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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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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 52 Documents
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Perancangan dan Pembuatan Sistem Infomasi Peminjaman dan Pengembalian Rekam Medis di Puskesmas Arjasa Kabupaten Situbondo Nuril Firdausiah; Andri Permana Wicaksono; Novita Nuraini; Bakhtiyar Hadi Prakoso
Jurnal Rekam Medik & Manajemen Informasi Kesehatan Vol. 4 No. 1 (2025): April
Publisher : Indonesian Journal Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.47134/rmik.v4i1.1919

Abstract

Medical record service activities at the Arjasa Community Health Center in Situbondo Regency still often experience missfiles. A missfile is a medical record file that is misplaced or not found on the medical record storage shelf in the filling room. This missfile occurs because there is no device that controls the entry and exit of medical records, meaning that incoming and outgoing medical records are not recorded in either the medical record tracer or expedition book. resulting in delays in returning medical records to both inpatient and outpatient units. The time limit for borrowing medical records in the outpatient unit is 1x24 hours and 2x24 hours for inpatient care. To minimize delays in returning medical record data which can result in missfiles, this project aims to design and create an information system for borrowing and returning medical records at the Arjasa Community Health Center, Situbondo Regency. This type of research is Research and Development research using the Waterfall method. Data collection was carried out by interviews, documentation and observation. This research produces a website-based information system for borrowing and returning medical records with the advantage of reminders on WhatsApp users. Program flowcharts, data flow diagrams, and entity relationship diagrams are used in designing this information system, and the black box testing method is used for testing.
Perancangan dan Pembuatan Sistem Informasi KLPCM di Rumah Sakit Citra Husada Jember Mohammad Maulana Rifki Fadilah; Muhammad Yunus; Mudafiq Riyan Pratama; Demiawan Rachmatta Putro Mudiono
Jurnal Rekam Medik & Manajemen Informasi Kesehatan Vol. 4 No. 1 (2025): April
Publisher : Indonesian Journal Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.47134/rmik.v4i1.1920

Abstract

Incomplete filling of medical records (KLPCM) is an indicator of the quality of nursing care. Citra Husada Hospital experienced an 83.5% medical record incompleteness rate in the fourth trimester of 2022, with the highest form of incompleteness occurring in the pre-surgical assessment at 59.68%. Furthermore, the KLPCM review process still relies on Excel, which presents several drawbacks, such as non-specific columns, a lack of user-friendliness, and the need for high precision due to small input fields. As a result, the KLPCM review process is time-consuming and prone to input errors. Based on these issues, a KLPCM information system is needed at Citra Husada Hospital in Jember. The system development method used is the Prototype method, with data collection techniques including interviews, observation, and documentation. The system is web-based, developed using the PHP programming language with the Laravel framework and a MySQL database. The system's features include user management, doctor management, form and form content management, patient management, KLPCM medical record analysis, reports, and incompleteness notifications. The system testing results, conducted using black box testing, showed that all functionalities work properly.
Analisis Implementasi SIMRS Registrasi Rawat Jalan dan UGD Metode HOT-FIT di RSU Penyangga Perbatasan Betun Benedicta Cherlyn Pera; Maya Weka Santi; Atma Deharja; Mudafiq Riyan Pratama
Jurnal Rekam Medik & Manajemen Informasi Kesehatan Vol. 4 No. 2 (2025): Oktober
Publisher : Indonesian Journal Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.47134/rmik.v4i2.1921

Abstract

RSUPP Betun in Malaka Regency began implementing the Hospital Management Information System (HMIS) in June 2021 to support outpatient and emergency department (ED) registration. A preliminary study identified several issues, including a lack of staff training, technical disruptions with hardware and software, and network instability. This study aims to analyze the implementation of HMIS in the Outpatient Registration and ED units at RSUPP Betun using the HOT-FIT method. The research is qualitative, using interviews, observations, and documentation for data collection. The study's informants included seven individuals: the head of the medical records department, five registration staff, and one IT staff member. The results indicated that training improved user knowledge, but additional features, such as an alert system, are still required. Organizational support, funding, and inter-unit communication had a positive impact. However, the technological aspect revealed the need for better technical guidelines and higher-quality information. IT services were responsive, but the limited human resources hindered HMIS maintenance. Overall, HMIS has not yet fully improved service effectiveness due to suboptimal data integration. Recommendations include regular training, technical guidelines, a helpdesk feature, automatic logout, and SIMRS infrastructure updates.
Perancangan dan Implementasi Sistem Informasi Rekam Medis Elektronik Rawat Jalan Berbasis Web Di Puskesmas Umbulsari Jember Muhammad Misbahul Muttaqiin; Mudafiq Riyan Pratama; