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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 138 Documents
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Hubungan Pengetahuan dan Sikap Perawat Terhadap Kelengkapan Rekam Medis Pasien Rawat Inap di RSUD Kabupaten Klungkung: The Relationship Between The Nurse's Knowledge and Attitude Towards The Completeness of The Medical Record of Inpatients at The Klungkung Regency Hospital Ns. Deva Eddy Romansyah, S.Kep., M.M. Deva Eddy Romansyah
Indonesian Journal of Health Information Management Vol. 3 No. 1 (2023)
Publisher : Sekolah Tinggi Ilmu Kesehatan Mitra Husada Karanganyar

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.54877/ijhim.v3i1.93

Abstract

Rumah sakit merupakan salah satu pelayanan jasa yang dalam melakukan aktifitasnya, tidak boleh lepas dari perkembangan ilmu pengetahuan dan teknologi. Sikap yang baik dan pemeriksaan harus dimiliki seorang perawat agar mampu membuat dokumentasi rekam medis pasien dengan konsisten dan baik. Tujuan penelitian untuk mengetahui hubungan pengetahuan dan sikap perawat terhadap kelengkapan rekam medis pasien rawat inap di RSUD Kabupaten Klungkung. Metode penelitian ini adalah observasional analitik dengan pendekatan cross sectional. Penelitian ini dilaksanakan di RSUD Kabupaten Klungkung pada bulan Mei 2022 sampai dengan Agustus 2022 dengan teknik sampling yaitu accidental sampling. Populasi sebanyak 215 orang dan sampel sebanyak 140 orang. Instrumen penelitian yang digunakan berupa kuesioner. Hasil penelitian mengenai hubungan pengetahun dan sikap perawat terhadap kelengkapan rekam medis pasien rawat jalan di RSUD Kabupaten Klungkung mendapatkan hasil analisis P sebesar 0,000 < 0.05. Simpulan penelitian ini bahwa ada hubungan pengetahun dan sikap perawat terhadap kelengkapan rekam medis pasien rawat jalan di RSUD Kabupaten Klungkung.
Perbedaan Tingkat Kepuasan Pasien BPJS Dan Pasien Non BPJS Terhadap Pelayanan Pendaftaran Rawat Jalan Di RSU Indo Sehat Kebakkramat Febriyani Fauzi Marfuah; Astri Sri Wariyanti; Trismianto Asmo Sutrisno
Indonesian Journal of Health Information Management Vol. 3 No. 1 (2023)
Publisher : Sekolah Tinggi Ilmu Kesehatan Mitra Husada Karanganyar

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.54877/ijhim.v3i1.94

Abstract

Rumah Sakit sebagai salah satu fasilitas pelayanan kesehatan yang kompleks dituntut untuk memberikan pelayanan dan informasi kesehatan yang tepat dan berusaha memenuhi segala aspek mutu kesehatan dengan selalu memberikan pelayanan sebaik mungkin dan memberikan jaminan kesehatan berupa BPJS kesehatan. Tingkat kepuasan pasien dianggap sebagai salah satu dimensi yang sangat penting, berkualitas dan merupakan salah satu indikator utama dari standar suatu fasilitas kesehatan. Tujuan penelitian ini untuk mengetahui perbedaan kepuasan pasien BPJS dan non BPJS terhadap pelayanan pendaftaran rawat jalan di Rumah Sakit Umum Indo Sehat Kebakkramat. Jenis penelitian ini adalah survei analitik. Populasi yang digunakan adalah pasien rawat jalan pasien BPJS dan pasien non BPJS yang terdaftar mendapat pelayanan di rumah sakit. Cara pengumpulan data menggunakan kuesioner dan analisis data menggunakan uji Chi Square Test. Dari penelitian tersebut diketahui kepuasan pasien BPJS sebesar 76,7% dan kepuasan pasien non BPJS sebesar 60%. Hasil penelitian didapat nilai p-value 0,259 (p>0,05) yang artinya tidak ada perbedaan yang signifikan. Kesimpulan dari penelitian ini adalah tidak ada perbedaan tingkat kepuasan pasien BPJS dan pasien non BPJS terhadap pelayanan pendaftaran rawat jalan di RSU Indo Sehat Kebakkramat. Saran Kepuasan Pasien BPJS dan non BPJS di RSU Indo Sehat Kebakkramat perlu dipertahankan dan terus ditingkatkan.
Transformasi Digitalilasi Posyandu: Mobile Apps Posyandu Menggunakan Glide Apps Wahyu Wijaya Widiyanto; Irmawati Mathar; Wahyu Ratri Sukmaningsih
Indonesian Journal of Health Information Management Vol. 3 No. 1 (2023)
Publisher : Sekolah Tinggi Ilmu Kesehatan Mitra Husada Karanganyar

