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INDONESIA
Indonesian Journal of Health Information Management (IJHIM)
Published by Sekolah Tinggi Ilmu Kesehatan Mitra Husada Karanganyar
ISSN : -     EISSN : 28072596     DOI : https://doi.org/10.54877
Core Subject : Health,
Health Professions Public Health
Indonesian Journal of Health Information Management (IJHIM) is a scientific journal managed by Study Program of Health Information Management Applied Bachelor and Diploma 3 of Medical Record and Health Information, STIKes Mitra Husada Karanganyar. IJHIM contains research publication in medical record, health information management, health information technology, health information system, health quality management, hospital statistic, and coding. The frequency of IJHIM publication is three times in a year (February, June, and November). The focus and scope of IJHIM is in the field of Health Information Management with the following themes: Medical Record Management Health Information Clinical Audit Coding Audit Medical Record audit Health Information Technology Health Information System Health Service Statistic
Arjuna Subject : Profesi Kesehatan - Profesi Kesehatan (Lain-Lain)
Articles 6 Documents
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Search results for , issue "Vol. 1 No. 1 (2021)" : 6 Documents clear
LITERATURE REVIEW : PELEPASAN INFORMASI MEDIS KEPADA PIHAK ASURANSI Almas Ummi Fatharina; Sri Sugiarsi; Trismianto Asmo Sutrisno
Indonesian Journal of Health Information Management Vol. 1 No. 1 (2021)
Publisher : Sekolah Tinggi Ilmu Kesehatan Mitra Husada Karanganyar

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (37.854 KB) | DOI: 10.54877/ijhim.v1i1.1

Abstract

Abstract Release of medical information must be subject to applicable procedures and must be with the patient's consent. Patients must make a stamped written statement that has authorized a third party to request medical data from a doctor. The purpose of this study is to determine the policy of releasing medical information and the flow of procedures for releasing medical information to the insurer. The research method in this study is to use a literature review design, namely research that examines research articles on the release of medical information to insurance parties by comparing, summarizing, and drawing conclusions. The search strategy used keywords and operator bundles used in this study, namely "medical records" or "information release" or "insurers". The result of the research is that a hospital is in the process of releasing medical information using policies in the form of SOPs, cooperation agreements with insurance parties, and orally. In addition, there are hospitals that have different procedures for releasing medical information because they do not only serve one insurance party, but there are several insurance parties that are served such as BPJS, Jasa Raharja, and Askes. However, in the process of releasing medical information, there are hospitals that are not yet in accordance with the flow of medical information release procedures that have been determined by the Hospital. Therefore, the hospital conducts outreach on the flow of procedures for releasing medical information so that the officer in charge has a better understanding of the release of medical information. Keyword : medical records, information release, insurers Abstrak Pelepasan informasi medis harus mengacu pada prosedur yang berlaku dan harus dengan persetujuan pasien. Pasien harus membuat pernyataan tertulis bermaterai bahwa telah memberi kuasa kepada pihak ketiga untuk meminta data medis dari dokter. Tujuan penelitian ini adalah untuk mengetahui kebijakan pelepasan informasi medis dan alur prosedur pelepasan informasi medis kepada pihak asuransi. Metode penelitian dalam penelitian ini adalah menggunakan desain literature review yaitu penelitian yang mengkaji artikel-artikel penelitian tentang Pelepasan Informasi Medis Kepada Pihak Asuransi dengan cara membandingkan, meringkas, dan mengambil kesimpulan. Strategi pencarian menggunakan keyword dan booelan operator yang digunakan dalam penelitian ini yaitu “rekam medis” or “pelepasan informasi” or “pihak asuransi”. Hasil penelitian terdapat Rumah Sakit yang dalam proses pelepasan informasi medis menggunakan kebijakan dalam bentuk SOP, perjanjian kerjasama dengan pihak asuransi, dan secara lisan. Selain itu terdapat Rumah Sakit memiliki alur prosedur pelepasan informasi medis yang berbeda-beda karena tidak hanya melayani satu pihak asuransi saja, tetapi ada beberapa pihak asuransi yang dilayani seperti BPJS, Jasa Raharja, dan Askes. Akan tetapi dalam proses pelepasan informasi medis terdapat Rumah Sakit yang belum sesuai dengan alur prosedur pelepasan informasi medis yang telah ditentukan oleh Rumah Sakit. Oleh karena itu pihak Rumah Sakit melakukan sosialisasi mengenai alur prosedur pelepasan informasi medis agar petugas yang bertanggungjawab lebih paham mengenai pelepasan informasi medis.
LITERATURE REVIEW : PERANCANGAN TRACER DALAM PENYIMPANAN DOKUMEN REKAM MEDIS Riya Ismawati; Rohmadi
Indonesian Journal of Health Information Management Vol. 1 No. 1 (2021)
Publisher : Sekolah Tinggi Ilmu Kesehatan Mitra Husada Karanganyar

