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Muhammad Yunus
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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 265 Documents
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Persepsi Pengguna Pada SIMRS Medify Berdasarkan Model DeLone dan McLean Agsari, Ardisa Lintang; Budi, Savitri Citra; Azizah, Delia Nur; Aulia, Farida Zulfi; Antika, Tabita; Palimirmaningtyas, Titah Winengku; Natalia, Dewi
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 5 No 4 (2024): September
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v5i4.4636

Abstract

The advancement of information technology has driven a new paradigm in healthcare service delivery. The implementation of Medify as a new Hospital Management Information System (SIMRS) at RSUD Wates is a response to government regulations regarding health data management and digital transformation in Indonesia. This study aims to analyze user perceptions of the Medify SIMRS. This research is descriptive with a quantitative approach. Data collection was carried out through interviews, observations, and questionnaires. The questionnaire guide uses the DeLone and McLean analysis model, which includes six variables. The study population involved medical record officers at RSUD Wates and other healthcare workers using medical records at the hospital. The study found that the highest user perception percentages were on six aspects: system quality at 50,0%, information quality at 51,5%, service quality at 49,2%, perceived satisfaction at 53.0%, perceived usefulness of the system at 41,7%, and system benefits at 53,8%. Most respondents agreed that the Medify SIMRS is implemented and used for services. The highest evaluation score interpretation was in the aspect of system quality and perceived satisfaction, with a value of 72.1%, which falls into the Good criteria.
Faktor-Faktor Yang Mempengaruhi Kepuasan Pengguna Sistem Informasi Manajemen Rumah Sakit (SIMRS) Rawat Inap di RSUD Dr Moewardi Wulandari, Dewi Septiana; Sutrisno, Trismianto Asmo; Sugiarsi, Sri
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 5 No 4 (2024): September
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v5i4.4764

Abstract

The Hospital Management Information System (called SIMRS) is an application used for managing all medical record data in hospitals. In the implementation of the SIMRS for inpatient services at Dr. Moewardi Hospital, there are still variables that need improvement, such as poor layout, inadequate color composition, and incomplete information.  The aim of this research was to determine the factors that influence the satisfaction of inpatient SIMRS users. The research design was an observational analytic study with a cross-sectional approach. The study population consisted of all 1,843 users of the inpatient SIMRS, with a sample size of 106 respondents. Data collection was conducted using a questionnaire, and data analysis was performed using multiple linear regression tests. The study results showed that the variables of content, accuracy, and timeliness have a partial influence on user satisfaction, while the variables of format and ease of use do not. Additionally, there was a simultaneous influence of the variables content, accuracy, format, ease of use, and timeliness on user satisfaction. The study suggests that periodic evaluation and improvement of the HMIS should be carried out to achieve optimal user satisfaction
RANCANG BANGUN REKAM MEDIS ELEKTRONIK PELAYANAN RAWAT JALAN BERBASIS WEB Amaliyah, Hikmah; Yunus, Muhammad; Roziqin, Muhammad Choirur; Pratama, Mudafiq Riyan
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 5 No 4 (2024): September
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v5i4.4781

Abstract

Patrang Health Center as a health facility that organizes medical records in supporting the provision of individual health services is carried out semi-manually and hasn’t implemented SIMPUS where the recording is still performed manually and assisted by using Google Sheet. The average number of daily visits that aren’t comparable to the staff available and haven’t optimized technology has hampered the process of providing medical records so it can affect the quality of service. This requires a system that can support the implementation of medical records so it can optimize the staff in providing outpatient services. This study aims to built an electronic medical record of outpatient services at the Patrang Health Center by using the R&D as a research type and using the Waterfall as a system development method which includes the phases of defining requirements, design system, implementation and testing the system using the Black Box testing method where the menus and functions are in accordance with user requirements and run successfully. The system has a menu to record registration activities, examinations, medicine data management and making reports so that it can improve the quality of officers in providing services.
Technology Readiness and Acceptance Model (TRAM) Pada Pengguna Rekam Medis Elektronik Andriani, Rika; Pertiwi, Julia; Nisaa, Arifatun
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 5 No 4 (2024): September
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v5i4.4795

