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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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Identifikasi Penyebab Keterlambatan Penyediaan Dokumen Rekam Medis Rawat Jalan di Rumah Sakit Husada Utama Surabaya Tahun 2020 Astrid Kartika Dewi Aprilia; Ida Nurmawati; 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.v1i4.2130

Abstract

Fast and precise services are the desire of consumers. The speed of document provision of medical records to the PDS can be an indicator in measuring satisfaction. Based on the SPM of the hospital when providing outpatient medical records is ≤ 10 minutes. Husada Utama Surabaya Hospital has implemented medical records management, but there are problems in the implementation, in the provision of medical record documents less than the maximum and delayed. The aim of this research is to determine the factors causing delays in the provision of patient medical record documents in outpatient services based on 7M (man, money, method, material, machine, motivation, and media). This type of research is qualitative. Data collection used observation sheets and interview guidelines to 4 respondents. The results showed that the education, knowledge, and training of employee about the science of medical records is still lacking, the budget was managed by the financial management and there were no details for the needs of the medical record unit, there is no SOP about the provision of outpatient medical record documents, the medical record file is only a thin sheet of HVS paper, the folder used is easily damaged, outpatient medical records employee never get a reward from the leadership, room and rack filling cannot store medical records medical records properly. In conclusion, the factors that caused the delay in providing medical record documents are man, money, method, material, motivation, and media. The results of this study can be an evaluation material for Husada Utama Hospital to improve the service provision of medical records for outpatients.
Analisis Faktor Penyebab Penurunan BOR di RSUD Sleman Anggun Elyana; Feby Erawantini; Suratmi Suratmi
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.v2i1.2131

Abstract

One indicator of the fulfillment of health services to the community, especially in hospitals, was the calculation of the Bed Occupancy Rate (BOR). Factors that caused inefficient BOR need to be analyzed. The impact of a inefficient BOR returning decrease of income economic to the hospital. The purpose of this research is to analyze causative factors of decrease BOR in Regional Public Hospital of Sleman. This research is a qualitative research, with the intention of digging deeper causative factors of decrease BOR. research conducted at Regional Public Hospital of Sleman in February-March 2020 with analyze unit is inpatient care unit at Regional Public Hospital of Sleman. Data collection methods by interview and observation as well data analyze by fishbone diagrams. The results showed that the cause of the decrease in BOR was due to uncertain doctor visit schedules, lack of availability of beds, system errors, lack of reward and punishment, number of competing hospitals and less optimal reporting census monitoring. Suggestions to fix the problems that occur in the process of inpatient services due to a decrease in BOR can be improved Evaluate the SPO of inpatient services, Hold outreach to officers, fix SIMRS, improve the performance of marketing parties to attract patients and provide patients with a complete service and policy development (SK) related to reward and punishment.
Sistem Informasi Peminjaman dan Pengembalian Rekam Medis Berbasis SMS Gateway Eltigeka Devi Apriliani; Sustin Farlinda; Feby Erawantini; Mochammad Choirur Roziqin
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.v1i4.2135

Abstract

The process of borrowing and returning medical record at Ambulu Public Health Center still use manual book and make return of medical record documents that are not in accordance with SOP (Standard Operational Procedure). The purpose of this research is to design and create an information system of borrowing and returning the medical records based SMS gateway at Ambulu Public Health Center. The method used in this research is waterfall. The stages of the waterfall is requirements analysis, system design, create system, and system testing. The data collected by interview, observation, and FGD (Focus Group Discussion). The results of this research is the information systems of borrowing and returning the medical records based SMS gateway as message or automatic reminder. The suggestion for Ambulu Public Health Center is use information system of borrowing and returning the medical record based SMS gateway can make simple the reports.
Perancangan Sistem Informasi Peminjaman dan Pengembalian BRM Rawat Jalan di Rumah Sakit Husada Utama Lidya Nur Fatimatuz Zuhro; Ida Nurmawati; Rossalina Adi Wijayanti; Gilang Nur Permana
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.v1i4.2136

Abstract

Borrow and return outpatient medical records at the Husada Utama Hospital in Surabaya still uses manuals by referring to the date of discharge from the hospital to search for files that have not been returned or for file tracking so that it can cause difficulties for officers in tracking outpatient medical records. Data of delay in the return of outpatient medical records in February-March 2020 counted for 117 (14.88%) of the total files late from the 786 total outgoing files. SOP (Standard Operational Procedure) that applies at Husada Utama Hospital regarding hospital service standards is explained by the medical records of Specialist Practices which are returned within 1X24 hours on the same day. While the medical record file in the inpatient room is submitted no later than 2X24 hours after the date the patient is discharged from the hospital. This research  was aimed to design a web-based outpatient medical records and loan information system at the Husada Utama Hospital in Surabaya. The type of research is qualitative research with data collection methods of observation and interviews. The subjects of this research were the head of the medical record and the outpatient medical record officer. The method used by researchers is the waterfall method. The results of this research can be seen that the design of information systems for borrowing and returning outpatient medical record files are made according to the needs of users, making the system starts from the needs analysis so it produce a system design that suits your needs.
Analisis Penerapan RME Pada Unit Coding Rawat Jalan RSUD K.R.M.T Wongsonegoro Semarang Amaliya Nikmatul Rohmah; Ida Nurmawati; Indah Muflihatin; Syaifuddin Syaifuddin
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.v1i4.2137