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (32.757 KB) | DOI: 10.54877/ijhim.v1i1.2

Abstract

Abstract Tracer Medical recordis a tool used to control the use of medical record documents which are usually used to replace medical record documents that come out of storage shelves. Problems that occur in the storage system are misfiles and delays in returning medical record documents anddesigns tracer that are not up to standard. The method used is a literature review to determine thedesign tracer based on aspects of size, material and color, content, pouch and request slip. It was concluded that the size used was in accordance with the standard, which was equal to or larger than the medical record, the material used was strong and brightly colored so that it was easy to search, contained the contents of the patient's name, medical record number, the purpose of the medical record or borrower and the date of discharge and there was a pocket. and the request slip on the tracer . Keywords : tracer, design, medical record Abstrak Tracer rekam medis adalah sarana yang digunakan untuk mengontrol penggunaan dokumen rekam medis yang biasanya digunakan untuk menggantikan dokumen rekam medis yang keluar dari rak penyimpanan. Permasalah yang terjadi pada sistem penyimpanan yaitu misfile dan keterlambatan pengembalian dokumen rekam medis serta rancangan tracer yang tidak sesuai standar. Metode yang digunakan adalah literature review untuk mengetahui rancangan tracer berdasarkan aspek ukuran, bahan dan warna, isi, kantong dan slip permintaan. Didapatkan kesimpulan ukuran yang digunakan sudah sesuai standar yaitu sama atau lebih besar dari rekam medis, bahan yang digunakan kuat dan berwarna mencolok agar mudah dalam pencarian, memuat isi berupa nama pasien,nomor rekam medis,tujuan rekam medis atau peminjam dan tanggal keluar serta terdapat kantong dan slip permintaan pada tracer tersebut. Kata Kunci : tracer,perancangan,rekam medis
LITERATURE REVIEW FAKTOR YANG MEMPENGARUHI KETEPATAN PETUGAS KODING DIAGNOSIS BERDASARKAN UNSUR 5M Vera Yulianti Budiyani; Astri Sri Wariyanti; Sri Wahyuningsih
Indonesian Journal of Health Information Management Vol. 1 No. 1 (2021)
Publisher : Sekolah Tinggi Ilmu Kesehatan Mitra Husada Karanganyar

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (41.622 KB) | DOI: 10.54877/ijhim.v1i1.3