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.54877/ijhim.v3i1.95

Abstract

Posyandu adalah suatu Upaya Kesehatan Bersumberdaya Masyarakat (UKBM) dimana pelayanannya dilaksanakan dari, oleh, dan untuk masyarakat. Posyandu Mawar I Plombon Mojolaban, tertelak di Desa Plumbon, RT 03 RW 10 Mojolaban, Sukoharjo. Posyandu Mawar I Plumbon Mojolaban memiliki 7 kader yang mengurus jalannya kegiatan posyandu. Posyandu Mawar 1 Plumbon Mojolaban merupakan Posyandu khusus balita, selama ini pencatatan dan pelaporan Posyandu masih dilakukan secara manual dengan menggunakan lembar formulir yang diberikan oleh bidan desa. Proses pencatatan dan pengolahan data masih dilakukan secara manual menggunakan tulisan tangan sehingga berisiko adanya salah tulis, mudah sobek, dan kurang jelas tulisannya. Tujuan penelitian ini adalah untuk menganalisis sistem pencatatan dan pelaporan yang digunakan di Posyandu Mawar I Plumbon Mojolaban dan membuat perancangan sistem informasi pencatatan yang dibutuhkan di Posyandu Mawar I Plumbon Mojolaban. Jenis penelitian ini merupakan penelitian kualitatif menggunakan metode System Development Life Cycle (SDLC) dengan model Waterfall. Informan dalam penelitian ini adalah kader Posyandu Mawar I Plumbon, Mojolaban. Hasil penelitian ini berupa aplikasi pencatatan data balita yang dibuat menggunakan Glide Apps dengan uji black box secara fungsional sukses.
Literature Review : Komunikasi Efektif Dalam Pelaksanaan Interprofessional Kolaborasi Di Rumah Sakit Noor Lita Sari; Anisa Noviyanti
Indonesian Journal of Health Information Management Vol. 3 No. 1 (2023)
Publisher : Sekolah Tinggi Ilmu Kesehatan Mitra Husada Karanganyar

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.54877/ijhim.v3i1.96

Abstract

Interprofessional collaboration (IPC) is a collaboration between health professionals with different educational backgrounds to form a collaborative team to improve the quality of effective health services. The purpose of this research is to find out the types of professions involved in interprofessional collaboration, to know the components of effective communication in interprofessional collaboration, to know the components of collaboration in the application of interprofessional collaboration, to know the inhibiting factors in interprofessional collaboration. The method used is Literature Review design. The results showed that the components of collaboration in the application of interprofessional collaboration are cooperation, partnership, coordination, and decision making. The inhibiting factors for interprofessional collaboration communication are attitudes and behavior, there are still officers who are lazy, forgetful, tired, different opinions, and in a hurry which causes the CPPT documentation to be ineffective. So it is recommended for the leader to motivate his subordinates by giving sanctions and punishments.
Tinjauan Keakuratan Kode External Cause Diagnosis Cedera Kepala Berdasarkan ICD-10 Pada Rekam Medis Pasien Rawat Inap Di RSUP Dr. Soeradji Tirtonegoro Reza Widiantoro; Astri Sri Wariyanti; Ninawati
Indonesian Journal of Health Information Management Vol. 3 No. 1 (2023)
Publisher : Sekolah Tinggi Ilmu Kesehatan Mitra Husada Karanganyar

