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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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Kab. jember,
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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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Faktor Penyebab Ketidaklengkapan Rekam Medis Rawat Inap di RSUD dr. Saiful Anwar Malang Ana Nafidatul Khoiroh; Novita Nuraini; Maya Weka Santi
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.v2i1.2080

Abstract

One of efforts to improve the quality of healthcare facilities is to improve the quality of medical record services including completeness, speed and accuracy in providing information for health care needs. A complete and accurate medical record can be used as a reference to health services, legal bases, supporting information to improve medical quality, medical research and be used as a basis to assess the performance of hospitals. The purpose of this research identifies the factors causing the incompleteness of the replenishment of inpatient medical record in the RSUD Dr. Saiful Anwar Malang. The type of research used is qualitative. Data collection techniques by way of document study, interviews and observation. Document studies are conducted on 100 inpatient medical record documents that have not been conducted assembling, while the interview is conducted to the IRNA 2 medical record officer to determine the factors causing the incompleteness of medical record documents. Observation is done to complete the interview data. The results of the analysis on 100 inpatient medical record files were obtained that the incomplete number of medical records was 79%, with the most incompleteness presentation on the responsibilities of the doctor which includes medical resumes, casemix sheets, and surgery reports. The interview and observation results show that the main causation factor for the filing of an inpatient medical record of a surgical ward is from the doctor's awareness and discipline in filling in the medical record documents. As a solution to improve the completeness of medical record filling is by spur motivation and increase the discipline of doctors in filling medical record documents by providing reward and punishment and to repair SOP filling medical record of hospitalizatio.
Desain Formulir Pengkajian Awal Neonatus di Rumah Sakit Tingkat III Baladhika Husada Jember Rizky Farah Dilla; 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.v1i3.2083

Abstract

The neonatal preliminary assessment form is one of the important forms, because it includes informationabout newborns. Baladhika Husada Hospital in Jember is one of the hospitals which still does not have apreliminary assessment form specifically for newborns or neonates, there still uses initial assessment formsfor general patients. The purpose of this study was to design a neonatal initial assessment form at BaladhikaHusada Hospital Level III Jember. This type of research is a qualitative study with research subjects includingSp.A doctors, midwives, nurses, chief medical records, and medical records officers. Data collectiontechniques in this study used interviews, observation, brainstorming. The results of this study were seen fromthe physical aspects of the neonatal initial assessment form using white paper with a size of 70 grams F4 (33cm and 21.5 cm) in portrait form. Viewed from the anatomical aspects of the neonatal heading assessmentform, the logo, the name of the agency, the address of the agency, and the title of the form, for theintroduction, are represented by the title. Viewed from the aspect of the contents of the neonatal preliminaryassessment form, the data added consisted of obstetric status, anthropometric vital signs, apgar scoreassessment, and physical examination starting from B1 - B7. Suggestions from researchers on the results ofthe neonatal initial assessment form design are expected to be implemented at Baladhika Husada HospitalLevel III Jember.
Tinjauan Pelaksanaan General Consent pada Pasien Baru Rawat Jalan RSUP dr. Sardjito Bhre Diansyah; Gamasiano Alfiansyah; 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.v1i3.2084

Abstract

One of the accreditation instruments is Patient and Family Rights (HPK) 6.3 which states that patients andtheir families were provided with an explanation of the scope of the general consent. Based on preliminaryresearch at the outpatient registration unit at RSUP dr. Sardjito Yogyakarta, the average new registeredpatients reached 43.25 patients per day and 89% of them did not receive an explanation about thecontents of the general consent form. This research aims to identify the current general consent form foroutpatients in 2020, identify the procedure applied in delivering information of the general consent foroutpatients, and identify factors obstructing the application of the general consent. This research wasqualitative. The data were collected through interviews and observations. The subjects of the researchinvolved officers of the inpatient registration unit at RSUP dr. Sardjito Yogyakarta and the head of themedical record and health information department. The results of this research show that the registrationofficers do not inform the general consent information for new patients because they have more concernon the speed of registration process without telling the content of general consent and unavailability ofSOP in providing general consent information that cause less proper work implementation.
Analisis Faktor Penyebab Keterlambatan Pengembalian Berkas Rekam Medis Rawat Jalan di RSUPN Dr. Cipto Mangunkusumo Rizky Farah Dilla; Demiawan Rachmatta Putro Mudiono; Gamasiano Alfiansyah
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.v1i4.2085

