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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 265 Documents
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Tinjauan Sistematis Terhadap Implementasi Rekam Medis Elektronik Pada Pelayanan Rawat Jalan Diastri, Anggraina; Kurniawan, Rico
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.v6i3.5891

Abstract

The implementation of Electronic Medical Records (EMR) in Indonesia presents a strategic opportunity to improve the quality and efficiency of healthcare services by optimizing access to medical information and strengthening coordination among healthcare professionals. However, its implementation still faces major challenges, particularly in terms of data security and workforce readiness. This study aimed to evaluate the benefits, challenges, and impacts of EMR adoption on medical practice and healthcare delivery. The research was conducted using a systematic literature review method with a PRISMA approach. A total of 4,475 articles were identified from four major databases: PubMed, Google Scholar, ScienceDirect, and Scopus. After screening titles, abstracts, and full texts, 10 articles met the inclusion criteria and were further analyzed. The findings indicated that EMR can accelerate access to patient information, enhance coordination among medical teams, and reduce the risk of documentation errors. This review suggests that EMR has significant potential to improve the efficiency, accuracy, and quality of outpatient services. However, the success of its implementation largely depends on technical readiness, human resource capacity, and infrastructure support. Further efforts should focus on improving digital literacy among healthcare workers, strengthening data security, and developing infrastructure to support the optimal implementation of EMR systems.
Menentukan Arah Strategis Digitalisasi Rekam Medis Elektronik Melalui Analisis SWOT dan Matriks IFAS-EFAS Yulida, Rina; Handayani, E. Ria Susi; Nofitriyani, Nofitriyani
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.v6i3.5962

Abstract

Panti Rini Hospital has implemented Electronic Medical Records (EMR) to improve the quality of healthcare services. The initial development for outpatient services began in 2014, followed by inpatient development in 2022. However, its implementation still faces challenges, including limited data interoperability between units and unstable system performance. This study aimed to analyse internal and external factors influencing EMR development in the inpatient unit using SWOT analysis, as well as IFAS and EFAS matrices. A descriptive method was used, with data collected through interviews, observations, and document reviews. The findings showed internal strengths such as ease of data access, strong human resource support, and sufficient budget allocation. Weaknesses included limited IT personnel and the continued use of a hybrid system. External opportunities included policy support from the government and the Foundation, while threats involved the need for integration with the national health information system and server instability. Based on the analysis, Panti Rini Hospital was positioned in Quadrant I of the Grand Strategy Matrix, with an IFAS score of 2.84 and an EFAS score of 2.55. This indicates the hospital should adopt an aggressive strategy to strengthen EMR digitalisation and improve healthcare service efficiency and effectiveness.
Tingkat Kepuasan Pasien Rawat Jalan di Klinik Delima Sehat Menggunakan Model SERVQUAL Rizqulloh, Lutfiyah; Artati, Diah Kari
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.v6i3.5986

Abstract

Delima Sehat Clinic in Semarang has become one of the healthcare facilities with the highest number of BPJS participants in the city and has experienced an increase in patient visits. However, patient dissatisfaction remains regarding waiting times, referral procedures, staff attitudes, and limited parking space. This study aimed to evaluate patient satisfaction with the services provided and to identify the SERVQUAL dimension with the most significant influence on the healthcare service process. A cross-sectional study design with a descriptive method was used. The sample consisted of 80 outpatients selected through accidental sampling. Data were collected using a validated SERVQUAL questionnaire with a four-point Likert scale. Descriptive statistics were employed for data analysis. The assurance dimension showed the highest satisfaction level (76.25%) with an average score of 3.88±0.33, while the tangibles dimension recorded the lowest satisfaction (36.25%) with an average score of 3.69±0.50. Overall, patient satisfaction reached 78.75% with an average score of 3.90±0.30. It is recommended that clinic management pay closer attention and make improvements particularly in the tangibles dimension, such as expanding the waiting area and enhancing the comfort of facilities, while continuing to maintain the quality of other service dimensions.
Sentralisasi Pelaporan Rawat Jalan Berbasis Elektronik di Rumah Sakit X Awaluddin, Mohamad Robby; Yunengsih, Yuyun; Abdussalaam, Falaah
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.v6i3.6026

