cover
Contact Name
Muhammad Yunus
Contact Email
m.yunus@polije.ac.id
Phone
+628123413933
Journal Mail Official
j-remi@polije.ac.id
Editorial Address
Program Studi Rekam Medik Politeknik Negeri Jember Jl. Mastrip PO Box 164, Jember, Jawa Timur
Location
Kab. jember,
Jawa timur
INDONESIA
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan
ISSN : -     EISSN : 2721866X     DOI : https://doi.org/10.25047/jremi
Core Subject : 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.
Articles 275 Documents
Evaluasi Kinerja Petugas Koding Dan Klaim Jkn Rawat Inap di RSUP dr. Hasan Sadikin Bandung Nur Amaliyatul Fadlilah; Efri Tri Ardianto; Sustin Farlinda
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 3 (2020): June
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v1i3.2059

Abstract

Performance is a work that can be achieved by a person or a group of people in one organization, inaccordance with the authority and responsibilities of each, in order to achieve organizational goals. Thefactors that affect performance are motivation, opportunity, ability. Based on the results of a preliminarystudy at RSUP Dr. Hasan Sadikin, Bandung, the performance of the coding officer and JKN claims wereconsidered to be less than optimal, because there were still many medical record files that were not yetencoded. Resulting in a delay in BPJS payments to hospitals. The purpose of this study was to evaluate theperformance of the coding officer and JKN claims for inpatients at Dr. RSUP. Hasan Sadikin Bandung. Thistype of research is a qualitative study by describing the situation at the time of the study with the aim ofproviding a clear picture of the performance of the coding officer and inpatient JKN claims. The results ofthis study were the first results coding officers and inpatient JKN claims never get a reward from theleadership let alone get praise and certificates of appreciation for their performance in accordance withexisting procedures. Both the coding officer and the inpatient JKN claim have attended training and 3seminars on medical records especially about codification. Thirdly, the existence of SPO regarding theimplementation of coding and claims of JKN is hospitalized so that it can facilitate the officers in carrying outtheir duties.
Analisis Faktor Penyebab Rendahnya Bed Occupancy Rate (BOR) di Rumah Sakit Mitra Medika Kabupaten Bondowoso Widiyanto Widiyanto; Rossalina Adi Wijayanti
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.v1i4.2060

Abstract

BOR (Bed Occupancy Rate) di Rumah Sakit Mitra Medika Bondowoso masih rendah dimana pada bulan Oktober sebesar 59%, November sebesar 55% dan Desember sebesar 57%. Kondisi tersebut kemungkinan disebabkan oleh jumlah sumber daya manusia yang kurang, fasilitas atau prasarana yang masih belum lengkap, faktor lingkungan baik itu lingkungan internal dan eksternal maupun sikap petugas dalam memberikan pelayanan kepada pasien. Tujuan dri penelitian ini adalah untuk menganalisis faktor penyebab rendahnya persentase BOR di Rumah Sakit Mitra Medika Bondowoso. Jenis penelitian ini adalah penelitian kualitiatif dengan menggunakan teknik pengumpulan data wawancara, observasi dan dokumentasi yang melibatkan 5 responden meliputi kepala rekam medik, HRD, perawat, petugas rekam medik dan petugas administrasi atau pendaftaran. Penentuan prioritas utama penyebab masalah menggunakan metode USG (Urgency, Seriousnes, Growth) yang dilaksanakan dengan melakukan skoring. Selanjutnya menentukan alternatif solusi melalui diskusi bersama dengan responden. Hasil penelitian menunjukan bahwa penyebab utama rendahnya persentase BOR di Rumah Sakit Mitra Medika Bondowoso adalah fasilitas atau sarana dan pasarana yang masih belum lengkap. Alternatif solusi yang disarankan untuk mengatasi masalah tersebut dengan cara penyediaan fasilitas atau sarana dan prasarana yang masih belum lengkap. Sebagai saran, Rumah Sakit Mitra Medika Bondowoso harus segera berbenah dan melengkapi fasilitas atau sarana dan prasarana yang masih belum tersedia.
Desain Prototype Aplikasi Pencatatan Korban Bencana Pendukung Mitigasi Bencana di Kabupaten Jember Vanny Permata Sari; Feby Erawantini; Rinda Nurul Karimah; Dony Setiawan Hendyca Putra
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 3 (2020): June
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v1i3.2069

