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Muhammad Yunus
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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 275 Documents
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Pembuatan Aplikasi Peminjaman Berkas Rekam Medik Berbasis Web di RSUP Klaten Moh Maulana; Andri Permana Wicaksono; 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.v2i1.2153

Abstract

Medical records according to Permenkes No. 269 of 2008 is a file containing notes and documents about patient identity. The problem that often arises in Klaten General Hospital is the length of the file search process due to the absence of applications that control the entry and exit of files, when officers borrow and return only to write in the control book. Supporting all the problems and objectives needed by the data, so the data collection methods used are observation and interviews. Analysis of the data obtained from the interview and observation process is to draw conclusions and identify the most urgent problems. The goal to solve this problem is to make an application that controls the borrowing and return of the RM file so that the officer knows quickly where the file will be sought. The application is made using the waterfall method in the workflow process and uses several programming languages such as PHP, HTML and CSS. The results of the application have been tested by several users using blackbok testing, but still do not know how effective and efficient when the application is tested in actual service.
Identifikasi Faktor Penyebab Ketidaksesuaian Pelaksanaan Retensi Dokumen Rekam Medik Inaktif di RS Husada Utama Kota Surabaya Dwi Winda Agustin; Rossalina Adi Wijayanti; Gilang Nur Permana
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.v2i1.2156

Abstract

Hospitals as a health service facility are required to make medical records Retention is the transfer of inactive DRM to inactive filing to reduce the amount of DRM that is on an active filing rack. The number of visits in the Husada Utama Hospital in Surabaya each year has increased that is not proportional to the large capacity of storage space, causing an incompatibility of the implementation of medical record document retention SOP. The purpose of this study was to identify problems using five elements of management namely man, money, method, material, machine. This research is a type of qualitative research. The results of this study are the identification of problems that occur and the causes of the problem are knowledge, education, training, operational costs, inactive storage space, medical record shelves, scanning equipment, computers and SOP. As a result of these problems will result in a buildup of medical record files which causes narrowing in the storage room that affects the hospital's accreditation standards. The alternative solutions to problems are the existence of SOP socialization, attending training, the existence of a budget for procurement of equipment, the expansion of storage space and the addition of medical record file shelves, the provision of scanning tools and computers as well as SOP evaluation.
Analisis Faktor Penyebab Pending Klaim Akibat Koding Berkas Rekam Medis Pasien Rawat Inap di RSUPN Dr. Cipto Mangunkusumo Salma Firyal Nabila; Maya Weka Santi; Yusirwan Tabrani; Atma Deharja
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.v1i4.2157

Abstract

Klaim BPJS Kesehatan adalah pengajuan biaya perawatan pasien peserta BPJS oleh pihak rumah sakit kepada pihak BPJS Kesehatan yang dilakukan secara kolektif dan ditagihkan kepada pihak BPJS Kesehatan setiap bulannya. Setelah itu BPJS Kesehatan akan melakukan persetujuan klaim dan melakukan pembayaran untuk berkas yang layak, namun untuk berkas yang tidak layak klaim atau pending (unclaimed) harus dikembalikan ke rumah sakit untuk diperiksa kembali. Kejadian pending klaim di RSUPN Dr. Cipto Mangunkusumo disebabkan oleh beberapa hal diantaranya administrasi, medis, koding, tidak layak dan lainnya. Berdasarkan studi pendahuluan ditemukan berkas pending klaim pada bulan januari 2020 sebanyak 788 dari 2539 pasien rawat inap yang menggunakan Jaminan Kesehatan Nasional. Dari permasalahan tersebut maka dilakukan analisis terkait faktor penyebab pending klaim akibat koding melalui pendekatan fenomenologi yang meliputi input dan proses pada bagian Koding di RSUPN dr. Cipto Mangunkusumo. Hasil penelitian terkait SDM diperlukan penambahan jumlah sumber daya manusia serta sosialisasi pembaharuan dari aturan koding. Terkait Sarana dan Prasarana yaitu keterbatasan ruangan petugas koding diperlukan pertemuan secara rutin. Terkait Teknologi yaitu mendukung proses klaim berkas rekam medis pasien diintegrasikan dengan proses manajemen lain yang terdapat di SIMRS. Berdasarkan analisis proses terkait Perencanaan yaitu telah memiliki SOP penyelesaian permasalahan pending klaim. Terkait Pengorganisasian yaitu perlu dibuat job description khususnya pada petugas bagian coding. Terkait Pelaksanaan yaitu proses pengklaiman dilihat dari alur yang ada telah sesuai dengan SOP yang berlaku serta pada analisis proses terkait Evaluasi yaitu mengadakan pertemuan rutin atau rapat bulanan.
Analisis Faktor Penyebab Keterlambatan Pengembalian Berkas Rekam Medis Rawat Inap di RS Universitas Airlangga Abdul Haqqi; Novita Nur Aini; Andri Permana Wicaksono
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.v1i4.2158

