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RAMMIK : Jurnal Rekam Medik & Manajemen Informasi Kesehatan Gg. Broto Manunggal V, Brajan, Tamantirto, Kec. Kasihan, Bantul, Daerah Istimewa Yogyakarta 55184
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INDONESIA
Jurnal Rekam Medik & Manajemen Informasi Kesehatan (RAMMIK)
Published by Indonesian Journal Publisher
ISSN : -     EISSN : 28294777     DOI : 10.47134/rmik
Core Subject : Health,
Dentistry Health Professions Medicine & Pharmacology Public Health Veterinary
RAMMIK : Jurnal Rekam Medik & Manajemen Informasi Kesehatan is an journal which provides a platform to scientist and researchers all over the world for the dissemination of knowledge in Health Information Management , medical record and related fields, especially in : Health information management studies Classification of Codification of Diseases and Actions Health Information Systems Health Information Technology Health Information Quality Management.
Arjuna Subject : Profesi Kesehatan - Profesi Kesehatan (Lain-Lain)
Articles 23 Documents
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Analisis Kebutuhan Tenaga Rekam Medis dengan Metode Workload Indicator Staffing Need (WISN) Effa Tuzzakiyah; Ria Chandra Kartika; Dessya Putri Ayu; Dina Fitriyah; Surya Dewi Puspita
Jurnal Rekam Medik & Manajemen Informasi Kesehatan Vol. 1 No. 2 (2022): Oktober
Publisher : Indonesian Journal Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (384.317 KB) | DOI: 10.47134/rmik.v1i2.20

Abstract

As the enacment of National Healt Coverage (JKN), certaintly the number of patients who seek treatment in hospitals has increase due to the patient no longer think about the cost of an expensive problem. The occurrence of the coopertion between the BPJS Paru Hospital Surabaya, certainly made a number of cisits increases it can be seen in the increase in the number of cisits the patient in Paru Hospitals Surabaya years 2014 to 2016. Calculatio of the new workforce needs in the unit procedures is indispensable in order to improve the quality of service. If the increasing number of visits certainly have an effect on basic tasks performed by officers of the procedures. Therefore required the calculation of labbor needs on the Unit Procedures Paru Hospital Surabaya. Type of this research is descriptive, by describing the calculation of labor needs medical record on the Unit Procedures tah the Paru Hospital Surabaya. Data collection methods used in this study. Interview Procedures and observations officer to find out the acerage time taken at each activity. From the results of research on workforce needs calculation Unit Procedures Paru Hospital Surabaya found to shift the morning amoun ted to 3 officers. Ther result is greater compared to the number of staff available at this time. If the number of officers alreay according to needs will facilitate the pro cess of service to patients and improven the quality of work.
Analisis Faktor Penyebab Ketidaklengkapan Resume Medis Rawat Inap di Puskesmas Cermee Bondowoso Siti Alifa Lufianti; Rossalina Adi Wijayanti; Demiawan Rachmatta Putro Mudiono; Indah Muflihatin
Jurnal Rekam Medik & Manajemen Informasi Kesehatan Vol. 1 No. 2 (2022): Oktober
Publisher : Indonesian Journal Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (373.561 KB) | DOI: 10.47134/rmik.v1i2.21

Abstract

The patient's medical resume form is a summary of the entire period of patient care and treatment as has been attempted by health workers and related parties. Based on a preliminary study in March 2021, researchers obtained data information on incomplete medical resume forms, the highest incompleteness was found in the identification component, which was 86.7%, the next incompleteness was in the Authentication component, which was 80%, the next incompleteness was in the Authentication component. important reports that is equal to 56.7%. The purpose of this study was to analyze the factors causing the incomplete filling of the patient's medical resume form. This type of research uses qualitative research, the subject of this research consists of 1 head of puskesmas, 3 inpatient doctors, and 1 medical record officer, the object of this research is to use an inpatient medical resume form to determine the factors that cause incomplete medical resume forms. inpatient. The results found in this study are that the first priority is that there is no SOP (Standard Operational Procedure) regarding filling out medical resumes, so it is determined efforts to make SOPs for filling out medical resumes in accordance with medical record service standards
Analisis Hubungan Ketepatan Penulisan Diagnosis dengan Keakuratan Kode Diagnosis pada Kasus Obstetri dan Ginekologi di Rumah Sakit Tk. IV DKT Kediri Citra Alifa Puspaningtyas; Hartaty Sarma Sangkot; Prima Soultoni Akbar; Endang Sri Dewi; Avid Wijaya
Jurnal Rekam Medik & Manajemen Informasi Kesehatan Vol. 1 No. 2 (2022): Oktober
Publisher : Indonesian Journal Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (172.817 KB) | DOI: 10.47134/rmik.v1i2.22

