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Muhammad Yunus
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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 265 Documents
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Akurasi Pengkodean Injury dan External Causes Berdasarkan ICD-10 dan ICD-9 CM di Rumah Sakit X Sukawan, Ari; Putra, Dony Setiawan Hendyca; Barsasella, Diana; Rahmawati, Fitria Dewi
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 6 No 1 (2024): December
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v6i1.5572

Abstract

Accurate disease diagnosis coding is essential as it affects morbidity reporting, errors in determining medical procedures, billing issues, and invalidity as legal evidence. One example is injury coding, where ICD-10 guidelines require the 4th and 5th digits to indicate the location and activity associated with the injury. A preliminary study at X Hospital revealed that 80% of medical records had inaccurate injury coding, and external cause codes were absent. The issue is suspected to stem from the lack of coder training on injury and external cause coding. This study aims to assess the accuracy of injury and external cause coding based on ICD-10 and ICD-9 CM. It uses a descriptive approach with a sample of 65 medical records out of a total population of 77 from the fourth quarter of 2023, selected using simple random sampling. Data were collected through observation by reviewing medical records and completing observation sheets, then analyzed univariately. The results showed 66.2% of injury codes were inaccurate, 100% of external cause codes were inaccurate, and 83.08% of procedure codes were accurate. Most inaccuracies were due to the omission of the fifth digit for fractures and the absence of external cause coding.
Perancangan SIM-Klinik Bagian Pendaftaran Di Klinik X Kabupaten Malang Maulana, Mohammad; Khalifatulloh, Bhre Diansyah Dinda
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 6 No 2 (2025): March
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v6i2.5352

Abstract

The Clinic Management Information System is not yet available at X Clinic, and with 5.000 patient visits in the past three months, the absence of this system has resulted in lengthy service processes. A preliminary study found that many patients visiting X Clinic do not bring their Patient Identity Book (KIB), which further delays the service process. Additionally, medical record duplication frequently occurs in the clinic. This study aimed to design a Clinic Management Information System (SIM-Klinik) using the waterfall model, a systematic and sequential software development approach. The study employed the Research and Development (R&D) method, which is a systematic approach used to create new products or enhance the quality of existing ones. The findings indicated that X Clinic required an information system capable of efficiently and accurately managing patient registration data. The SIM-Klinik design process begins with user needs analysis, followed by the development of DFD Level 0, DFD Level 1, and an ERD model. It is expected that X Clinic will utilize the research findings as a consideration for developing and implementing the SIM-Klinik, ensuring that the infrastructure and facilities align with the system's needs.
Analisis Penerimaan Karyawan Terhadap Implementasi Sistem ERP dengan Metode TAM di Rumah Sakit X Gresik Rahmawati, Nahardian Vica; Widhiani, Elsa Fatika; Kusdiyana, Ari; Nurdiana, Fara
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 6 No 2 (2025): March
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v6i2.5360

Abstract

X Hospital in Gresik frequently encounters delays in financial reporting, prompting them to seek a solution by implementing an ERP system. This study aimed to examine the relationship between perceived ease of use and perceived usefulness with the level of acceptance at X Hospital in Gresik. The research design was quantitative, utilizing a cross-sectional method. The study employed a total sampling technique, involving 100 respondents. The findings indicated that 48 respondents (48%) rated X1 as good, 66 respondents (66%) rated X2 positively, and 49 respondents (49%) considered Y to be good. The results showed a significant relationship between perceived ease of use and acceptance levels, with a p-value of 0.000. Additionally, a significant relationship was found between perceived usefulness and acceptance levels, with a p-value of 0.002 at X Hospital. Regular monitoring and evaluation are necessary, considering the continuous technological updates received by users. The hospital is advised to conduct regular monitoring and evaluation to gather user feedback for ERP development.
Faktor yang Berhubungan dengan Penerimaan Sistem Pendaftaran Online Rumah Sakit Wardani, Ana Kusuma; Rifai, Ahmad; Pitoyo, Achmad Zani
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 6 No 2 (2025): March
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v6i2.5465