Abstract

RSUD K.R.M.T Wongsonegoro Semarang City is one of the hospitals that have implemented an electronic medical record at the end of December 2017. Information systems that support management and service to patients are electronic medical records, especially in outpatient coding units. One factor that plays an important role in the successful application and use of information technology is the user factor. The level of user readiness to accept information technology has a major influence in determining the success or failure of the application of the technology. The purpose of this study was to evaluate the application of electronic medical records in outpatient coding units based on the Technology Acceptance Model (TAM) method. This type of research is qualitative research with the data collection methods, namely interviews, observation and documentation. The subjects of this study were outpatient coding officers. The results showed that based on the aspects of usefulness in the use of electronic medical records in outpatient coding units be very beneficial for officers. Based on the aspect of ease in showing the acceptance of electronic medical records, it is considered easy to understand, flexible enough with the work of officers and easy to used to assist with work. Based on the aspect of interest, it is obtained that outpatient coding officers also show their interest in the system, and plan to use the system in the future, although there are some obstacles. The solution obtained from the problem is making guidelines for the use of electronic medical records, adding electronic signature features to electronic medical records for patient medical resume forms, striving for electricity and electricity networks to remain stable, making updates or updating electronic medical records.
Analisis Beban Kerja Petugas Filling Rekam Medis Rawat Jalan dengan Metode WISN di RSU Haji Surabaya Tahun 2020 Nur Hasanah Ayu Purnamawati; Novita Nuraini; Yuni Astuti
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.v2i1.2139

Abstract

Surabaya Haij General Hospital is one of the type B educational hospitals that has stored medical record files in the filling room. Surabaya Hajj General Hospital has 37 Outpatient Clinics with the number of visits in 2020 is 93,232 patients with an average number of old patient visits per day is 890.14 patients and the average number of new patient visits per day is 42.18 patients (Haji Hospital Surabaya, 2018) with 95.48% of old patients to the total number of outpatient visits. Outpatient filling is obtained that there are still a lot of outpatient medical records file that have been scattered or not yet entered on the filling rack. The purpose of this study is to analyze the workload of outpatient filling staff with the Work Load Indicator Staff Need (WISN) method at RSU Haji Surabaya in 2020. This research uses descriptive research type, with the method of observation and interview of 6 outpatient medical records filling officers. The object of this study is the workload of medical records filling officers. The results showed that the calculation of available working time for outpatient filling staff was 113,100 minutes / year, the main activities of outpatient filling staff at RSU Haji Surabaya were 44 minutes, Standard workload for outpatient filling officers at RSU Haji Suarabaya was 49,952 files / year, Standard allowance for outpatient filling staff at Surabaya Haji Hospital is 0.195 hours / year, with the results of the WISN calculation is 8 officers and a WISN ratio of 19.6.
Analisis Lama Waktu Penyediaan Berkas Rekam Medis Rawat Jalan untuk Pasien Lama Poli Bedah Onkologi di RSAL dr. Ramelan Surabaya Tahun 2020 Bastin Nur Aliefia; Gamasiano Alfiansyah; Indah Muflihatin
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.v2i1.2142

Abstract

Polyclinic at RSAL dr. Ramelan Surabaya which has the most number of patient visits every day is poly surgical oncology than other poly surgery which is ± 55 - 60 patients, here researchers see that with the many requests for medical record files, the supply of medical record files must be as fast as possible and must still meet existing standards. But in reality the supply of medical record files still exceeds the standard. The results of the observations I made to search for 1 file took 5 minutes until the file was recorded in the register of each poly, aiming that the file with no. The RM has been sent and then barcoded or sent via SIMRS, it should be marked that the medical record file must already be in the clinic but here the file is still placed on the table very long which is about 15 minutes and can also be more than it should be sent to the polyclinic. That way the file does not get to the clinic according to the Hospital Minimum Service Standards (SPM). The aim is to find out how long it takes to provide medical records in outpatients for poly surgical oncology patients at RUMKITAL Dr. Ramelan Surabaya. This type of research is qualitative. Data collection techniques in the form of interviews and observations. The population in this study were all outpatient medical record files for oncology surgery patients in March 2020. The results obtained from the study were the length of time the provision of outpatient medical record files for old poly surgical oncology patients exceeded the established standard that required an average time 11 minutes for each file arrived at the polyclinic.
Evaluasi Rekam Medis Elektronik di Tempat Pendaftaran Pasien Gawat Darurat dan Rawat Inap RSUD K.R.M.T Wongsonegoro Kota Semarang Eka Cintiya Febrianti; Ida Nurmawati; Indah Muflihatin
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.v1i4.2145