Abstract

18 of 31 sub-districts in Jember Regency are areas prone to floods, landslides, tornadoes and tsunamis.The number of disasters resulted in the difficulty of officers to record the number of victims that exist and thedelivery of information related to disaster data, needs in the area of the disaster and so forth is difficult toconvey. This research was aimed to design a prototype application for recording disaster victims to help thelocal government of Jember specifically for supporting disaster mitigation. The method applied in this studywith 2 stages, namely the first stage to analyze the problems and system design needs, researchers relatedto the collection of necessary data such as retrieving data on disaster victims in Jember Regency andlegislation related to application users and the second stage doing system design such as making flow andmodeling of disaster victim registration applications that provide solutions to problems in the scope of usingavailable resources. Data collection techniques are interviews, observation and documentation withqualitative data analysis methods. The results of this study are prototype design of web-based disasterregistration applications that are designed according to user needs using Microsoft Visio applications. Theresults of the design of the prototype design are expected to be a reference for web-based disasterregistration application specifications in the Jember Regency government environment.
Analisis Pelaksanaan Layanan Perawatan Dukungan dan Pengobatan (PDP) HIV–AIDS di Rumah Sakit Daerah Balung Rintan Illahi Wahyu; Faiqatul Hikmah; Rossalina Adi Wijayanti; Niyalatul Muna
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.v1i4.2070

Abstract

The implementation of HIV - AIDS Support and Treatment (PDP) Care Services at Balung Regional General Hospital is not yet in line with the target. This is evidenced by the number of PLHIV fulfilling the requirements to start treatment, not all of them are taking ARV treatment, so an analysis of these services is needed. The purpose of this study was to analyze the implementation of HIV - AIDS support and treatment (PDP) care services at Balung Regional Hospital. This type of research is qualitative, using interview, observation and documentation data collection methods. Informants in this study were 1 doctor, 1 counselor and 1 nurse and 8 ODHA This type of research is qualitative, the result of this study is an analysis of the implementation of HIV-AIDS support and treatment care services using 4M indicators (man, method, material and mechine). The results of the study were obtained that the analysis of PDP services based on the aspects of man, namely the availability of resources in the service is lacking and knowledge of HIV – AIDS  related to HIV - AIDS is still low, aspects of the method that there are SOP but there is no clear jobdesc, material aspects there is a medical record used for know the development of ODHA, but the officers in filling it are still incomplete, aspects of the mechine are available tools that are used to assist the process of conducting maintenance services such as general inspection tools and SIHA. Efforts to resolve the problem above so that the Balung Regional General Hospital for submitting letters to the Health Office regarding job analysis, the role of the medical recorder for checking the filing of ODHA medical record files and for problems of low knowledge of HIV – AIDS can be done by counseling in privacy.
Analisis Perhitungan Kebutuhan Tenaga Kerja Petugas Rekam Medis Kiara Berdasarkan Teori WISN di RSUPN Dr. Cipto Mangunkusumo Adlien Fadillah; Atma Deharja; Jalahan Pandiangan
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.v2i1.2071

Abstract

The increasing number of patients required higher of medical record services. It can affect on workload officers. It is known that every day there are 350-400 patients with 20 new patients who come for treatment at RSCM Kiara. One service achievement of 32% in January 2020 with priority KPI (Key Performance Indicator) is the provision of medical record files withput patient agreement up to poluclinic < 30 minutes, of the percentage should be 100%. Based on the pre survey at RSCM showed towards 6 Kiara RSUPN Dr. Cipto Mangunkusumo medical record officers, it can be inferred that the officers having a double job at the same time. The high workload that the officers experienced is a side effect from not having enough numbers of officers. It implies that the officers could have several problems, including physical fatigue. The purpose of this study was to determine the number of labor requirements based on WISN theory for the assembling and filling officer of Kiara RSUPN Dr. Cipto Mangunkusumo. This research using a qualitative method with 6 respondents. Based on the workload calculation using the WISN method, it is known that the number of workers needed in the assembling unit is 2 people and in the filing unit is 15 people. With the results of the calculations of labor needs based on WISN theory, it can be used as an effort to plan the addition of officers numbers in order to improve the quality of hospital services according to the existing workload.
Analisis Kerahasiaan Rekam Medis Berdasarkan Hak Akses Ruang Filing Rawat Jalan di RSUD Dr.Saiful Anwar Malang Eva Tri Wicahyanti; Maya Weka Santi; Rossalina Adi Wijayanti
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.v2i1.2073