Abstract

One of the hospital's obligations is to organize a medical record. Good or bad medical record-up is a description of the quality of the hospital. The minimum service standard for the patient's return of the patient's medical record is completed by obtaining medical services until the medical record file returns to the medical record room within 2x24 hours. The return of an inpatient medical record in Universitas Airlangga Hospital takes more than 2 X 24 hours, even up to 1 week is calculated since the patient returned home and the file has not been completed 100%. Such problems will result in delayed reporting, provision of old patient medical record files should still be sought in the last location of the borrower's medical record file if not found in the filing rack. There is still an unrecorded return time in the expedition book. There is a problem with the delay in the return of an inpatient medical record so that it is necessary to identify the problem that aims to correct or minimize potential problems. The identification methods used are observation and interview methods. Observations are performed on data sources collected either primary data or secondary data related to the cause of the return of the medical record file. The interview is conducted by the researcher to the officer related to the late return of the inpatient medical record file. The study uses the 5M method (Man, Machine, Method, Material, and Money) by Harrington Emerson.
Identifikasi Faktor Penyebab Penumpukan Berkas Rekam Medis Aktif di RS Husada Utama Nurul Kamilia; Rossalina Adi Wijayanti; Ida Nurmawati
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.v1i4.2160

Abstract

Based on the results of a preliminary study conducted at the Husada Utama Hospital it is known that in 2018 there was an accumulation of active medical record files which were 310 files. The impact of the accumulation of medical record files is the provision of medical record files will take longer so that patients often complain, officers become fatigued quickly in doing their work so that it will also have an impact on the depreciation process that should be done every day, and officers also feel uncomfortable and disturbed because the accumulation of medical record files also interferes with access to filing officers when retrieving and returning medical record files. This study aims to identify the factors causing the accumulation of active medical record files in Husada Utama Hospital. This type of research uses qualitative and data collection by interview, observation, and documentation. The results obtained that the results showed that the cause of the accumulation of medical record files that affect from the Man side is that the officer has never attended medical records training, from the Money side that is still not getting a budget for storage shelves, from the Material side there is a medical record file that is not using a map, in terms of Machine that is the number of storage racks not according to needs and in terms of Method which is the implementation of a storage system, alignment, and retention that is not in accordance with the Standard Operating Procedure (SOP).
Analisis Pelaksanaan Sensus Harian Rawat Inap di RSUD Dr. Saiful Anwar Malang Ferly Ferly; 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.v1i4.2163

Abstract

Abstract Information obtained from the daily inpatient census in the form of data that will be processed into information needed by the hospital, so that the daily inpatient census activities must be carried out correctly in accordance with procedures so that the data generated is accurate and can be used as a basis for decision making for management. This study aims to analyze the factors causing the inactivity of inpatient daily census activities correctly using a fishbone diagram. This research is a qualitative descriptive study conducted at Dr. Saiful Anwar Malang in February - March 2020. The subjects of this study were the daily census officer of the inpatient room, and the daily census officer of the medical record section. Data was taken by interview and observation methods. Data were analyzed using fishbone diagrams. The results of this study indicate that the factors that cause the inability of the inpatient daily census to be conducted correctly are Man (misperception of the inpatient census daily officer between the understanding day of care with the length of stay, educational background of the officer not from the medical record, and the officer has never attended training on the census), Money (there is no funding budget for training implementation, Materials (census information system on billing system is not implemented, census recapitulation is still manual using paper forms and Microsoft excel), Method (Daily SOP for inpatient census has not been revised), Machine (census application on billing system is not implemented) Fishbone diagrams where the in-patient census daily activities are carried out correctly are mostly caused by Man factors and Materials factors.
Evaluasi Rekam Medis Elektronik Bagian Coding Rawat Inap RSUD K.R.M.T Wongsonegoro Kota Semarang Septina Dwi Indrawati; 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.v1i4.2164

