outpatient coding officers in RSUP Dr. Kariadi Semarang. This type of research is a descriptive study with an interview and observation approach. The object of this study was outpatient coding officer in RSUP Dr. Kariadi. The results showed that the risks in outpatient coding officers there are 5 risks that can occur. Risks regarding workplace accidents as well as work system risks can be found in outpatient coding. The solution is to create an SOP on the safety of outpatient coding officers.]]>
<![CDATA[Studi Literatur : Faktor Penyebab Ketidakpuasan Pasien di Pelayanan Pendaftaran Rawat Jalan RSU Haji Surabaya 2020 ]]>
<![CDATA[Agni Candramawa Sholikha]]>;
<![CDATA[Rossalina Adi Wijayanti]]>;
<![CDATA[Novita Nuraini]]>
<![CDATA[ J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 2 No 1 (2020): December ]]>
Publisher : <![CDATA[Politeknik Negeri Jember ]]>
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DOI: 10.25047/j-remi.v2i1.2112
<![CDATA[Patient satisfaction is the result of the patient's assessment of the service received based on truth and reality that is then compared to his expectations. The results of observations made by researchers at Surabaya Haji Hospital based on medical record data on the number of outpatients visiting Surabaya Haji Hospital in January to March 2020 there is a decrease in the number of outpatient visits each month. The purpose of this study was to determine the level of patient satisfaction in the outpatient registration at RSU Haji Surabaya. This study uses a literature review method of 10 journals using measurement techniques of 5 dimensions of health service quality, namely tangibles, reliability, responsiveness, assurance, and empathy. The results of the literature review indicate that the satisfaction of the quality dimension is considered the most satisfied is the dimension of assurance and reliability, while the highest dimension of dissatisfaction is the dimension of tangibles and empathy.]]>
<![CDATA[Desain Rak Penyimpanan Berkas Rekam Medis di Rumah Sakit Universitas Airlangga Surabaya ]]>
<![CDATA[Day Rahmania]]>;
<![CDATA[Andri Permana Wicaksono]]>;
<![CDATA[Novita Nuraini]]>
<![CDATA[ J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 2 No 1 (2020): December ]]>
Publisher : <![CDATA[Politeknik Negeri Jember ]]>
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DOI: 10.25047/j-remi.v2i1.2113
<![CDATA[Filling room has an important role in maintaining medical records, especially in terms of storage and protection of medical records. The creation of officers ease in taking and storing medical records in supported by the existence of an ergonomic storage space that is adapted to the anthropometric aspects. The design of the storage rack in accordance with the anthropometric data of the officer can facilitate the work of the officers. Storage racks at Airlangga University Hospital are not in accordance with the anthropometry of the officers, resulting in work discomfort and fatigue. The purpose of this study was to analyze the ergonomics aspects of the storage rack based on the anthropometry of the filling officer. This type of research is descriptive and data collection is done by observation. The population of this study was 5 filing officers. The results of this study indicate that the condition of the storage rack in the filling room of the Airlangga University Hospital is not in accordance of the filling officer. The anthropometry of the filling officer used in designing the rack, namely the reach of the hand up to 202 cm, is used to measure the height of the medical record file storage rack, data fathom length 162 cm is used to reference the length of the medical records file storage rack and shoulder width data used to reference the distance between medical record file storage rack.]]>