Abstract

Activity of determining the disease code and writing the diagnosis must be in accordance with the correct medical terminology and the classification rules that apply in Indonesia, namely ICD-10 in order to get the right and accurate code. This study aims to analyze the relationship between the accuracy of writing a diagnosis and the accuracy of the diagnosis code in obstetrics and gynecology cases at Rumah Sakit Tk. IV DKT Kediri. The method used in this research is analytic research with cross sectional approach. Based on Slovin's formula, the sample used was 100 medical record documents of inpatients. The sampling technique used is simple random sampling. The data collection technique used observation with a checklist instrument. Data on the accuracy of writing the diagnosis and the accuracy of the diagnosis code were analyzed univariately, while the relationship between the accuracy of writing the diagnosis and the accuracy of the diagnosis code was analyzed using SPSS with Chi-Square test. The results showed that the accuracy of writing the diagnosis was 56%, the accuracy of the diagnosis code was 43%, and there was a relationship between the accuracy of writing the diagnosis and the accuracy of the diagnostic code for obstetrics and gynecology cases at Rumah Sakit Tk. IV DKT Kediri (p < 0.025).
Pencatatan dan Pelaporan Vaksinasi COVID-19 dengan Aplikasi PCare Vaksinasi di Puskesmas Seputih Banyak Azizatul Azza; Mieke Nurmalasari
Jurnal Rekam Medik & Manajemen Informasi Kesehatan Vol. 1 No. 2 (2022): Oktober
Publisher : Indonesian Journal Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (396.239 KB) | DOI: 10.47134/rmik.v1i2.28

Abstract

COVID-19 has spread throughout the world, so it has a pandemic status. One of the countries infected with the COVID-19 pandemic is Indonesia. The Indonesian government's efforts to stop the spread of COVID-19 are through the COVID-19 vaccination. Every health service facility that carries out the COVID-19 vaccination must record and report the results of the COVID-19 vaccination service through the Vaccination PCare application. The obstacles found at the Seputih Banyak Health Center were data that numbered in the thousands so that the officers were overwhelmed when entering data. This study aims to determine the implementation of recording and reporting of COVID-19 vaccination using the Vaccination PCare application. Data collection in this study was carried out by observing the input, process, and output of the recording and reporting of COVID-19 vaccination using the Vaccination PCare application. . The data analysis used descriptive analysis. The results showed that during the recording and reporting of COVID-19 vaccination, regulations, human resources, process and output were by the provisions, while the facilities are not entirely appropriate. Facilities that are not appropriate are the unavailability of wifi and printers.
Analisis Aspek Keamanan Informasi Data Pasien Pada Penerapan RME di Fasilitas Kesehatan Siti Sofia; Efri Tri Ardianto; Niyalatul Muna; Sabran Sabran
Jurnal Rekam Medik & Manajemen Informasi Kesehatan Vol. 1 No. 2 (2022): Oktober
Publisher : Indonesian Journal Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (182.832 KB) | DOI: 10.47134/rmik.v1i2.29

Abstract

Data security issues are becoming increasingly serious as the trend of data theft is increasing. This causes not only material losses but also psychological victims. The purpose of this study was to determine how the information security of patient data in the application of RME in terms of information security aspects. The method used is a literature review by analyzing 20 articles from various sources. The results of the study show that from the articles reviewed in terms of 6 security aspects, namely username and password, changes or deletions of data by administrators, electronic signatures and the use of PINs, aspects of using data backup processes to anticipate patient data hacking, restrictions on access rights by using user id & password for each user, as well as log file usage. Overall, health facilities basically have carried out data security on the information systems they use, but in practice there are still health facilities that do not fully meet the data security aspect or are not optimal in using the techniques used. System managers need to develop techniques or ways to secure data more optimally that can fulfill 6 aspects of information security in electronic medical records.
Analisis Kelengkapan Pengisian Ringkasan Pulang Terhadap Kelancaran Klaim Badan Penyelenggaraan Jaminan Sosial Kesehatan di Rumah Sakit PTPN VIII Subang Aminuddin Sholeh
Jurnal Rekam Medik & Manajemen Informasi Kesehatan Vol. 2 No. 1 (2023): April
Publisher : Indonesian Journal Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.47134/rmik.v2i1.30

