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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 6 Documents
 1 
Search results for , issue "Vol 3 No 3 (2022): June" : 6 Documents clear
PEDOMAN FORMAT DOKUMENTASI PENGKAJIAN KEPERAWATAN ORANG DENGAN GANGGUAN JIWA (ODGJ) Ike Puspa Adityas; Dony Setiawan Hendyca Putra
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 3 No 3 (2022): June
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v3i3.2453

Abstract

Mental assessment is process of collecting data systematically documenting determine health status of people with mental disorders. Mental assessment documentation format must provided based on needs of health service facility and should pay attention to guidelines for design aspects of the documentation format covering physical, anatomical, and content aspects. Study aims produce documentary format guideline for assessment people with mental disorders based on standard design documentation format. Study used the literature review method using 14 articles with combination of the theme form design article and mental nursing assessment. The technique of collecting data by collecting articles through academic repositories and then applying reselection articles using inclusion and exclusion criteria. Results of study, physical aspect use HVS 70 gram, portrait orientation rectangle shape, A4, white paper with black ink. Anatomical aspect, there a heading that explains the identity of agency and identity of format including title of the documentation format, the introduction is included in the title format, the instruction is placed at the bottom left of format, body includes grouping, type and size of letters, color, margins, line spacing, and how to fill in. Close is approval room containing signature and name. Content aspects consist items of identity, reasons for entry, predisposition, physical examination, psychosocial, mental status, social relationships, preparation for going home, coping, spiritual, psychosocial and environmental, knowledge, medical aspects, nursing problems, and additional information. Research suggestions, the format of the mental disorders nursing assessment documentation can be used as a reference guide in health service agencies
TINJAUAN KELENGKAPAN PENGISIAN SERTIFIKAT PENYEBAB KEMATIAN DI RUMAH SAKIT : LITERATURE REVIEW Fitriani Fitriani; Ervina Rachmawati; Novita Nuraini; Indah Muflihatin
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 3 No 3 (2022): June
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v3i3.2526

Abstract

The death cause's certificate is used to document the major cause of the death and to identify the mortality circumstance that used to inform about the health policy and to enhance the strategy of the death prevention and recording. The purpose of this study is to investigate the percentage of completeness towards the filling of the cause of death certificate and to know the factor causing the incompleteness towards the filling of the death cause's certificate. This type of study is the literature review with 11 selected journals according to the inclusion criteria. There are four components in the analysis of the completeness towards the filling of the death cause's certificate namely, patient identification, important report, author authentication, and good recording. In the result of the study, the lowest percentage component was found in the important report at 55.96% and the highest percentage component was found in the author's authentication at 93.72%. The most dominant factor in the incompleteness towards the filling of the death cause's certificate is due to the absence of SOP and the excessive number of components in the death cause's certificate. The suggestion for future researchers is they might redesign the death cause’s certificate by attaching the sections or columns as needed.
EVALUASI KEBERHASILAN IMPLEMENTASI SIMRS DI RUMAH SAKIT X KABUPATEN JEMBER DENGAN PENDEKATAN METODE TTF Suhartatik Suhartatik; Doni Setiawan Hendyca Putra; Sustin Farlinda; Andri Permana Wicaksono
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 3 No 3 (2022): June
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v3i3.2586

Abstract

X Hospital in Jember regency applies a hospital management system or hospital information system (SIMRS) since 2012. The results of a pilot study conducted by the researcher showed that there are still several issues in the implementation of hospital management information systems (SIMRS) including data mismatches and incomplete features. The objective of this study was to evaluate the success of the SIMRS implementation at X Hospital in Jember regency using the Task Technology Fit (TTF) theory. This study was quantitative research. Data collection techniques used questionnaires with a total of 54 respondents as the sample. The results showed that the identification of the TTF variable at the X Hospital in Jember regency showed that the Task Characteristic (TAC) had a total score of 80.1%, Technology Characteristic (TEC) had a total score of 77.5%, Task Technology Fit (TTF) had a total score. 78.17%, Performance Impact (PI) has a total score of 78.19%, and Utilization (U) has a total score of 80.25%. The suggestion proposed by the researcher regarding the above problems is that the hospital needs to make improvements and development of systems related to data consistency, feature completeness, and feature optimization in SIMRS according to user needs to increase the success of its implementation.
ANALISIS PENYEBAB KETIDAKLENGKAPAN PENGISIAN INFORMED CONSENT DI RSUD dr. ABDOER RAHEM SITUBONDO Irene Anjar Pratiwi; Efri Tri Ardianto; Atma Deharja; Indah Muflihatin
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 3 No 3 (2022): June
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v3i3.2601