Abstract

The preliminary study revealed that the outpatient reporting system at Hospital X is still fragmented across individual polyclinics, with the reporting process conducted manually using Microsoft Excel. This condition results in a time-consuming report compilation process. The aim of this study is to develop a centralized outpatient reporting system integrated within a single information system. This centralization is expected to enhance the effectiveness of medical record staff in compiling outpatient reports. The research employed a research and development (R\&D) method with a systematic approach to improve the existing system. The information system was designed using the waterfall method and developed with Visual Studio Code software. The outcome of this study is an outpatient information system equipped with various features to support the compilation of outpatient service reports. Based on the study’s findings, Hospital X has the potential to further develop this reporting system to be more optimal and fully integrated with the existing Hospital Management Information System (HMIS).
Sistem Deteksi Dini Pneumonia Balita Berdasarkan Rekam Medis Menggunakan Algoritma C4.5 Melinda, Tashya Eka; Roziqin, Mochammad Choirur; Vestine, Veronika; Putra, Muhammad Ifantara
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.v6i3.5369

Abstract

The detection of pneumonia cases in children under five at Jabung Public Health Center has not reached the targeted rate. From 2019 to 2022, the number of identified cases remained below the expected target of 4.45%. This study aimed to design and develop an early detection system for childhood pneumonia based on medical records using the C4.5 algorithm. The research applied the waterfall development method and utilised data collection techniques including interviews and document analysis. The subjects were program officers for childhood pneumonia and medical record staff, while the objects were medical records of children diagnosed with pneumonia and acute respiratory infections (ARI). System development involved several stages, starting with data preprocessing, including data cleaning, selection, reduction, and transformation. Data mining was conducted using the C4.5 algorithm with the help of RapidMiner software. The result was an early detection system tailored to the needs of Jabung Public Health Center. The system achieved an accuracy rate of 97.50% based on the confusion matrix. This system was expected to assist health workers in identifying pneumonia cases in children more effectively, thereby improving disease monitoring and early treatment efforts at the community healthcare level.
Evaluasi Penerapan SITB pada Klinik Swasta di Kota Denpasar dengan Metode HOT-FIT Putra, Gede Wirabuana; Pradnyani, Putu Erma
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 6 No 4 (2025): September
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v6i4.4932

Abstract

Tuberculosis (TB) incidence in Indonesia ranks second highest globally, with case detection supported by the Tuberculosis Information System (SITB). In Bali Province, the majority of TB cases are concentrated in Denpasar City. This study aimed to evaluate the implementation of SITB in private clinics in Denpasar using a qualitative design with the Human, Organization, Technology, and Net Benefit (HOT-FIT) evaluation framework. Data were collected through in-depth interviews with six purposively selected informants from private clinics applying the Public–Private Mix (PPM) strategy and analyzed using thematic content analysis. The findings showed that, in terms of the Human factor, SITB was easy to use with relatively good user satisfaction, although staff competencies were not fully aligned; in terms of the Organization factor, medical record professionals were not yet involved in SITB reporting; in terms of the Technology factor, SITB quality was considered good, with user-friendly web-based access and available guidelines; and in terms of the Net Benefit factor, SITB improved efficiency in TB recording and reporting, although financial benefits remained limited. The study recommends strengthening human resource capacity in health information management, simplifying SITB data, and reinforcing government–private sector collaboration to support Indonesia’s TB elimination target by 2030.
Faktor Risiko Leiomyoma Uterus di Rumah Sakit Umum Pusat Dr. Kariadi Semarang Prasetyo, Adi; Nuraini, Novita; Rachmawati, Ervina; Vestine, Veronika
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 6 No 4 (2025): September
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v6i4.6009

Abstract

Uterine leiomyoma is a benign tumor originating from the smooth muscle and fibrous tissue of the uterus, with a global prevalence of 60–75% among women of reproductive age. In 2023, 978 cases of uterine leiomyoma were recorded at Dr. Kariadi General Hospital, Semarang. The incidence of uterine leiomyoma has shown a continuous increase in morbidity and mortality rates over the years. This study aims to analyze the association between risk factors—age, obesity, parity, hormonal contraceptive use, and family history—and the occurrence of uterine leiomyoma. A case-control design was employed using secondary data, involving 70 cases and 70 controls selected through simple random sampling. Data analysis was conducted using univariate and bivariate methods with the chi-square test. The results revealed significant associations between uterine leiomyoma and age (p=0.029; OR=6.048), obesity (p=0.001; OR=3.579), and parity (p=0.037; OR=0.448). In contrast, hormonal contraceptive use (p=0.426) and family history (p=1.000) showed no association. It can be concluded that women aged 20–50 years, those with obesity, and multiparous or grand multiparous women are at higher risk of developing uterine leiomyoma. Strengthening health education and early detection among at-risk groups is recommended through health promotion, healthy dietary practices, and regular physical activity.
Analisis Kelengkapan Rekam Medis Dengan Kelayakan Klaim BPJS Pasien Rawat Inap Jayanti, Asykar; Waskito, Dito Yogo; Sugiarsi, Sri
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 6 No 4 (2025): September
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v6i4.6198