Abstract

One of the existing forms of one of the medical records is a discharge..sumaary containing the patient's clinical data. The purpose of this study is to identify the completeness of filling out the discharge summary sheet of the medical record of the patient of the BPJS hospital in the PTPN VIII Subang hospital in 2021. This type of study is a descriptive quantitative study. Randomized Sampling Technique The population of this study is a summary extract from the medical record of patient. The sample in this study is 84 discharge forms of a patient, the results showed the completeness of filling in the patient's identification by date of birth by 95% and by gender equal to 78%. The completeness of completion of the important report for the obsolete element is 79%, and for the input of the diagnostic element - 67%. The completeness of authentication for the item Date of completion is 72%, and for the item "Doctor's..name" - 87%. Correct documentation of bug fixes is 99%, and records are clear and readable at 82%. The effect of the completeness of the repayment summary on BPJS claims is current 39% and not smooth 61%.
Gambaran Penerapan PERMENKES Nomor 55 Tahun 2013 tentang Penyelenggaraan Pekerjaan Perekam medis dalam Pengkodean Diagnosis Medis dan Tindakan di Puskesmas Surabaya Timur Sitepu, Ariko; Asharudin, Ahmad; Agung Pratama, Arsa; Prasetyawan, Reynaldo; Marini, Rin; Sutha, Diah Wijayanti
Jurnal Rekam Medik & Manajemen Informasi Kesehatan Vol. 3 No. 1 (2024): April
Publisher : Indonesian Journal Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.47134/rmik.v3i1.46

Abstract

Perekam medis dan Informasi Kesehatan merupakan tenaga kesehatan yang wajib ada dalam penyelenggaraan pelayanan kesehatan dan sesuai dengan PERMENKES RI No. 55 tahun 2013. Penelitian ini dilakukan pada lima Puskesmas yang berada di wilayah Surabaya Timur dengan tujuan untuk mengetahui penerapan PERMENKES RI No. 55 tahun 2013 Pasal 13 ayat 3 tentang penyelenggaraan pekerjaan Perekam medis dalam melaksanakan sistem klasifikasi klinis dan kodefikasi penyakit yang berkaitan dengan kesehatan dan tindakan medis seusai dengan ICD-10 dan ICD-9. Jenis penelitian ini adalah penelitian deksriptif dengan pendekatan kualitatif. Pengumpulan data dilakukan melalui wawancara dan observasi pada petugas Perekam medis yang melakukan klasifikasi klinis dan kodefikasi penyakit. Hasil penelitian menyatakan bahwa Perekam medis dalam melakukan pengkodingan di Puskesmas wilayah Surabaya Timur tidak melakukan pengkodingan diagnosa medis dan tindakan tetapi hanya sebatas pengecekan ulang koding yang sudah diisi oleh dokter, perawat atau unit terkait yang memberikan pelayanan, dalam hal ini masih belum sesuai dengan PERMENKES No. 55 Tahun 2013 Pasal 13 Ayat 3 tentang penyelenggaraan pekerjaan Perekam medis, yang harusnya Perekam medis melakukan pengkodingan. Sosialisasi tentang pelaksanaan pekerjaan Perekam medis untuk mempunyai kewenangan dalam melaksanakan sistem klasifikasi klinis dan kodefikasi penyakit yang berkaitan dengan kesehatan dan tindakan medis sesuai terminologi medis yang benar sangat diperlukan
Gambaran Penyebab Pending Claim BPJS Kesehatan Akibat Ketidaktepatan Kode Diagnosis di Rumah Sakit Universitas Sebelas Maret (UNS) Cindy Rozza Bella; Pratama, Aldi; Zaenal Abidin, Arif
Jurnal Rekam Medik & Manajemen Informasi Kesehatan Vol. 3 No. 2 (2024): Oktober
Publisher : Indonesian Journal Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.47134/rmik.v3i2.47