Abstract

The incompleteness of informed consent in general surgery cases inpatients at dr. Abdoer Rahem Situbondo hospital has an increase every month in the first trimester of 2019. The highest increase occurred in March, which was 74% from the previous 64% in February. Based on the Minister of Health of the Republic of Indonesia No. 129 of 2008, the minimum standard for filling out informed consent is 100%. The purpose of this research was to analyze the factors causing the incomplete filling of informed consent in inpatient general surgery cases at Dr. Abdoer Rahem Situbondo using Simamora's performance theory. The type of this research is qualitative analysis. The research design used is action research. Data collection techniques used were interviews, questionnaires, documentation, CARL (Capability, Accessibility, Readiness, Leverage), and brainstorming. The preliminary study was carried out from January to February 2020. Data collected were an inpatient general surgical case informed consent form, which had been returned to the medical record unit. The results obtained from this research are that there has never been an evaluation of informed consent’s incompleteness. No award was given for the performance of completeness informed consent. There has never been any learning such as a seminar or training on filling out the informed consent.
PERANCANGAN DAN PEMBUATAN REKAM MEDIS ELEKTRONIK BERBASIS WEB DENGAN MEMANFAATKAN QR CODE DI PUSKESMAS KARYA MAJU KABUPATEN MUSI BANYUASIN Detty Artin Meirina; Sustin Farlinda; Feby Erawantini; Muhammad Yunus
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 3 No 3 (2022): June
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v3i3.2607

Abstract

Information technology provides many conveniences in the management and can process data and information, then distribute it more efficiently, flexibly, and accurately. Information technology is also adopted in the health sector to produce information in making a decision relating to the management of health services and to support the implementation of health development managed by health information systems. Data and information on health information systems are obtained from medical records documents, so medical record documents must have good quality information. The problems found at Puskesmas Karya Maju are a manual recording of medical record documents. Sometimes, officers have difficulty finding medical records documents because the officer mistakenly put the medical record documents into their places, leading to a lack of quality of the resulting data information. This research aims to design and create web-based electronic medical records with the QR Code, which are expected to overcome the problems arising from the manual recording and processing of medical records. The type of research used is qualitative research with the Waterfall system method consisting of analysis, design, coding, and testing. Data collection techniques using interviews, documentation, and observations. The result of web-based electronic medical records equipped with QR Code is when the patient comes back for treatment, and the patient does not need to bring KIB. The patient needs to bring a smartphone that has been logged in with the patient’s account, and the officer will scan the QR Code to find the patient’s identity and medical records.
Faktor Penyebab Keterlambatan Waktu Pengembalian Berkas Rekam Medis Pasien Rawat Inap Faizah Wardhina; Nina Rahmadiliyani
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 3 No 3 (2022): June
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v3i3.3164

Abstract

The activity of returning medical record files for inpatients at Mawar Hospital has a standard return time of 1 x 24 hours after the patient returns. Medical records that experience delays in returning will have an impact on the delay in data processing, delays in submitting insurance claims, and delays in service to patients. The purpose of this research was to determine the factors causing the delay in returning inpatient medical record files at Mawar Hospital. The research method used is qualitative. The research subjects were the head nurse of the inpatient room and the head of the medical record, also called the main informant. In this study, the validity of the data was also carried out by triangulation to other informants, an inpatient nurse. The conclusions of this study are the factors that cause delays in returning the medical record files of inpatients at Mawar Hospital: man factor are doctors or nurses, the material factor is an incomplete filling of medical record files, the method factor is incomplete standard operating procedures, the money factor is no budget for granting rewards for doctors or nurses in carrying out their duties.

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