Abstract

Dr. Soeradji Tirtonegoro General Hospital, as a Public Service Agency in collaboration with BPJS Kesehatan, has encountered challenges in achieving patient service claim targets. In June 2024, 71.23% of submitted claims were deemed eligible, while 28.77% were pending out of 1,950 total claims, resulting in the hospital’s Director Performance Index target of 93.75% for resolving pending BPJS Kesehatan claims not being met. This study aims to analyze the relationship between medical record completeness and the eligibility of inpatient BPJS Kesehatan claims. An observational analytic approach with a cross-sectional design was applied to a sample of 361 inpatient BPJS Kesehatan claim files submitted between September and November 2024. Data analysis was conducted using the Fisher Exact Test with SPSS version 23. The results revealed a significant relationship between medical record completeness and claim eligibility (p = 0.000). It is therefore recommended that healthcare professionals and coders pay greater attention to aspects influencing the accuracy of claim documents by providing specific diagnoses and procedures, strengthening coder competencies to ensure precise diagnostic coding, and implementing concurrent analysis prior to patient discharge with the involvement of case managers, in order to minimize incomplete medical records and reduce pending claims.
Efisiensi Pengelolaan Tempat Tidur Rawat Inap Berdasarkan Grafik Barber Jhonson di RS X Lampung Marsim, Etanaulia; Setiawan, Susilo; Dwiyovita, Rizka; Bahri, Yessiana Luthfia; Latifah, Rif'at Mukhidatul; Annisa, Syifa
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 6 No 4 (2025): September
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v6i4.5908

Abstract

The imbalance in bed utilization across several inpatient units at Hospital X poses challenges to service efficiency, such as prolonged waiting times and an increased risk of nosocomial infections. This study aims to evaluate the efficiency of bed management at Hospital X in 2024 using the Barber Johnson Graph method. This research employed a quantitative descriptive design using secondary data obtained from daily inpatient census reports. The analyzed indicators included Bed Occupancy Rate (BOR), Average Length of Stay (AvLOS), Turn Over Interval (TOI), and Bed Turn Over (BTO). The results showed a BOR of 75.91%, an AvLOS of 2.91 days, a TOI of 0.92 days, and a BTO of 95.56 times per year. Based on the Barber Johnson Graph, only BOR and BTO met the efficiency standards, while AvLOS and TOI were below the standard. These findings indicate that although bed occupancy levels and usage frequency were optimal, the relatively short length of stay and rapid bed vacancy intervals require further evaluation. This study provides valuable insights for hospital management in formulating policies to sustainably optimize inpatient service efficiency.
Tingkat Pengetahuan Pasien dan Keluarga tentang Hak dan Kewajiban di Rumah Sakit X Fauziah, Rachmania Syifa; Sugiarti, Ida
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 6 No 4 (2025): September
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v6i4.6047

Abstract

All healthcare facilities, including hospitals, are responsible for providing clear information regarding patients’ rights and obligations. A preliminary study at Hospital X revealed that staff did not fully explain the rights and obligations stated in the general consent form, but only gave a brief overview of the right to receive effective and efficient services and the obligation to comply with hospital regulations. This study aims to describe the knowledge of patients and their families regarding the rights and obligations outlined in the general consent form at Hospital X in 2025. Using a quantitative descriptive design with 100 respondents selected through accidental sampling, data were collected via questionnaires and analyzed descriptively. The results showed that 40% of respondents had good knowledge, 27% had moderate knowledge, and 33% had poor knowledge. These findings suggest that inpatient registration officers should provide a complete explanation of patients’ rights and obligations to ensure patients and their families have a clear understanding. Additionally, it is recommended that hospitals assign dedicated officers to handle the general consent process apart from inpatient registration staff to ensure that information regarding patients’ rights and obligations is effectively communicated.

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