Abstract

Confidentiality of medical records at RSUD Dr. Saiful Anwar Malang still had several obstacles in implementation, where there were non-medical record officers who enter and exit the outpatient filing room although there was finger prints and written warnings stating that "other than medical record officers are prohibited from entering" in the outpatient filing section. The purpose of this report is to analyze the confidentiality of medical records based on the right of access to outpatient filing rooms at RSUD Dr. Saiful Anwar Malang. This report used qualitative methods, and the analysis method used is 5M management aspects (man, money, material, method, and machine) to identify the problems and look for priority causes use USG (Urgency, Seriousness, Growth) techniques. The results of this report indicate that the management aspects of man, method, material, and machine are the factors causing the lack of secrecy of the medical record based on the right of access to outpatient filing rooms at RSUD Dr. Saiful Anwar Malang. The priority cause of the problem in this report is the ignorance of officers in relation to the existing SOP / Medical Record Services Book. The priority results of the cause of the problem produce a solution, it are necessary to conduct socialization about SOP for storing medical records and Medical Record Services Book relating to the secrecy of medical records to all medical records officers, especially filing officers before being placed in their work units and evaluating every three months by monitoring the implementation of SOP /Medical Record Services Book by an outpatient filing coordinator.
Analisis Ketidaksesuaian Kode Diagnosis pada SIMRS dengan Berkas Klaim BPJS Klinik Obgyn Ika Rahmadhani; Rossalina Adi Wijayanti; Novita Nuraini
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.v1i4.2075

Abstract

Ketidaksesuaian kode Diagnosis utama pada SIMRS dan pada berkas Kalaim BPJS sangat penting karena jika tingkat ketidakakuratan tinggi maka berdampak pada ketidakakuratan data morbiditas penyakit yang akan mempengaruhi data pelaporan 10 besar penyakit. Berdasarkan data hasil observasi di RSUD DR Saifur Anwar Malang terhadap ketidaksesuain kode diagnosis utama pada SIMRS dengan kode berkas Klaim BPJS menunjukkan bahwa sebesar 25.8% kode diagnosis utama pada SIMRS tidak diisi atau tidak lengkap, dan sebesar 48.3% kode diagnosis utama yang tertera pada SIMRS tidak sesuai atau tidak sama dengan kode yang tertera pada berkas klaim (casemix), serta sebesar 25.8% kode yang tertera pada SIMRS sesuai dengan kode yang tertera pada berkas klaim (casemix). Tujuan Penelitian ini yaitu Menganalisis Ketidaksesuaian Kode Diagnosis Utama Pada SIMRS Dengan Berkas Klaim BPJS Klinik Obgyn Di RSUD Dr. Saiful Anwar Malang berdasarkan metode Motivation, Opputunity dan Ability. Jenis penelitian yang digunakan yaitu penelitian kualitatif dengan metode pengumpulan data wawancara dan observasi. Hasil yang didapatkan pada saat observasi sebanyak 146 berkas klaim BPJS klinik Obgyn pada tanggal 26-28 Februari dan 3 Maret 2020 angka ketidaksesuain kode diagnosis sebesar 72.6%. Dari hasil analisis didapatkan bahwa ketidaksesuain tersebut terjadi karena kurangnya kedisiplinan petugas Koding di poliklinik dalam menginputkan kode di SIMRS, tidak adanya pelatihan terkait tata cara kodefikasi diagnosis yang benar, petugas entri data di poliklinik bukan lulusan rekam medik serta tidak adanyan job description spesifik yang mengatur tentang pelaksanaan kodefikasi diagnosis untuk kasus rawat jalan.
Evaluasi Kinerja Petugas Distribusi Berkas Rekam Medis Rawat Jalan di RSUD dr. Saiful Anwar Malang Najla Kamil; Novita Nuraini; Maya Weka Santi
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 3 (2020): June
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v1i3.2076