Abstract

Abstract The inaccuracy of the results of the coding of the diagnosis and medical action produced by the inpatient coder. Percentage of coding accuracy was only 74.67% while coding imprecision reached 25.33%. It is still found that the coding accuracy in providing disease coding is still not accurate. The accuracy in coding the diagnosis is of course caused by several factors according to the conditions of each health service institution. The purpose of this study was to determine the factors that influence the accuracy of coding officers in providing disease codes based on 5M management elements. The method used in this research is literature review by examining journals with criteria, namely research that has been published, at least comes from accredited journals, and journals related to factors that affect the accuracy of the officer coding the diagnosis and then presented in the form of a conclusion. The results of this study were the factors that influenced the accuracy of the coding officer in giving disease codes based on theelement man , namely the qualifications of the coder, based on theelement, it money was not coding on the 4th or 5th characters, based on theelement material, there was a doctor's writing that was not clearly legible and the usage. Unusual abbreviations, based on theelements method are the inaccuracy of selecting the main diagnosis and the absence of SPO for determining the code, based on theelement machine is the absence of supporting coding books and SIMRS is not user friendly. It was found that the use of medical terminology that was not correct made the coders misperceived so that they were wrong in giving the diagnosis code. Keywords: Coding Officer, 5M Management Elements Abstrak Ketidaktepatan hasil koding diagnosis dan tindakan medis yang dihasilkan koder rawat inap. Presentase ketepatan koding hanya 74,67% sedangkan ketidaktepatan koding mencapai 25,33%. Masih ditemukan bahwa ketepatan pengkodean dalam pemberian kode penyakit masih kurang tepat. Ketepatan dalam pengkodean diagnosis tentunya disebabkan oleh beberapa faktor sesuai kondisi masing-masing institusi pelayanan kesehatan. Tujuan penelitian ini untuk mengetahui faktor yang mempengaruhi ketepatan petugas koding dalam pemberian kode penyakit berdasarkan unsur manajemen 5M. Metode yang digunakan dalam penelitian ini adalah literature review dengan mengkaji jurnal dengan kriteria yaitu penelitian yang telah dipublikasikan, minimal berasal dari jurnal terakreditasi, dan jurnal yang berkaitan dengan faktor yang mempengaruhi ketepatan petugas koding diagnosis kemudian disajikan dalam bentuk simpulan. Hasil penelitian ini adalah faktor yang mempengaruhi ketepatan petugas koding dalam pemberian kode penyakit berdasarkan unsur man adalah kualifikasi koder, berdasarkan unsur money adalah tidak melakukan pengkodean pada karakter ke 4 maupun ke 5, berdasarkan unsur material adalah adanya tulisan dokter yang tidak terbaca dengan jelas dan penggunaan singkatan yang tidak lazim, berdasarkan unsur method adalah ketidaktepatan pemilihan diagnosis utama dan belum adanya SPO penentuan kode, berdasarkan unsur machine adalah ketidaktersediaanya buku-buku penunjang koding dan SIMRS tidak user friendly. Ditemukan penggunaan terminologi medis yang tidak tepat membuat koder salah persepsi sehingga salah dalam pemberian kode diagnosis. Kata kunci: Petugas Koding, Unsur Manajemen 5M
LITERATURE REVIEW : PENERAPAN MANAJEMEN RISIKO DI UNIT FILING Vivi Anika Retno Mumpuni; Sri Sugiarsi; Tunjung Bayu Sinta
Indonesian Journal of Health Information Management Vol. 1 No. 1 (2021)
Publisher : Sekolah Tinggi Ilmu Kesehatan Mitra Husada Karanganyar

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (58.32 KB) | DOI: 10.54877/ijhim.v1i1.4