Abstract

The online registration system has been implemented by many healthcare service providers, including Kanjuruhan Hospital, Malang Regency. This system aims to facilitate patient access to hospital registration from anywhere without the need for long waiting times. The objective of this study is to examine outpatient perceptions regarding the usefulness and ease of use of the online registration system and its impact on their acceptance of the system. This research adopts a quantitative analytical approach, focusing on outpatients using the online registration system. The study is based on the Technology Acceptance Model (TAM) with a cross-sectional approach. A total of 80 respondents were selected as the sample, and data were analyzed using the Spearman rank test. The findings indicate that the perceived usefulness variable in relation to user acceptance yielded a p-value of 0.000 < 0.05, and the perceived ease of use variable in relation to user acceptance also yielded a p-value of 0.000 < 0.05. These values demonstrate a correlation between the two variables, as the correlation values are lower than the significance level. The study concludes that user acceptance is significantly influenced by perceptions of usefulness and ease of use.
Perbandingan Kinerja Algoritma KNN-DT-RF-SVM untuk Deteksi Dini Risiko Kematian Ibu Rahagiyanto, Angga; Prakoso, Bakhtiyar Hadi; Yunus, Muhammad; Vestine, Veronika; Suyoso, Gandu Eko Juliato; Deharja, Atma
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 6 No 2 (2025): March
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v6i2.5658

Abstract

Maternal Mortality Rate (MMR) in Indonesia remains a significant health issue, with data indicating a mortality rate far exceeding the Sustainable Development Goals (SDGs) target. This study aimed to explore and compare the performance of K-Nearest Neighbors (KNN), Decision Tree (DT), Random Forest (RF), and Support Vector Machine (SVM) algorithms in detecting maternal mortality risk. Using a medical dataset of pregnant women from Sumbersari Community Health Center, models were developed to classify three pregnancy risk categories: low risk (KRR), high risk (KRT), and very high risk (KRST). Model evaluation was conducted based on accuracy, precision, recall, and F1-score metrics. The results showed that the Random Forest algorithm achieved the highest performance with an accuracy of 76.7%, followed by Decision Tree and SVM with 70%, while KNN had the lowest accuracy at 50%. The main challenge encountered was data imbalance in the classification of very high-risk cases. This study suggests the use of data balancing methods such as SMOTE and additional data augmentation to enhance model performance. These findings can serve as a foundation for Puskesmas to implement machine learning-based early detection systems to reduce maternal mortality rates.
Pengembangan Anestesi Rekam Medis Elektronik (AREME) untuk Dokumentasi Asuhan Keperawatan Anestesiologi Abadi, Bagus Wahyu; Cing, Marta Tania Gabriel Ching; Hardiyani, Tati; Annisa, Rully
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 6 No 2 (2025): March
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v6i2.5715

Abstract

The role of anesthesia nurses in the anesthesiology nursing care process is crucial in providing care to patients. One essential aspect that should not be overlooked in this process is documentation. Anesthesiology nursing care documentation (ASKAN) is a record that documents all actions performed by anesthesia nurses on patients. Students of the D4 Anesthesiology Nursing Program at Universitas Muhammadiyah Purwokerto face several challenges in using conventional reporting methods. This study aims to develop a nursing care documentation method using information technology through a computer-based application. The research and development method was employed in this study to design the application. Observations and interviews with students of the D4 Anesthesiology Nursing Program at Universitas Muhammadiyah Purwokerto were conducted to explore the researched phenomenon. The researchers designed the Anesthesia Electronic Medical Record (AREME) application for recording and documenting anesthesiology nursing care electronically. The development of the AREME application follows anesthesiology nursing care standards based on the ASKAN guidelines. The implementation of AREME in ASKAN documentation demonstrates that this application can facilitate the documentation process, which was previously conducted conventionally.
Kepuasan Pasien di Fasilitas Pelayanan Kesehatan (MJ Health) Johor Bahru, Malaysia Nisaa, Arifatun; Noor, Ahmad Fariz Bin Mohd; Peng, Chong Lik
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 6 No 2 (2025): March
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v6i2.5790