Abstract

Keterlambatan pengembalian berkas rekam medis dapat mempengaruhi pelayanan rekam medis dan akan menghambat kegiatan selanjutnya, seperti kegiatan assembling, koding, analisis, indeks. Pengembalian berkas rekam medis rawat jalan di RSUPN Dr. Cipto Mangunkusumo masih mengalami keterlambatan. Pada bulan januari sampai dengan februari total berkas rekam medis rawat jalan yang terlambat sebanyak 282 berkas (0,016%) dari 17.616 berkas. Tujuan dari penelitian adalah menganalisis faktor  penyebab keterlambatan pengembalian berkas rekam medis rawat jalan di RSUPN Dr. Cipto Mangunkusumo. Jenis penelitian yang digunakan adalah kualitatif. Teknik pengumpulan data berupa wawancara dan observasi. Subjek penelitian ini adalah Kepala Rekam Medis, Petugas Penanggung Jawab Operasional Unit Rekam Medis, Petugas Filling, Petugas Pengembalian Berkas. Penelitian  dilakukan pada bulan februari sampai bulan maret 2020. Hasil dari penelitian yang didapatkan yaitu pengetahuan dan sikap beberapa petugas masih belum paham dengan SOP pengembalian berkas rekam medis dan kepatuhan sikap petugas pengembalian masih kurang baik. Sarana dan prasarana sudah mendukung, hanya kurangnya ketelitian pada sumber daya petugas pengembalian. Sudah diberikan motivasi oleh koordinator pelayanan Unit Rekam Medis, dan sudah terdapat (SOP) pengembalian berkas rekam medis. Upaya yang dilakukan adalah memberi tahu perawat tentang batas waktu pengembalian berkas rekam medis rawat jalan, kepala rekam medis memberi teguran kepada perawat yang terlambat mengembalikan berkas rekam medis, memberikan motivasi kerja dan sering melakukan sosialisasi SOP terkait pengembalian berkas rekam medis rawat jalan.
Analisis Pelaksanaan Pelayanan Antenatal Care (ANC) pada Ibu Hamil di Puskesmas Candipuro Kabupaten Lumajang Ika Rahmadhani; Faiqatul Hikmah
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.v1i4.2089

Abstract

Angka Kematian Ibu (AKI) merupakan indikator derajata kesehatan suatu bangsa. Salah Satu upaya mengurangi angka AKI yaitu dengan menyelengarakan pelayanan Antenatal Care (ANC) yang berkualitas guna mencegah resiko kematian ibu dan janin. Standar pelayanan Antenatal Care (ANC) dapat dinilai melalui indikator capaian K1 dan K4. Puskesmas Candipuro merupakan salah satu puskesmas dengan jumlah rentang kunjungan antara K1 dan K4 cukup jauh yakni sebesar 21,2%, dengan nilai K1 sebesar 108% dan nilai K4 sebesar 86.8%. Tahun 2017 tercatat bahwa terdapat 2 kematian ibu di wilayah Puskesmas Candipuro. Tujuan penelitian ini untuk menganalisis pelaksanaan pelayanan Antenatal Care (ANC) pada Ibu Hamil di Puskesmas Candipuro Kabupaten Lumajang .Jenis  penelitian ini penelitian kualitatif. Hasil penelitian ini adalah analisis pelayanan Antenatal Care (ANC)  berdasarkan faktor input yaitu adanya kekurangan SDM, kurangnya penyerapan dana BOK, Ruang KIA yang tidak mendukung proses pemeriksaan dan tidak adanya SOP karena hilang, kemudian faktor proses yaitu pelaksanaan anamnesis yang kurang rinci, pemeriksaan 10 T yang tidak dilaksanakan setiap pemeriksaan yang menyebabkan resiko tinggi yang dialami ibu hamil tidak dapat di deteksi secara dini, serta pencatatan hasil pemeriksaan ibu hamil kedalam berkas rekam medis tidak lengkap, serta faktor output yang berupa proritas permasalahan. Prioritas permasalahan tersebut yaitu Kesenjanagan Cakupan K1 dan K4. Permasalahan kedua yaitu Kematian ibu yang terjadi di wilayah kerja puskesmas Candipuro disebabkan oleh pemeriksaan yang kurang lengkap dan rinci. Permasalahan yang ketiga yaitu perlunya dilaksanakan tata ulang ruang poli KIA agar mendukung proses pelayanan yang efektif dan efisien. 
Analisis Penyebab Ketidaksesuaian SPO Pengisian General Consent di Rumah Sakit Universitas Airlangga Nuril Amalia; Novita Nuraini; Andri Permana Wicaksono; Rosita Prananingtias
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.v1i3.2090