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.54877/ijhim.v3i1.97

Abstract

A preliminary survey was conducted, showing that 10 out of 10 external code medical records for the diagnosis of head injuries were inaccurate. The purpose of this study was to determine the accuracy of the external cause code for diagnosing head injuries based on the ICD-10 in the medical records of inpatients at dr. Soeradji Tirtonegoro. The research type was descriptive, with a retrospective approach. The study was conducted in the filing room. Time in May 2018. The total population of medical records for inpatients diagnosed with head injuries was 175 medical records. The sample size is 44 documents, with a systematic sampling technique. The instruments used were checklists, questionnaires, and observation guidelines. How to collect data from unstructured interviews and observation. Data analysis is descriptive in nature. The results of accuracy of the code external causes a diagnosis of head injury from 44 medical record documents 100% inaccurate code. Inaccuracy is incorrect code, there are 17 cases (39%) and there is incorect 5 categories code as many as 27 cases (61%). The conclusion is that inaccuracies occur because the officer has not carried out the inclusion and exclusion guidelines on the selected code, or the bottom of a chapter, block, category, or sub category in determining the selected code, directly coding without looking at the ICD when getting external cause information that often appear, and officers do not carry out coding up to 5 character digits because the standard for coding in hospitals is 15 minutes and officers still have to do an analysis of the completeness of medical records, code for claims, code in medical records, and still input into a computer.
Literatur Review Determinan Kualitas Pelayanan Pendaftaran Terhadap Kepuasan Pasien TPPRJ Di Puskesmas Indonesia Evina Widianawati
Indonesian Journal of Health Information Management Vol. 3 No. 1 (2023)
Publisher : Sekolah Tinggi Ilmu Kesehatan Mitra Husada Karanganyar

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.54877/ijhim.v3i1.100

Abstract

Pusat Kesehatan Masyarakat (Puskesmas) merupakan pusat pelayanan kesehatan tingkat pertama di masyarakat. Ketidakpuasan pasien terhadap pelayanan kesehatan berkisar 60% dari 10 pasien. Fenomena yang ditemukan antara lain keluhan pasien tentang jumlah antrian, waktu tunggu yang lama, dan kurangnya fasilitas seperti kursi di ruang tunggu pendaftaran. Penelitian ini merupakan studi literatur dengan sumber data menggunakan database google Scholar. Dari 76 artikel terpilih, lima artikel memenuhi kriteria inklusi dan eksklusi. Hasil penelitian menunjukkan bahwa dimensi bukti fisik, reliabilitas, daya tanggap, jaminan, dan empati baik dengan persentase 40%-75%. Namun, beberapa Puskesmas perlu meningkatkan pelayanannya, seperti kebersihan fasilitas (bukti fisik) dan kurangnya kemampuan staf dalam melayani pasien (keandalan). Saran bagi petugas pendaftaran rawat jalan di Puskesmas hendaknya memberikan pelatihan atau seminar untuk meningkatkan kemampuannya dalam melayani pasien dan mencapai kepuasan pasien yang optimal.
Pengaruh Kualitas Informasi dan Kualitas Sistem terhadap Kepuasan Pengguna Rekam Medis Elektronik Rawat Jalan di RSKIA Sadewa Yogyakarta DELA
Indonesian Journal of Health Information Management Vol. 3 No. 2 (2023)
Publisher : Sekolah Tinggi Ilmu Kesehatan Mitra Husada Karanganyar

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.54877/ijhim.v3i2.102

Abstract

Sesuai Pasal 3 dalam PMK No. 24 Tahun 2022 yang menyebutkan bahwa setiap fasilitas pelayanan kesehatan wajib menyelenggarakan rekam medis elektronik dan untuk mendukung RPJMN terkait perluasan cakupan dan pengembangan jenis layanan telemedicine, digitalisasi rekam medis dan rekam medis online maka rumah sakit sebagai salah satu fasilitas pelayanan kesehatan wajib menyelenggarakan rekam medis elektronik. Rekam medis elektronik diimplementasikan guna mempermudah petugas dalam memasukan data, memproses dan menyajikan informasi. Oleh sebab itu, penggunaan rekam medis elektronik perlu dievaluasi. Salah satu model evaluasi kesuksesan sistem dapat dilakukan dengan menggunakan model DeLone McLean. Tujuan utama dari penelitian ini yaitu untuk mengetahui pengaruh kualitas informasi dan kualitas sistem dengan kepuasan pengguna rekam medis elektronik rawat jalan di RSKIA Sadewa Yogyakarta. Pada penelitian ini digunakan data primer yang diperoleh dari 42 kuesinoer yang disebarkan kepada pengguna rekam medis elektronik rawat jalan. Teknik analisis data yang digunakan pada penelitian ini adalah uji regresi linear berganda. Hasil uji linear berganda menunjukan nilai Sig. yaitu 0.000 < 0.05, maka dapat diartikan terdapat pengaruh kualitas informasi dan kualitas sistem terhadap kepuasan pengguna rekam medis elektronik rawat jalan di RSKIA Sadewa Yogyakarta.
Analysis Of The Differences In Real Rates And Ina-Cbgs Rates In Delivery Case Of Inpatible Patients For Cost Control At Pandan Arang Boyolali Hospital Sutrisno, Bowo
Indonesian Journal of Health Information Management Vol. 3 No. 2 (2023)
Publisher : Sekolah Tinggi Ilmu Kesehatan Mitra Husada Karanganyar

