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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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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 275 Documents
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ANALISIS FAKTOR RISIKO PADA PENYAKIT KARSINOMA PARU (C34) PASIEN RAWAT INAP DI RUMAH SAKIT BALADHIKA HUSADA JEMBER Salma Firyal Nabila; Dony Setiawan Hendyca Putra; Sustin Farlinda; Efri Tri Ardianto
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 2 No 2 (2021): March
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v2i2.2197

Abstract

Lung carcinoma or commonly known as lung cancer is one of the main causes of death from disease in theworld that reach 7.6 million deaths or about 13% of all cancer diagnoses. Baladhika Husada Jember Hospitalis a third-level hospital in Jember Regency that has oncology and chemotherapy services including a cancerdiagnosis. Based on existing data of the morbidity and mortality rates of pulmonary carcinoma are alwaysincreasing from 2016 until 2018. This study aims to analyze the risk factors for lung carcinoma such as age,gender, smoking history, genetic history, and predisposition of other lung disease based on medical records ofinpatients with the pulmonary disorder at Baladhika Husada Hospital in Jember. The research method usedquantitative analysis with a cross-sectional research design. The number of samples was 98 respondents.Data analysis used the chi-square test for bivariate and the logistic regression test for multivariate. Thebivariate analysis result shows that each independent variable had an influence on lung carcinoma cases.Multivariate analysis shows that the variable had a simultaneous influence (p value=0,000). Partially, eachvariable has an influence, age (p value=0,003), smoking history (p value=0,003), genetic history (pvalue=0,002), predisposition of other lung disease (p value=0,000), except on genders (p value=0,857). Theconclusion is the risk factors can explain the effect on the incidence of pulmonary carcinoma by 84.8%. Thisresearch is expected to be used as information to cope with the increased morbidity and mortality rates ofpulmonary carcinoma.
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.
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.
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.
ANALISIS FAKTOR KINERJA PENGISIAN DOKUMEN REKAM MEDIS RAWAT INAP KLINIK dr. M. SUHERMAN JEMBER Aditya Dwi Arimbi; Selvia Juwita Swari; Novita Nuraini; Indah Muflihatin; Gamasiano Alfiansyah
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 2 (2020): March
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v1i2.2238

Abstract

Percentage of incompleteness of filling in the medical records of the Clinic Dr. M. Suherman shows thatthe Minimum Service Standards in the Hospital are not yet 100%. Incomplete data has shown that thecompleteness of filling medical record documents is still not in accordance with the specified standards.The incompleteness of filling out the medical record document may be caused by the performance factorof the officer in completing the inpatient medical record document. The purpose of this study is to analyzethe performance factors in filling out the record documents. The purpose of this study was to analyze theperformance factors in filling out medical records of inpatients at the Clinic dr. M. Suherman Jember. Thisstudy uses qualitative research that aims to identify and analyze performance factors in filling inpatientmedical record documents at the Clinic dr. M. Suherman Jember, who will be associated with performancetheory with personal factors, leadership factors, team factors, system factors, and situational factors, andusing the USG (Urgency, Seriousness, Growth) method to determine the main factors of the 5 factors thataffect performance as well as efforts to correct problems using brainstorming. The results of this studyobtained priority causes of the incompleteness of filling medical records documents for inpatients at theClinic dr. M. Suherman Jember is the lack of awareness of each individual related to filling medical recorddocuments, lack of evaluation and monitoring, lack of socialization, lack of understanding related to SOPfor filling medical record documents because there is no SOP for filling medical record documents, so theClinic, Dr. M. Suherman asked researchers to make SOPs for filling in the records of inpatients. As asuggestion, do a commitment to complete the completeness of filling medical record documents, conductsocialization, evaluation and routine monitoring, as well as making SOP for filling medical recorddocuments.
SISTEM INFORMASI PEMINJAMAN DAN PENGEMBALIANREKAM MEDIS DENGAN BARCODE DAN NOTIFIKASI WHATSAPP DI RUMAH SAKIT WIJAYA KUSUMA LUMAJANG Hayu Ning Widyastuti; Andri Permana Wicaksono; Sustin Farlinda; Ervina Rachmawati
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 2 (2020): March
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v1i2.2239

Abstract

The medical record file control activity at Wijaya Kusuma Lumajang Hospital has not been well implemented.This is evidenced by the absence of the use of tracers as a substitute for files that leave the medical recordrack and the use of expedition books only on borrowing inpatient medical record files. This study aims todesign and create a medical record lending and return information system with a barcode and web-basedWhatsApp notification at Wijaya Kusuma Lumajang Hospital that produces patient labels, tracers, reports onborrowing and return of medical records. This type of research is the development of a prototype method withqualitative data collection techniques in the form of interviews, observation, documentation, and brainstorming.The stages of the prototype method include analyzing user needs, making prototypes, adjusting prototypes tothe user's wishes, creating new systems, testing systems, adjusting the system to the user's wishes, andusing the system. The results of this study are information systems for borrowing and returning medicalrecords with a web-based barcode and WhatsApp notification system that facilitates the process of trackingfiles and overcoming problems in the process of borrowing and returning medical records
ANALISIS KUALITATIF DOKUMEN REKAM MEDIS RAWAT INAP PADA PASIEN TUBERKULOSIS PARU Novita Nuraini; Demiawan Rachmatta Putro Mudiono; Mitha Audia Rachma
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 2 (2020): March
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v1i2.2240

Abstract

Qualitative analysis is a review of filling medical records relating to the consistency of the contents of the medicalrecord. A good medical record must contain complete medical records. This study aims to analyze qualitativeinpatient Medical Record Documents (DRM) in pulmonary tuberculosis patients in Tongas Probolinggo RegionalHospital in the first quarter of 2017. This research type is descriptive with a qualitative approach with datacollection techniques of observation and interviews. The results of this study are that there are still documentson pulmonary tuberculosis medical records at Tongas Probolinggo Regional Hospital which are still incompleteand inaccurate. One of them is in the administrative qualitative analysis, which is the incomplete patient addresswriting100%, because nurses pay less attention and remind patients / guardians in filling out informed consentsheets. In addition, medical staff did not apply 100% of the writing of the tuberculosis standard abbreviationcontained in the SOP of the Tongas Hospital Standard Standard, because there was still a lack of socializationfrom the RM unit to medical personnel related to the use of the tuberculosis standard abbreviation. In aqualitative medical analysis, there were no X-ray examination results on patients who had X-ray examinationsas many as 19 documents, because in Tongas Regional Hospital did not have an examination result sheet, sothe results of the examination were not written in the DRM. So the quality of DRM in patients with pulmonarytuberculosis both administratively and medically is still not good. It is better if the accuracy and discipline ofmedical staff are needed in filling DRM

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