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Muhammad Yunus
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m.yunus@polije.ac.id
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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 23 Documents
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Search results for , issue "Vol 2 No 1 (2020): December" : 23 Documents clear
Analisis Penyebab Keterlambatan Pengembalian Berkas Rekam Medis Rawat Jalan di Rumah Sakit Mitra Medika Bondowoso Adlien Rizqo Fadillah; Novita Nuraini; Feby Erawantini; Ervina Rachmawati
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 2 No 1 (2020): December
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v2i1.2213

Abstract

The delay in returning medical record file can affect medical record service and will hampered further activities, such as assembling, coding, analysis, or index activities. The return of outpatient medical records in Mitra Medika Bondowoso Hospital is still experiencing delays. In the first quarter of 2019 the total number of late outpatient medical records was 871 out of 7404 files or 11.76%. The purpose of the study was to analyze the causes of the delay in returning the outpatient medical record file at Mitra Medika Hospital. This research using qualitative research. To gather all of the important data the researchers using various techniques such as interview, observation, and documentation. The subjects of this study were 1 head of medical record, 1 medical record officer, and 5 poly nurses. The results of this study that there was still lack of knowledge and attitude, inadequate infrastructure or facilities. There was no motivation given by the head of the medical record, and the SOPs about the returning of outpatient medical record files had never been socialized. Things that can be taken are making an efforts to socialize SOPs to increase knowledge of health professionals, giving a warning from the head of medical records to nurses who are late returning medical record files, redesigning outpatient expedition books, providing work motivation and updated SOPs related to returning medical record files outpatient.
Analisis Faktor Penyebab Ketidaklengkapan Rekam Medis Pasien Rawat Inap di Puskesmas Kotaanyar Dian Fadilah Ayu Lestari; Indah Muflihatin
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 2 No 1 (2020): December
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v2i1.2217

Abstract

Based on the results of a preliminary study conducted at the Kotaanyar Public Health Center, 30 medical records of inpatients in April and May 2019 are known, which were identified based on patient identification, important reports and their authentication, the average overall number of incompleteness was 720 (53.08%). The incompleteness of the medical record has an impact which results of administrative and clinical data are not accurate, This incompleteness also creates a loss in fulfilling the patient's right to the contents of their medical record, obstruction of reporting activities and submission of claims and cause the quality of health services are low. This study aims are to analyze the factors causing incomplete medical records of inpatients, determining priority causes of problems using USG (Urgency, Seriousness, Growth) and remedial efforts are using brainstorming. This type of research uses qualitative and data collection by observation, interviews, questionnaires and documentation. The results obtained that the priority cause of the incomplete medical records problem of inpatients are there is no SOP (Standard Operational Procedure). Efforts to fix the problem are making SOP, put the SOP in the inpatient unit where it can be reached, conduct socialization at any time and renew SOP according to the SOP renewal agreement.
Desain Formulir Pendukung Surveilans Infeksi Nosokomial di Rumah Sakit Baladhika Husada Jember Ana Nafidatul Nafidatul Khoiroh; Rinda Nurul Nurul Karimah; Ida Nurmawati
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 2 No 1 (2020): December
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v2i1.2249

Abstract

Nosocomial infections if not reported will affect the quality of service and patient satisfaction. This happened at Baladhika Husada Hospital in Jember, namely the absence of a surveillance form for nosocomial infection. This form is important as evidence in determining accreditation standards because accreditation requires documentary proof in writing. This study aims to design an infection surveillance support form based on SNARS edition 1 of 2017. The type of research used in this study is the Research & Development study to design a support form for nosocomial infection surveillance. Data collection techniques using interview, observation, and brainstorming techniques. The subjects of this study were medical record officers, doctors, nurses, PPI, and SNARS accreditation team. This research resulted in identification of the physical aspects of the paper used is F4 paper with a weight of 70 gr and white. The anatomical aspects used on the form are the head of the form located at the top, there are instructions on the form, the font used is arial with a space of 1.15. The content aspect consists of completeness of items, sorting of items, grouping of items, abbreviations, symbols and ways of filling have been adapted to other forms and user needs. The results of this study are in the form of designs that are expected to be used for consideration in planning a form, especially infection surveillance forms. So that the hospital is easier in carrying out recording and reporting activities regarding nosocomial infection surveillance.

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