Abstract

In the process of submitting a BPJS Health claim, not all files submitted can be claimed. Claim status is declared ineligible or pending. A pending claim occurs if the claim file submitted by the hospital is incomplete or does not comply with the requirements set by BPJS Health. Delayed claims can disrupt hospital cash flow and cause losses for the hospital and BPJS Health participants. This research aims to describe the causes of pending claims at UNS Hospital. This research is a quantitative descriptive study with a population of 182 inpatients pending claim files at UNS Hospital for the period August-October 2023. The sample for this research is 78 pending claim files based on diagnosis code verification. The sampling technique is total sampling. Based on the data obtained, the number of files with coding confirmation is 78 pending claim files or 11.3% of the total pending claims in the period August – October 2023. This data shows that the majority of pending claim files are due to inaccurate diagnosis. The factor causing pending claims from BPJS Health inpatients at UNS Hospital occurs due to differences in perception between hospital staff and BPJS Health and is not purely due to coder error, but due to a lack of supporting data as a diagnosis enforcer which affects the accuracy of the code.
ANALISIS ASPEK KEAMANAN DATA PASIEN DALAM IMPLEMENTASI REKAM MEDIS ELEKTRONIK DI RUMAH SAKIT X Efri Tri Ardianto; Sabran; Nurjanah, Lensa
Jurnal Rekam Medik & Manajemen Informasi Kesehatan Vol. 3 No. 2 (2024): Oktober
Publisher : Indonesian Journal Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.47134/rmik.v3i2.54

Abstract

Rekam kesehatan berbasis komputer merupakan rekaman pasien secara elektronik untuk mendukung pengguna mengakses secara lengkap & akurat. Manfaat rekam medis elektronik (RME) sangat penting tetapi terdapat beberapa ancaman yg menjadi perhatian khusus dpt berdampak merugikan. Pencurian data kesehatan mengalami peningkatan menjadi permasalahan serius. Berdasarkan observasi & wawancara ditemukan permasalahan dari aspek keamanan di Rumah Sakit X. Tujuan penelitian untuk menganalisis aspek keamanan data pasien dlm penerapan RME berdasarkan aspek kerahasiaan, integritas, autentikasi, ketersediaan, akses kontrol, nir-sangkal. Penelitian menggunakan pendekatan kualitatif, pengumpulan data melalui wawancara, observasi, dokumentasi dgn subjek penelitian 7 responden. Data dianalisis dg reduksi data, penyajian data & kesimpulan. hasil menunjukkan bahwa keamanan dari aspek kerahasiaan yaitu login menggunakan username & password namun belum melakukan penggantian secara berkala serta belum adanya SOP. Dari aspek integritas terdapat fitur edit data untuk pengguna sesuai tupoksi, edit data dlm jumlah besar tidak dapat dilakukan secara langsung namun harus sesuai SOP. Aspek Autentikasi sudah menerapakan tanda tangan elektronik bersertifikat menjamin keabsahan. aspek ketersediaan RME hanya ddt diakses dilingkungan rumah sakit dengan VPN sehingga mudah diakses. Aspek kontrol akses untuk membatasi hak akses pengguna diterapkan username & password. Aspek Nir-sangkal terdapat riwayat bagi pengguna yg mengakses data pasien.
Keamanan Sistem Informasi Rekam Medis Elektronik Di Rumah Sakit Islam Jakarta Sukapura Endah Wardani; Happy Putra, Daniel; Sonia, Dina; Yulia, Noor
Jurnal Rekam Medik & Manajemen Informasi Kesehatan Vol. 3 No. 2 (2024): Oktober
Publisher : Indonesian Journal Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.47134/rmik.v3i2.1756

Abstract

The implementation of Electronic Medical Records (EMR) in all health service facilities is outlined in Minister of Health Regulation Number 24 of 2022, with a deadline of 31 December 2023. Ensuring the security of EMR is vital to protect patient data privacy, prevent unauthorized data access, and avoid breaches. This study evaluates the security practices of EMR systems at the Islamic Hospital Jakarta Sukapura using a descriptive qualitative research method with seven informants. The study focuses on six key aspects of EMR security: privacy, integrity, authentication, availability, access control, and non-repudiation. The results show that the hospital has established security procedures, such as using usernames and passwords, but there are significant areas for improvement. The study notes the need for automatic logout features to prevent unauthorized access when computer screens are left unattended and emphasizes the importance of regularly updating passwords to improve security, as well as hospitals using encryption and firewall technologies to protect data during transmission and storage. Apart from this, research shows that some staff members still use default passwords, posing a security risk. Overall, this study provides recommendations for strengthening RME security frameworks in hospitals.

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