Abstract

Provision of outpatient medical record documents is the time required to provide medical recorddocuments from the patient registering to the examination. According to Minister of Health Decree No. 129of 2008 which states that the provision of outpatient medical record files is less than 10 minutes. Based onthe observation time of providing medical record documents at Dr. Hospital. Saiful Anwar Malang for morethan 10 minutes. The longest time for providing medical record documents is in the process of distributingmedical record documents from the distribution rack to the clinic for 14.84 minutes. To find the factors thatcause delays in the distribution of food, an evaluation of the performance of the distribution officers iscarried out with the performance theory of Motivation, Opportunity, and Ability. The aim is to determine thedelay factor in the distribution of medical record documents which causes the quality of hospital services todecrease. Based on observations, interviews and documentation, it is known that the factors causingdelays in distribution are lack of motivation and sanctions, lack of discipline among officers and no clearSOP regarding the distribution of medical records. Then there is a need for clear performance monitoringand preparation of SOPs related to the distribution of medical record documents.
Evaluasi Kinerja Petugas Distribusi Berkas Rekam Medis Rawat Jalan di RSUD dr. Saiful Anwar Malang Najla Kamil; Dony Setiawan Hendyca Putra; Feby Erawantini; Niyalatul Muna
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.v2i1.2077

Abstract

Patrang Health Center has implemented medical records management, but there are problems in the implementation of medical record management. when duplicating medical record numbers at Patrang Health Center. Duplication in the Patrang Community Health Center results in a decrease in the quality of medical records. The purpose of this study was to analyze the causal factors and determine the priority causes of duplicate medical record numbers at Patrang Health Center. This type of research is qualitative. The technique of collecting data in this study is observation of data duplication of medical records and interviews with respondents based on 7M indicators. Data processing with CARL criteria. The results of this study were found in studies that found the main priority of less useful duplication of the medical record number on the medical record data map with a score of 144. Further problems were officers, filing space was less extensive, filing shelves were inadequate and patients did not carry KIB with a score 108. With the discovery of priorities leading to duplication, the study provides the main solution that discusses the medical record number written on the front and sides of the file as well as other solutions to overcome the problem and made a draft policy to reduce the incidence of duplicate medical record numbers that have been approved.
Analisis Kebutuhan Electronic Medical Record (EMR) Pasien Rawat Jalan Dewasa Menggunakan Metode UCD di RSCM Evi Novitasari; Maya Weka Santi; Atma Deharja
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 3 (2020): June
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v1i3.2079

Abstract

RSUPN Dr. Cipto Mangunkusumo is a government hospital in Central Jakarta, Indonesia. The hospital hasnot used an electronic medical record with a land area of 12,1409 hectares and is still using manualmedical records, causing the length of documents to be distributed to each unit that needs it. Besides thedistance traveled causes the loss of files in it. The target achievement of medical record response time isstill very far from what has been set, which is equal to 90% of medical records reaching poly at <25minutes. Implementation of electronic medical records at RSUPN Dr. Cipto Mangunkusumo has not beenimplemented yet because the needs of the implementation of electronic medical records have not beenmet, so it is necessary to analyze the electronic medical records needs of adult outpatients. The researchmethod used is the user centered design method which is a design method that puts the user at the centerof a system design process. The process in the UCD method is to understand and determine the user'scontext, determine the needs of users and organizations, design solutions produced, and designevaluation of user needs. The results of the study are end-users of electronic medical records of adultoutpatients, namely doctors, nurses, medical recorders, and pharmacists. There are 3 needs for users andorganizations namely information needs, functional needs and non-functional needs. There are 13interface designs and interface design evaluation results, namely the design produced according to userneeds

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