Abstract

Abstract Risk is the possibility of unwanted or unexpected adverse effects in an activity. These risks can have a negative impact on officers who are present during activities, especially in theunit filing. There are several risks of work accidents experienced byworkers, filing such as fingers with staples attached to medical record documents,workers filing can get cough if they take or return medical record documents without wearing a mask. The purpose of the study was to determine the application of risk management in theunit filing. The research method used is Literature Review with a search strategy usingresults criteria Google Scholarwith the keywords "Risk management OR Implementation of Risk Management in theunit filing". The results of this study indicate that risk management in hospitals is carried out internally, therisk factor in theunit filing most prominentis that the officer can catch a cough if he does not use a mask, and the hand can cut the cover of the medical record document if he does not use gloves, attitude towards risk What happens in the filing unit is the creation of a work safety SOP to prevent unwanted risks. Factors that cause risk are chemical factors, biological factors, physical factors and ergonomic factors. Keywords : Risk Management, Application of Risk Management Abstrak Risiko merupakan kemungkinan terjadinya akibat buruk yang tidak di inginkan atau tidak terduga dalam sebuah aktivitas. Risiko tersebut dapat menghasilkan dampak negatif bagi petugas yang ada saat aktivitas terutama di unit filing. Terdapat beberapa risiko kecelakaan kerja yang di alami oleh petugas kerja filing seperti jari yang terkena steples yang menempel pada dokumen rekam medis, petugas kerja filing dapat terkena penyakit batuk jika mengambil atau menggembalikan dokumen rekam medis tanpa menggunakan masker. Tujuan penelitian untuk mengetahui penerapan manajemen risiko di unit filing. Metode penelitian yang digunakan adalah Literature Review dengan strategi pencarian menggunakan kriteria hasil Google Scholar dengan kata kunci “Manajemen risiko OR Penerapan Manajemen Risiko di unit filing”. Hasil penelitian ini bahwa pengelolaan manajemen risiko di rumah sakit di lakukan secara internal, faktor risiko di unit filing yang paling menonjol adalah petugas dapat terserang batuk apabila tidak menggunakan masker, dan tangan dapat tersayat sampul dokumen rekam medis apabila tidak menggunakan sarung tangan, sikap atas risiko yang terjadi di unit filing adalah dengan di buatkanya SOP keselamatan kerja untuk mencegah terjadinya risiko yang tidak di inginkan. Faktor yang menyebabkan terjadinya risiko yaitu faktor kimia, faktor biologi, faktor fisik dan faktor ergonomi. Kata Kunci : Manajemen Risiko, Penerapan Manajemen Risiko
LITERATURE REVIEW PROSES PENYUSUTAN DOKUMEN REKAM MEDIS DI RUMAH SAKIT Hanifah Apriliandawati; Antik Pujihastuti
Indonesian Journal of Health Information Management Vol. 1 No. 1 (2021)
Publisher : Sekolah Tinggi Ilmu Kesehatan Mitra Husada Karanganyar

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (37.849 KB) | DOI: 10.54877/ijhim.v1i1.5

Abstract

Abstract Medical record shrinkage carried out gradually starting from sorting, moving, assessing and destroying. Obstacles in the implementation of shrinkage medical record are the limited human resources in the filing section and the infrastructure to support the shrinkage of medical record is inadequate. The purpose of this research was to determine the implementation of depreciation of medical record. This research method used a literature review design. The results showed that the sorting of medical record documents was carried out based on a 5-year period by looking at the year the patient's last visit was treated. Transfer of medical record documents is done by moving medical record documents from the active room to the inactive room. Assessment of medical record documents is in accordance with the use and importance of medical record documents. Obstacles that hinder the implementation of shrinkage of medical record documents are human resources and infrastructure. Conclusion from the results of this study, depreciation was carried out by sorting out the medical record documents then moving the medical record documents that were inactive, after which an assessment of the medical record documents was carried out according to the usefulness and importance of the medical record documents so that they could identify obstacles in the implementation of shrinkage of medical record documents. Keyword : Depreciation, Retention, Medical Record Abstrak Penyusutan berkas rekam medis dilakukan secara bertahap yaitu dimulai dari pemilahan, pemindahan, penilaian dan pemusnahan. Kendala dalam pelaksanaan penyusutan yaitu terbatasnya sumber daya manusia di bagian filing dan sarana prasarana untuk menunjang pelaksanaan penyusutan dokumen rekam medis belum memadai. Tujuan penelitian ini untuk mengetahui pelaksanaan penyusutan dokumen rekam medis. Metode penelitian ini menggunakan desain literature review. Hasil penelitian menunjukkan bahwa pemilahan dokumen rekam medis dilakukan berdasarkan periode 5 tahun dengan cara melihat tahun kunjungan terakhir pasien tersebut berobat. Pemindahan dokumen rekam medis dilakukan dengan cara memindahkan dokumen rekam medis dari ruangan aktif ke ruangan inaktif. Penilaian dokumen rekam medis sesuai dengan kegunaan dan kepentingan dokumen rekam medis. Kendala yang menghambat pelaksanaan penyusutan dokumen rekam medis yaitu sumber daya manusia dan sarana prasarana. Simpulan dari hasil penelitian ini penyusutan dilakukan dengan memilah dokumen rekam medis kemudian memindahkan dokumen rekam medis yang sudah inaktif setelah itu dilakukan penilaian dokumen rekam medis sesuai dengan kegunaan dan kepentingan dokumen rekam medis sehingga dapat mengetahui penghambat dalam pelaksanaan penyusutan dokumen rekam medis. Kata Kunci : Penyusutan, Retensi, Rekam Medis
LITERATURE REVIEW : ASPEK KEAMANAN DAN KERAHASIAAN DOKUMEN REKAM MEDIS DI RUMAH SAKIT Nur Husnina; Trismianto Asmo Sutrisno
Indonesian Journal of Health Information Management Vol. 1 No. 1 (2021)
Publisher : Sekolah Tinggi Ilmu Kesehatan Mitra Husada Karanganyar

