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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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EVALUASI PENERAPAN SISTEM INFORMASI MANAJEMEN RUMAH SAKIT DENGAN MENGGUNAKAN METODE TAM Nindhiya Dwi Pratiwi
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 2 No 4 (2021): September
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v2i4.2476

Abstract

Pengembangan sistem informasi kesehatan dilakukan melalui kegiatan perencanaan sistem, analisis sistem, perancangan sistem, pengembangan perangkat lunak, penyediaan perangkat keras, uji coba sistem, implementasi sistem, serta pemeliharaan dan evaluasi sistem (Peraturan Pemerintah, 2014). Namun beberapa penelitian menunjukkan adanya permasalahan pada penerapan sistem informasi yang terdapat di rumah sakit. 38 % penerapan SIMRS yang tidak sesuai berdampak pada keputusan yang diambil oleh pihak rumah sakit menjadi tidak tepat. Tujuan dari penelitian ini adalah mengevaluasi hubungan antar variabel TAM (Technology Acceptance Model) serta perbedaan dan persamaan hasil penelitian evaluasi penerapan SIMRS pada 13 artikel. Metode yang digunakan adalah literature review. Dari hasil pencarian ditemukan 13 artikel yang sesuai dengan kriteria inklusi dan kriteria eklusi. 75 % hasil penelitian menunjukkan pengaruh yang positif antara perceived usefulness terhadap attitude toward using. 70 % hasil penelitian menunjukkan adanya pengaruh yang positif dan signifikan antara perceived usefulness terhadap behavioral intention to use. 78 % menunjukkan adanya pengaruh yang terjadi antara attitude toward using terhadap behavioral intention to use. 87 % dari hasil penelitian menunjukkan hubungan antara behavioral intention to use terhadap actual system use. Hasil review menunjukkan 4 persamaan dan 5 perbedaan hasil penelitian evaluasi penerapan SIMRS dari penelitian terdahulu. Upaya yang dapat dilakukan untuk mengatasi hal tersebut diantaranya meningkatkan keterampilan pengguna dalam menggunakan teknologi, perlu adanya Standar Operasional Prosedur (SOP) mengenai pengoperasian sistem informasi, melakukan evaluasi SIMRS secara berkala, memberikan contoh kepada para staff agar menumbuhkan minat, menyiapkan tim IT yang handal.
TINJAUAN PENYEBAB KLAIM PENDING BADAN PENYELENGGARA JAMINAN SOSIAL (BPJS) KESEHATAN DI RSU HAJI SURABAYA Ariqpurna Bayu Triatmaja; Rossalina Adi Wijayanti; Novita Nuraini
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 3 No 2 (2022): March
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v3i2.2252

Abstract

Badan Pelaksana Jaminan Sosial (BPJS) Kesehehatan provide health services to the public by using a prospective payment system. Surabaya Hajj General Hospital is one of the type B educational hospitals that has been collaborating with the BPJS since 2014. Based on primary data at Surabaya Haji Hospital it was found that the claim file had pending claims. This is due to incomplete claim file, inaccurate diagnostic code due to differences in perception between the coders and verifiers. This study aims to analyze the pending claims factor of the Health Social Security Administration Agency (BPJS) at Haji Hospital Surabaya. Problem identification uses 5M management elements (man, material, methods, machine, money). This type of research is descriptive qualitative, narrating the results of the study. In the man element that causes the pending claim is the officer still feels difficulty in reading the diagnoses and actions of patients due to the writing of doctors who are difficult to read, and incorrect diagnosis codes and actions due to differences in perception between the coder and verifier of the BPJS. The material element that causes the pending claim is the incomplete claim file, such as the results of patient support examinations. In the Method element that causes pending claims, there is no SOP governing the filling of a specific diagnosis file claim. On the machine element that causes pending claims is the computer used in the claim submission process often experiences long loading times and often experiences network disruptions. In the element of money in this study does not cause pending claims, because casemix officers can not know the amount of loss caused by pending claims.
ANALISIS FAKTOR YANG BERHUBUNGAN DENGAN KELENGKAPAN RESUME MEDIS – LITERATURE REVIEW Nafa Maharani; Atma Deharja; Rossalina Adi Wijayanti; Dony Setiawan Hendyca Putra
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 3 No 2 (2022): March
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v3i2.2667