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.54877/ijhim.v3i2.103

Abstract

Abstract The hospital will get payment based on the INA-CBG's rate which is the average cost spent by a diagnosis group. Childbirth is a process of expelling the products of conception (fetus and placenta) which are of sufficient gestational age and can live outside the womb through the birth canal or other means with the help or strength of the mother herself.The difference in real rates and INA-CBG's rates in cases of inpatient delivery at Pandan Arang Boyolali Hospital can result in hospital losses. This study aims to determine the difference between real rates and INA-CBG's rates in cases of inpatient delivery at Pandan Arang Boyolali Hospital. This type of research is analytic observational with a comparative approach. The population in this study were all medical record files of inpatients for delivery cases at Pandan Arang Boyolali Hospital in the second quarter of 2022, totaling 242 patients. The sampling technique is simple random sampling. Data analysis used the Mann Whitney test. The results of this study found that the real rate for inpatient delivery cases at Pandan Arang Boyolali Hospital was Rp. 341.321.130 while the amount of the INA CBGs tariff is Rp. 264.357.400.so it can be concluded that there is a difference in real rates and INA-CBGs in cases of inpatient delivery at Pandan Arang Boyolali Hospital Keywords. Real Tariff, INA CBGs Tariff, Labor
Hubungan Antara Pengetahuan Perawat Tentang Rekam Medis Dengan Kelengkapan Pengisian Catatan Asuhan Keperawatan Bedah di Rumah Sakit PKU Muhammadiyah Gombong Endang Sri Lestari; sri wariyanti, astri; Kusumawati, Erna Adita
Indonesian Journal of Health Information Management Vol. 3 No. 2 (2023)
Publisher : Sekolah Tinggi Ilmu Kesehatan Mitra Husada Karanganyar

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.54877/ijhim.v3i2.109

Abstract

Hospital as a health-care facilities are oblged to make medical records. One of the important things in the medical record document is the completeness of the medical record. According to Permenkes No.24 of 2022 recording and documentation must be complete, clear, and carried out after the patient receives health services by including the name, time and signature of the health woeker providing the service. Nurses as health workers are required to make nursing care records. The purpose of this study was to analyze the nurse relationship knowledge of medical records with surgical nursing care filling records. This study used observasional with a cross sectional approach. The subjects in this study were all nurse who served in the central surgical installation of PKU Muhammadiyah Gombong Hospital. The Object of research is the medical record files of inpatient who are analyzed with saturated samples technique. The research was conducted from september to november 2022 with a questionnaire. The research instrument to assess the level of knowledge abaut medical record. Statistical test using chi squared with SPSS The nurse’ knowledge of medical records with the completeness of filling in surgical nursing care records obtained a significance value of p= 0.024. However, this value did not meet the requirements because there were 3 cell that I got less than 5. The fisher extract test was carried out with a value of p= 0.016. In conclusion, there is a relationship between nurses’ knowledge of medical record s and the completeness of filling out surgical care records.
Pengembangan Sistem Informasi Manajemen Rumah Sakit Modul Analisis Kuantitatif Rekam Medis Dengan Menggunakan Metode Rapid Application Development Di RSJD Dr. RM. Soedjarwadi Provinsi Jawa Tengah Astri Ayu Prasetiyani
Indonesian Journal of Health Information Management Vol. 3 No. 2 (2023)
Publisher : Sekolah Tinggi Ilmu Kesehatan Mitra Husada Karanganyar

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.54877/ijhim.v3i2.110

Abstract

Abstract This quantitative analysis process is done manually using spreadsheet media. The assembling officers take time in conducting the monthly recapitulation. This study aims to develop a hospital management information system with inpatient medical record quantitative analysis module. It uses the Rapid Application Development method. The type of this study is Research and Development. This study is coonducted at RSJD Dr. RM. Soedjarwadi in November 2022 until January 2023. The subjects of this study were two Assembly Officers and two Electronic Data Processing Officers. Meanwhile the object of this study is the Quantitative Analysis of Medical Records Spreadsheet. The data is collected by observation and unstructured interviews. Moreover, the researcher uses Rapid Application Deveopment Software in processing the data. It consists of three stages wich are Planning, Designing System, and Testing System. The Result shows that the system which is made within 50 days can successfully carried out the testing with the Black-Box method in accordance with the needs of Assembly Officers. Keywords : Quantitative Analysis, Medical Record, Rapid Application Development Literature : 20 (2014, 2022)

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