Abstract

The incompatibility of SPO (Standart Operational Procedure) for General Consent completion was one ofmany problems that exist in the implementation of medical record activities at Airlangga UniversityHospital. SPO incompatibility in General Consent Completion could be seen from incorrect answer inGeneral Consent form for each indicator. From 21 samples of General Consent forms, there wasunsuitable answers in such as the identity of the person in charge (62%), the identity of the patient (71%),the approval for information release, privacy, personal values and patient confidence as well as thesignature and name of the witness (100%), the signature and the name of the patient person in charge(24%) and the date (43%). The purpose of this study was to analyze the cause of the SPO incompatibilityfor General Consent completion in Airlangga University Hospital. This type of research was qualitativeresearch and data collection obtained through interview. The subjects in this study were 5 registrationofficers at Airlangga University Hospital. The result of this study showed the causes of the GeneralConsent Completion SPO incompatibility were no specific training about medical records, the GeneralConsent Completion SPO did not explain the procedures to complete the form thoroughly, and there wasno socialization related to the General Consent Completion at Airlangga University Hospital. The solutionsfor this problem are, there should be an effort to improve the General Consent Completion SPO, providetraining for registration officers and conduct socialization on General Consent Completion.
Analisis Tingkat Kepuasan Pasien BPJS Unit Rawat Inap dengan Metode IPA di Rumah Sakit Baladhika Husada Jember Tahun 2019 Mitha Amelia Rahmawati; 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.v1i3.2092

Abstract

Inpatient services at Baladhika Husada Hospital in Jember still have problem to provide satisfaction to patientssuch as nurses not responsive and less friendly, room cleanliness is not maintained, electricity is oftenextinguished and air conditioners are not lit, toilet cleanliness is not maintained, the room is cramped andtemperature over the standard, inpatient BPJS registration process are complicated and parking space can’taccommodate. The purpose of this study was to determine the level of patient satisfaction of inpatient BPJSunits by the IPA method. Type of the research is quantitative research with descriptive techniques analysis.The IPA analysis method to measure the level of performance and importance based on quality, delivery,security, and morals by identifying the value of the gap and depicted in the Cartesian diagram. The level ofstatisfaction of inpatients based on the IPA method is known that the results of the analysis of the cartesiandiagra m illustrating four quadrans that top priority, maintained, low priority, and considered excessive. Theresults of the gap value based on quality, conductor, security, and morals are <1, but based on security thereis one attribute that has a gap >1. The main improvement efforts for brainstorming results are monitoring theperformance of cleaning services and conducting public speaking training for officers to improvecommunication
Evaluasi Sistem Penomoran Rekam Medis Menggunakan Metode Focus PDCA di RSUP Sanglah Sedyo Pinerdi; Atma Deharja; Ervina Rachmawati
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.v1i3.2095