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (55.171 KB) | DOI: 10.54877/ijhim.v1i1.6

Abstract

Abstract Security and confidentiality are very important factors in managing medical record files. In terms of security, the medical record file storage room was found to be dusty and humid which caused moldy medical records and also the raw materials for medical record folders still use low-quality materials. In the aspect of confidentiality, there is still a distribution of medical record files that have not been kept confidential and there are still damaged, folded and forms that are separated from the medical record folder, and left alone without any treatment on the damaged medical record. This study aims to determine the security and confidentiality of medical records. This study uses a literature review method with a search strategy using Google Scholar with the keywords Security Aspects of Confidentiality and Medical Records. The results of this study are the safety aspect in terms of the physical aspect of the ink used in black is uniform, the paper used is A4 size and weighs 70 grams. Biological aspects of the presence of fungi, bookworms, and insects such as termites, cockroaches, and mice. The chemical aspect of the medical record officer eating or drinking in the medical record room. Aspects of confidentiality there are still medical record officers who enter the medical record filing and medical record documents are still found that were brought by the patient or lost. Suggestions for the security aspect of the medical record file, the storage room should be equipped with maintenance tools such as a vacuum cleaner, spraying insects or given camphor, medical record storage space is limited by access rights such as fingerprints. Aspects of confidentiality of patients who consult to other polyclinics or want to carry out further examinations at supporting facilities are delivered by medical record distribution officers. Keywords : Confidentiality Security Aspect, Medical Records Abstrak Keamanan dan kerahasiaan adalah faktor yang sangat penting dalam pengelolaan berkas rekam medis. Dalam aspek keamanan terdapat pada ruang penyimpanan berkas rekam medis ditemukan ruangan berdebu dan lembab yang menyebabkan rekam medis berjamur dan juga pada bahan baku map rekam medis masih menggunakan bahan yang berkualitas rendah. Dalam aspek kerahasiaan masih terdapat pendistribusian berkas rekam medis yang belum terjaga kerahasiaan dan masih terdapat rekam medis yang rusak, terlipat dan terdapat formulir yang lepas dari map rekam medis, dan dibiarkan begitu saja tanpa ada perawatan pada rekam medis yang rusak. Penelitian ini bertujuan untuk mengetahui keamanan dan kerahasiaan rekam medis. Penelitian ini menggunakan metode literature review dengan strategi pencarian menggunakan Google Scholar dengan kata kunci Aspek Keamanan Kerahasiaan dan Rekam Medis. Hasil penelitian ini adalah aspek keamanan ditinjau dari aspek fisik tinta yang digunakan warna hitam sudah seragam, kertas yang digunakan ukuran A4 berat 70 gram. Aspek biologi adanya jamur, kutu buku, dan serangga seperti rayap, kecoa, dan tikus. Aspek kimiawi adanya petugas rekam medis makan atau minum di ruang rekam medis. Aspek kerahasiaanya masih ada petugas rekam medis yang masuk ke filing rekam medis dan masih ditemukan dokumen rekam medis yang di bawa pasien atau hilang. Saran aspek keamanan berkas rekam medis ruang penyimpanan hendaknya dilengkapi alat pemeliharaan seperti vacuum cleaner, dilakukan penyemprotan serangga atau diberi kamfer, ruang penyimpanan rekam medis di batasi oleh hak akses seperti fingerprint. Aspek kerahasiaan pasien yang konsultasi ke poliklinik lain atau ingin melakukan pemeriksaan lanjutan di fasilitas penunjang diantarkan oleh petugas distribusi rekam medis. Kata Kunci : Aspek Keamanan Kerahasiaan, Rekam Medis

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