Abstract

Although Johor Bahru offers a variety of healthcare services, including both public and private hospitals, there are still differences in patients' perceptions of the quality of care received. Several factors, such as waiting time, accessibility, medical facilities, healthcare professionals' skills, and communication between patients and medical staff, can influence patient satisfaction. This is particularly relevant to MJ Health, where no previous surveys have been conducted to assess patient satisfaction. Therefore, this study aimed to analyze patient satisfaction levels regarding healthcare quality at MJ Health Johor Bahru and identify the key factors contributing to their satisfaction. A quantitative approach was used, employing a questionnaire distributed to 250 respondents between February and July 2023. The findings indicate that staff professionalism (X3) has the most significant impact on patient satisfaction, with β = 0.35, p < 0.01. Given this result, hospitals are advised to conduct regular evaluations through patient satisfaction surveys to identify areas for service improvement and enhance overall healthcare quality.
Penyebab Pengembalian Klaim BPJS Rawat Inap Triwulan 1 Tahun 2024 di RSI Sultan Agung Semarang Rizki, Julia Nur; Sari, Arum Astika; Yektiningtyastuti, Yektiningtyastuti; Suprihatin, Eni
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 6 No 2 (2025): March
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v6i2.5853

Abstract

The process of submitting BPJS Kesehatan reimbursement claims in hospitals often encounters issues related to administration, regulatory discrepancies, and delays, affecting patient services and satisfaction. This study aimed to analyze the factors causing the return of BPJS inpatient claims during the first quarter of 2024 and strategies to reduce claim disputes. Utilizing a descriptive research design, the study examined 282 claim files returned by BPJS Kesehatan to Sultan Agung Islamic Hospital Semarang in the first quarter of 2024. The predominant reasons for claim returns were medical aspects (242 cases), coding issues (25 cases), and administrative factors (15 cases). Coding issues included inaccurate diagnosis codes due to files containing dual diagnoses and errors by BPJS Kesehatan verifiers in reviewing submission data. Medical and administrative returns were primarily due to incomplete supporting documents, as some results were not available at the time of submission, leading to their exclusion. Submissions were still made to avoid rejection due to predetermined deadlines. Improving the claims process is essential to stabilize hospital finances and enhance service quality.
Optimalisasi Pelayanan Klinis Melalui Clinical Pathway: Analisis Pengetahuan dan Sikap Praktisi Medis Sugiarti, Ida; Wahyuni, Ida; Sukawan, Ari
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 6 No 3 (2025): June
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v6i3.5818

Abstract

Dr. Soekardjo Hospital has a clinical pathway that is currently used mainly as a requirement for accreditation rather than as a service guideline. Previous studies have found that several clinical pathway procedures were overlooked, posing a risk of potential fraud. Under the Case Base Group-based National Health Insurance system, which demands cost efficiency and quality control, clinical pathways must be understood and implemented by healthcare professionals to optimise patient care. This study aimed to analyse the knowledge and attitudes of medical practitioners toward clinical pathway strategies. A quantitative research design was applied, with data collected through questionnaires completed by 30 respondents. Univariate analysis was used to describe respondent characteristics, while bivariate analysis with the chi-square test assessed variable relationships. The findings showed no significant association between education level, profession, or years of service with practitioners' knowledge and attitudes. However, a significant relationship was found between knowledge and attitude, indicating that better knowledge leads to a more positive attitude toward clinical pathway adoption. Therefore, improving knowledge is crucial. Training programmes should be developed to enhance the understanding and attitudes of medical practitioners to support the effective and consistent implementation of clinical pathways in hospital settings.
Visualisasi Spasial Kunjungan Pasien Rumah Sakit Menggunakan Sistem Informasi Geografis Rindiyani, Fadillah Dea; Fauzi, Harry; Nadi, Danu Tirta; Hakim, Agya Osadawedya; Aeni, Yomi Nur
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 6 No 3 (2025): June
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v6i3.5866

Abstract

Patient visit data at Bandung Paru Hospital is still managed conventionally, without integration with Geographic Information System (GIS) technology. This study aimed to develop and utilize GIS to visualize patient visits, supporting spatial data-based decision-making. A descriptive method was used, with the research population consisting of all patient visits to paru Hospital in 2024. The sample included outpatient and emergency patients selected through purposive sampling. Secondary data were taken from outpatient and emergency visit records, processed, and displayed in thematic maps using color gradients from green to red to indicate visit intensity, from low to high. The results showed that GIS can provide a spatial overview of patient visit distribution, helped identify visit patterns, and supported strategic planning such as improving facilities and services. Paru Hospital is encouraged to adopt GIS for spatial-based visualization of patient visit data, as it allows the data to be presented in interactive maps, offering clearer insights into the geographic distribution of patients.

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