Abstract

RSUD K.R.M. T Wongsonegoro The city of Semarang became one of the type B hospitals in the city of Semarang, which have applied the electronic medical record gradually the application of electronic medical records assessed as an effort to improve the quality of services increasing patient satisfaction improves the documentation accuracy reduces clinical error and speeds up patient data access. (Billy Maria in Andriani DKK 2017). One of the service units that require the speed, accuracy and accuracy of access to patient data is the coding part of the hospitalization of the person who handled the medical record and coding (PJRM). In its implementation, there were constraints that made the officers less satisfied with RME. The purpose of this research is to evaluate RME implementation using the PIECES method (performance, information, economic, control, efficiency, service). This type of research is qualitative research, by conducting observation methods and interviews to PJRM officers. The results of RME evaluation conducted using the PIECES method on the performance/performance aspect, RME has already produced a good performance. Based on information/information aspect, RME can provide accurate information quality, according to user needs, and easy to understand. Based on Economy/economy, RME has the value to be integrated with one hospital and have qualified resource. Based on Control/control aspect, RME has good integrity and security because it comes with username and password, has different permissions. Based on the Efficiency/data efficiency aspects of RME can be easily learned, operated, and processed. Based on the Service/service aspect: RME users feel that RME provides convenience for RME users. In conclusion, RME in the coding part of inpatient is good enough in terms of Performance, Information, Economy, Control, Efficiency and Control. The advice that can be given is to make improvements and development on RME to avoid errors, regulatory or regulation regarding steps when errors occur, as well as conducting socialization or training to RME users.
Tinjauan Pelepasan Informasi Rekam Medis Berdasarkan Aspek Hukum Keamanan dan Kerahasiaan Rekam Medis untuk Pendidikan di RSUD Sleman Futari Ayu Istikomah; Feby Erawantini; Dony Setiawan Hendyca Putra
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.v1i4.2169

Abstract

Regional general hospital of sleman (RSUD) is a hospital located in Sleman Regency with type B education. As a teaching education, Sleman District Hospital often borrows medical records for research (Education) related to the release of medical record information with third parties necessary. Because the character of medical record documents and their contents are confidential, the hospital must guarantee the confidentiality of the contents of the medical record file and legal protection for patients and hospitals. This research was aimed to find out how the release of medical record information based on legal aspects of the security and confidentiality of medical records for education in Sleman Hospital. This type of research is qualitative by collecting data using interviews, observation and documentation. The results of research at the Sleman Hospital in the application of releasing medical record information for educational purposes in the Sleman Hospital are still not by existing regulations related to the unavailability of expedition books or medical record file borrowing books where the book is very important in knowing the existence of medical record files that come out. And a special place for researchers when researching medical record files is not yet available due to limited space in the medical record unit of Sleman District Hospital.
EVALUASI KETIDAKTEPATAN PEMBERIAN KODE REKAM MEDIS RAWAT JALAN DI RS PHC SURABAYA Mahardika Nugraha; Dony Setiawan Hendyca Putra; Efri Tri Ardianto
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 2 No 2 (2021): March
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v2i2.2176

Abstract

Codification is an activity to transform a diagnosis into a code consisting of letters and numbers.Inaccuracies of coding can slow the process of insurance claims and decrease the quality of medicalrecords. Preliminary study results showed a percentage of inaccuracy in the diagnostic code of 4documents of a total of 10 outpatient medical record documents at PHC Surabaya Hospital. This researchaims to evaluate the correctness of an outpatient medical record file in Surabaya's PHC Hospital. This typeof research used qualitative research. The samples were 44 documents of the outpatient medical record inJanuary 2020. Data collection techniques using observation and documentation. The results of the studyshow that the code inaccuracies in an outpatient medical record document of 13 (29.5%) improper codeand 21 (70.5%) of the right code. The cause of its absence was an error in the code-granting suspect of15.4%, a mistake in giving control code and therapy of 61.5%, and an error in giving the fourth character inthe case of diabetes mellitus by 23.1%. Factors that lead to inaccuracy in the coding of an outpatientmedical record were the less thorough officers in conducting medical record reviews as well as mistakes indetermining the old case and new cases. The suggestions provided by researchers are to conduct routinecoding audits, repair SOP, socialization about the correct encoding procedures, and make a note for thecode which is often to be used.
Evaluasi Sistem Informasi Manajemen Dokumen Akreditasi (SISMADAK) Dengan Menggunakan Metode PIECES di Rumah Sakit Bhayangkara Lumajang Ines Meiyola Pradanthi; Feby Erawantini; Sustin Farlinda; 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.v2i1.2183

Abstract

Bhayangkara Hospital Lumajang is one of SNARS accredited health agencies and SISMADAK is used in the reporting process to KARS. The problems is still found in its application, which resulted in staff being less satisfied with SISMADAK. The aims of this study was to evaluate SISMADAK in terms of user satisfaction using the PIECES method. The study was quantitative descriptive study, which is described as a descriptive evaluation by comparing user satisfaction with information systems. The result of description evaluate of SISMADAK using PIECES method in Bhayangkara Hospital Lumajang about satisfaction percentage found 81% of performance variable was showed very good, 81% of information variable was stated very good, 69% of economic variable was good, 76% control variable was stated very good, 70% of efficiency variable was stated very good, and 80% of service variable was responded very good. For further advices were the planned of SISMADAK users need related information that is not yet available, beside the staff should increase the confidentiality of data on SISMADAK. The conclusion of this study is SISMADAK able to facilitate users in the hospital accreditation process of KARS.

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