Abstract

The highest proportion of electronic medical records (EMR) implementation in Indonesia is level 3. It is just used for administration. EMR can improve patient care management. EMR is used to record patient services at RSJD Dr. Arif Zainudin Surakarta. An evaluation was never carried out to assess the EMR system. Technology readiness and user acceptance are important for developing an effective and efficient EMR. This study aimed to analyze the interaction of technology readiness and user acceptance of EMR based on the Technology Readiness and Acceptance Model (TRAM). This was an analitic-quantitative research with a cross-sectional design study. Data from EMR users was collected with a structured questionnaire. Data was analyzed using descriptive statistical analysis and SEM-PLS. The finding showed that technology readiness has significant positive effects on perceived ease of use, perceived usefulness, and use intention; perceived ease of use has significant positive effects on perceived usefulness. Perceived ease of use and perceived usefulness do not have significant effects on use intention. To improve EMR acceptance, it is necessary to develop easier and more practical features.
Penyebab Pending Klaim Berdasarkan Aspek Diagnosis dan Ketepatan Kode Diagnosis Oktamianiza, Oktamianiza; Rahmadhani, Rahmadhani; Yulia, Yulfa; Ilahi, Vitratul; Putri, Kalasta Ayunda; Juwita, Fenty Salma
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 5 No 4 (2024): September
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v5i4.4884

Abstract

The pending BPJS claim occurred due to the rejection of the file by the BPJS health verifier. Problems with pending claims are caused by errors in determining the main diagnosis, incomplete diagnosis writing and code accuracy. This research aims to describe the causes of pending claims, including from the diagnostic aspect, namely the accuracy of the main diagnosis and the completeness of writing diagnosis as well as aspects of the accuracy of the diagnosis code. The research is descriptive in nature and the population is 35 medical records pending inpatient claims for 2023, the sample was determined by total sampling. The research data was analyzed univariately to determine the frequency distribution of causes of pending claims. The results of research on 35 pending claims showed that the accuracy of determining the main diagnosis was 19(54.3%), the accuracy of writing an incomplete diagnosis was 31(88.6%), and the accuracy of the incorrect diagnosis code was 29(82.9%). It is hoped that the doctor who is responsible for determining and writing the diagnosis can pay attention to the correctness of the diagnosis in the medical record and the coder can determine the correct diagnosis code based on ICD-10 and ICD-9 CM.
Pengembangan Modul Rekam Medis Elektronik (RME) Rehabilitasi Medik Rawat Jalan Jayanti, Asykar; Sugiarsi, Sri; Rohmadi, Rohmadi
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 5 No 4 (2024): September
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v5i4.4890

Abstract

The outpatient medical record documentation at RSUP dr. Soeradji Tirtonegoro already uses Electronic Medical Records (EMR), except for the Medical Rehabilitation clinic. This results in patient medical records data not being integrated into the EMR, requiring consulting doctors to access physical medical record files to view notes from the Medical Rehabilitation clinic. The aim of this research is to develop an electronic medical record system for outpatient medical rehabilitation. The research method used is Research and Development (R&D), with system development employing the Rapid Application Development (RAD) method. The outcome of this research is an electronic medical record module for outpatient medical rehabilitation, used by nurses, doctors, and therapists visiting the Medical Rehabilitation clinic to document patient records. It is recommended for future researchers to add a patient initial assessment module for nurses and doctors. It is also hoped that this system can be integrated with the billing system and digital claims, enabling the information system to be fully utilized in the services provided at the Medical Rehabilitation clinic.
Keakuratan Pemilihan UCoD Kasus Perinatal di Rumah Sakit X Tahun 2024 Amalia, Rizkiyatul; Aulia, Gaetsa Nurul
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 5 No 4 (2024): September
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v5i4.4915