Abstract

Each hospital is required to hold records or records of all services provided to patients called medical records. Increasing the effectiveness of recording medical data that is accurate, fast, can take advantage of current technological advances through the implementation of the Electronic Medical Record (EMR) system in hospitals. RSUD K.R.M.T Wongsonegoro is one of the hospitals that has implemented an electronic medical record (EMR) especially in the inpatient and emergency department registration units. The application of this electronic medical record still has some flaws that must be evaluated. This study aims to evaluate the implementation of electronic medical records at the emergency and inpatient registrations of Wongsonegoro Hospital. Data collection in this study consisted of observations and interviews. Identification of problems using the TAM (Technology Acceptance Model) method by reviewing from 3 aspects namely perceived usefulness, perceived ease of use, and behavioral intention to use. This type of research is descriptive qualitative by narrating the results of research based on the data obtained. The results obtained from this study are based on the aspect of usefulness (perceived usefulness), namely the use of electronic medical records in TPPGD and TPPRI, making the registration officer work faster and more effective.The aspect of ease (perceived ease of use) obtained from the interview results is that it is able to make it easier to accelerate the registration process in the TPPGD and TPPRI. The behavioral intention to use obtained is that the users of this system really need this electronic medical record and the registration officer at TPPGD and TPPRI plans to use the EMR in the future.
Analisis Faktor Penyebab Terjadinya Missfile Berkas Rekam Medis Rawat Inap di Rumah Sakit PHC Surabaya Tahun 2020 Muzaffatul Hasan; Efri Tri Ardianto; Dony Setiawan Hendyca Putra
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.v2i1.2147

Abstract

Based on the results of a preliminary study conducted at the Surabaya PHC Hospital in 2020 in the filing section of the Surabaya PHC Hospital there was still a missfile incident in the inpatient medical record file. Missfile is an incident where the medical record file is not found because of an error in placing the medical record file on the filing rack, this can cause a decrease in the quality of services provided. The importance of the role of medical record documents in creating information that is sustainable, researchers interested in examining the problem of the occurrence of errors (missfile). This study aims to analyze the analysis of the factors that cause the medical file file missfile in Surabaya PHC Hospital using the PTA (Problem Tree Analysis) method. This type of research is qualitative with observation and interview data collection techniques. The results of this study are the main factors causing missfile is the behavior of officers, level 1 contributing factors are There is no responsible person in the inpatient medical record file storage, less maximum use of facilities and infrastructure and SOP (Standard Operating Procedure) storage of inpatient medical record files never been socialized. Factors causing level 2 are the need for officers to be responsible for storing inpatient medical record files, lack of knowledge about tracers and the existence of maps in inpatient medical record files, lack of application of SOP (Standard Operating Procedure) does not match the reality because it is only limited accreditation fulfillment requirements. So the implementation of inpatient medical record file storage in Surabaya PHC Hospital is still not good, so that there is still a missfile. The hospital should increase the number of workers in the medical records unit in the filing section, conduct socialization on the importance of using tracers, accelerate the procurement of inpatient medical record file folders and apply SOPs as guidelines for officers in carrying out work. So that the implementation of inpatient medical record file storage for the better.
Analisis Beban Kerja Petugas Rekam Medis Bagian Filing dengan Metode WISN di RSD Mangusada Badung Tahun 2020 Raisa Putri Ramadhani; Sustin Farlinda; Atma Deharja
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.v2i1.2149

Abstract

Workload analysis is an attempt to find out the time used by officers to complete a particular task which is expected to know the proportion of the number of officers needed in a particular work unit in an agency. The Importance of Workload Analysis must be carried out routinely in order to obtain information about the description of the workload of units in an agency. This research aims to analyze the workload of medical records officers so that the workload level of the officer is known using the WISN (workload indicator staff need) method, The type of this research is qualitati with data collection techniques in the form of observation, interviews, documentation, and library research. The subjects of this study were 9 staff officers which 1 head of filing affair and 8 implementing staff. Based on human resource qualification research, there was enough job description, but based on patient visit rates after RME implementation since early 2020 showed a drastic decrease in visits where before the RME was applied the average number of patient visits 20,000 patients per month, while after applying RME for January and February there were 6,485 and 6,116. The results of the calculation of the workload know that the number of officers needed is the ideal number of officers needed, which is 4.96 so that it is rounded up to 5 so that it can be concluded that there is a need for relocation of as many as 4 people to other work units so that Mangusada Regional Hospital can provide maximum human resources as efficiently as possible.

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