Abstract

The duplication of medical record numbers during February 2020 at Sanglah Hospital reachs 7 cases, it iscaused by the mistake of the officer register patients at SIMARS and the handling of duplicate cases that doesnot optimal. The purpose of this study was evaluated the patient's medical record numbering system used theFOCUS PDCA method at Sanglah Hospital. This type of the study is qualitative. The data collecting methodused in this study were observation and interviews. The data analysis stage in this research included aninvestigation stage to find, organized, clarify, understand, select, plan, do, check, dan action. The results ofthis study were duplicate cases that occur because patients were uncooperative when discussed with officers,patient did not register, officers were not thorough, authentication systems for patient search menu was notintegrated, the absence of regulations regarding the handling of cases of duplicate medical record numbers,and duplicate case reporting only limited to merge medical record files. The solutions chosen to solve theproblem were developing SIMARS registration menu, making SOP for handling duplicate cases of SanglahHospital medical records, and making menu recording and reporting of duplicate medical record numbercases in E-PASTI.The planning done is an analys of the needs of emergency room registration officers,discussion of SOP design for handling duplicate medical record number cases, and analys the staff's needsfor the development of E-PASTI that results. The next stage is to give an advice in the IT field to developSIMARS in the patient registration search menu, request SOP authorization for the handling of duplicatemedical record number cases for the head of the medical record, and implement the menu recording andreporting of duplicate medical record number case cases.
Analisis Kepuasan Pengguna Electronic Health Record (EHR) dengan Menggunakan Metode Delone and Mclean di Unit Rekam Medis RSUPN dr. Cipto Mangunkusumo Resti Aprilia Tri Hendaryanti; 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.v1i3.2102

Abstract

The rapid development of technology requires humans to move forward to compensate for this. Ease thatis obtained along with technological advancements in carrying out all activities so that the time spentbecomes efficient and can reach wider society. RSUPN Dr. Cipto Mangunkusumo has followedtechnological developments by using EHR which is used to facilitate the process of service in the medicalrecord unit from the patient coming to the patient coming out. EHR at RSUPN Dr. Cipto Mangunkusumostill has shortcomings that is loading long enough 5 minutes for 1 file search that inhibits storage officersand agreement officers in providing patient medical records, other conditions are some menus related toreports are not appropriate and still cannot be accessed so officers must process data in advance to beused as a report and the unavailability of EHR learning modules specifically for new users. The study aimsto analyze the satisfaction of users of EHR at RSUPN Dr. Cipto Mangunkusumo using DeLone andMcLean methods with 6 indicators namely system quality, information quality, use, user satisfaction,individual impact and organizational impact. This type of research used qualitative research with 20respondents. Based on the analysis of user satisfaction it is known that the EHR facilitates the work ofofficers, the information provided is of high quality, the functions provided help the work of officers. It isexpected that the analysis of user satisfaction with EHR can be used as an effort to improve electronicmedical records by adding report print menus, updating servers and creating EHR learning modules.
Analisis Faktor Penyebab Kerusakan Berkas Rekam Medis di Rumah Sakit Universitas Airlangga Aulia Nurul Kholifah; Novita Nuraini; Andri Permana Wicaksono
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.v1i3.2104

Abstract

Medical records are files that contain records and documents regarding patient identity, examination results,treatment, actions and other services that have been provided to patients. Management of medical records is oneof medical support services. Based on the results of a preliminary study conducted at Airlangga UniversityHospital Surabaya it is known that in February 2020 amount 104 files were damaged so that the forms containedin them could be torn. This research was aimed to analyze the factors that cause damage to medical record filesat Airlangga University Hospital Surabaya. This type of research uses qualitative and data collection withinterviews and observations by using the analysis of 5M management elements is Man, Machine, Method,Material, Money. The population in this study is the medical records officer filing room section of 5 officers. Theresults obtained are that there are still many medical records officers who have a background not DIII medicalrecords, the lack of socialization of SOPs related to the maintenance of medical record files, limited number ofrack filing, and the less used folder material. So the suggestion made by the researchers is to redesign themedical record file folder by using a color code, and calculate the rack filing needs.

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