Abstract

In 2023, there were 20 cases of perinatal death at Hospital X. Among these cases, 11 (55%) were reported with UCoD as asphyxia, 6 (30%) as low birth weight, 1 (5%) as anencephaly, 1 (5%) as pulmonary hypoplasia, and 1 (5%) as pulmonary aplasia. According to the perinatal mortality coding rules in ICD-10 volume 2, diagnoses of asphyxia and low birth weight or prematurity cannot be selected as the UCoD. This affects the accuracy of mortality reporting. The aim of this study is to describe the accuracy of UCoD selection in perinatal cases and the use of the Perinatal Mortality Surveillance System (SMPK) at Hospital X in 2024. This study uses a descriptive quantitative approach with a case study method. Data were collected through observations, document reviews, and interviews. The results show that 80% of UCoD selections were inaccurate, while 20% were accurate according to the perinatal mortality coding rules in ICD-10 volume 2. It can be concluded that the inaccuracy in UCoD selection for perinatal cases is due to the lack of proper implementation of mortality coding and the incomplete use of the SMPK.
Aplikasi Monitoring dan Evaluasi Analisis Kuantitatif Pada Formulir Resume Medis Digital Di SMC RS Telogorejo Semarang tahun 2022 Agiwahyuanto, Faik; Suyoko, Suyoko; Anjani, Sylvia; Abiyasa, Maulana Tomy; Prasetya, Jaka
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 5 No 4 (2024): September
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v5i4.4918

Abstract

Hospital accreditation standards require periodic reviews of medical records as part of performance improvement efforts, with review results being regularly reported to the Hospital Director. A preliminary survey in the Inpatient Department (IRNAP) at Telogorejo General Hospital, Semarang City, conducted from January to February 2022, showed that the implementation of electronic medical records (EMR) for inpatient services began on October 26, 2021. It was found that certain sections, especially in the discharge summary form, were not fully completed by doctors. This study aims to design and develop an application for monitoring and evaluating the quantitative analysis of digital medical discharge forms at SMC Telogorejo Hospital Semarang in 2022. The research employs a descriptive method, analyzing quantitative variables in the EMR. The study population consists of 1,826 inpatient medical records from 2021, with a sample of 183 records selected using purposive sampling. The result of this study is the SIKUMIS application. The development of the SIKUMIS application is crucial in supporting the assurance of medical record service quality, particularly in the analysis of inpatient discharge summaries. This application is expected to strengthen the integrity and completeness of medical record data, as well as improve efficiency and accuracy in healthcare services.
Ketidaktepatan Kode Diagnosis Kasus Bedah RSU ‘Aisyiyah berdasarkan ICD-10 Khumaira, Nurul Fitri; Wahyuni, Annisa; Siska, Siska
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 5 No 4 (2024): September
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v5i4.5080

Abstract

The high rate of coding inaccuracies can impact medical treatment cost claims, increase the workload of medical record staff, and lead to poor epidemiological disease data recording. This study aims to identify inaccuracies in inpatient surgical diagnosis coding based on ICD-10. The study uses a descriptive method. The population consists of all inpatient surgical medical records at RSU Aisyiyah Padang in 2023, with a sample size of 84 records selected using simple random sampling. Data analysis was performed descriptively using univariate analysis to determine the frequency distribution and the percentage of coding accuracy based on ICD-10. The study results show that 26.19% of diagnosis codes were inaccurate, while 73.81% were accurate. Coding inaccuracies were categorized into three groups: incorrect codes, fourth character errors, and third character errors. The Neoplasms category had the highest percentage of incorrect codes. The inaccuracies were mainly caused by a lack of attention to detail by coders and differences between the doctor's diagnostic terminology and the ICD-10. Solutions to reduce these errors include improving knowledge, effective communication with doctors, and adherence to coding guidelines.
Kepuasan Pengguna Rekam Medis Elektronik Melalui Pendekatan EUCS di RSI Sultan Agung Rizqulloh, Lutfiyah; Putra, Ardy Nopiawan
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 5 No 4 (2024): September
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v5i4.5105

Abstract

Sultan Agung Islamic Hospital Semarang implemented RME gradually from 2019-2022 using SIMRS independently. However, in March 2023, the collaboration with a third party was not even a year old in early 2024 due to management changes; RME development was again carried out independently. The study aimed to evaluate user satisfaction with RME at RSI Sultan Agung Semarang using a cross-sectional design. The research sample comprised 32 respondents selected through purposive sampling: data collection with questionnaire instruments and descriptive data analysis. The results showed that the majority of respondents were satisfied with the RME system, with a percentage of satisfaction in the content aspect of 80.47%, accuracy of 77.05%, appearance of 73.21%, ease of use of 71.35%, and timeliness of 72.92%. All aspects fall into the excellent category, indicating that the RME system has met user needs. Further improvements need to be made to conduct periodic monitoring and evaluation of all aspects of the system and improve accuracy through a more rigorous data validation mechanism to meet user expectations and support more effective health services.

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