Abstract

A Medical resume is a summary of the whole medical patient's treatment. The incomplete medical resume can cause the patient's medical history to not continue with the patient's previous data. The various factors cause an incomplete medical resume. The research aimed to analyze the aspects related to the completeness of a medical resume. The study is a literature review with database from Google Scholar and Garuda. This research's keywords are factors related AND completeness OR complete AND medical resume OR medical resume OR discharge summary OR discharge summary. The manpower elements are 21,4 percent of good knowledge, 28,5 percent of long working tenure, 21,4 percent of civil servant employment status, 7,1 percent of good attitude, and 7,1 percent of higher education. The motivation elements are 14,2 percent of adequate supervision (monitoring and evaluation), 7,1 percent of good leadership, and 7,1 percent of reward and punishment. Media elements are 7,1 percent of how to pay for BPJS patients and 7,1 percent of directly related work conditions (unique table and chair to fill medical records) and other work environments (lighting and noise room to fill medical resumes). The main factor related to medical resume's completeness is tenure, and other high factors are knowledge and employment status. The writer suggests that health facilities should facilitate patient data completeness, especially for doctors with a new term, bad experience, and non civil servant employment status.
Analisis Sistem Informasi Pencatatan Ibu Hamil Di Kabupaten Jember Ilham Aditya Aji; Atma Deharja; Sustin Farlinda; Efri Tri Ardianto; Maya Weka Santi
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 3 No 2 (2022): March
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v3i2.2693

Abstract

The maternal mortality rate in East Java has increased over the last two years due to restrictions on antenatal care visits. In 2020 Jember Regency was ranked first in the maternal mortality rate (MMR) in East Java as many as 61 people out of 175.53 per 100,000 live births. The Jember Regency Government in 2017 has implemented an information system for recording pregnant women to suppress MMR in Jember Regency but currently, its use is not maximized because there are still obstacles such as users finding it difficult to use it. The purpose of this study was to analyze the information system for recording pregnant women in Jember Regency. This research is a quantitative study with a cross-sectional approach, this approach is used to see the relationship between one variable and another with the Technology Acceptance Model (TAM) method and the research subject is a midwife who uses information systems. The results of the study show that there is a significant relationship between the usability variable and perceived benefits (sig = 0.001, r = 0.483), privacy and confidentiality variables and perceived benefits (sig = 0.023, r = 0.879), and the perceived benefit variable on user intentions. (sig = 0.001, r = 0.468). The suggestion in this study is that the Health Service should make an SOP that requires users to use an information system for recording pregnant women for services to be more intensive and maximal in their use.
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
ANALISIS PENERIMAAN SIMRS DENGAN METODE TECHNOLOGY ACCEPTANCE MODEL DI RSD BALUNG KABUPATEN JEMBER Intan Winda Rohmatun Imamah; Eri Witcahyo; Sri Utami
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 3 No 2 (2022): March
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v3i2.2484

Abstract

SIMRS application is an important component in the application of medical record processing. In Balung Hospital, Jember, the application of SIMRS is still not running optimally, such as entering patient medical record data on SIMRS and the attitude of SIMRS users or admins who forget to enter patient data into SIMRS. This shows the attitude of users who lack awareness in using SIMRS. The purpose of this study was to analyze the acceptance of SIMRS, especially among SIMRS users in Balung Hospital using the Technology Acceptance Model (TAM) approach. The method used is analytic with cross sectional approach with interview and observation techniques. Analysis of research data using univariate analysis and bivariate analysis with simple linear regression. The results of this study show, there was an effect of Perceived Ease of Use on Attitude Toward Using SIMRS, there was an effect of Perceived Ease of Use on Perceived Usefulness, there was no effect of Perceived Usefulness on Attitude Toward Using, there was an effect of Perceived Usefulness on Behavioral Intention to Use SIMRS, there was an effect of Attitude Toward Using SIMRS on Behavioral Intention to Use SIMRS, and there was an effect of Behavioral Intention to Use SIMRS on Actual Usage of SIMRS. The suggestion of this research is that there is a need for regular monitoring and evaluation of the medical record unit and SIMRS in the use of SIMRS based on the performance of the user
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.

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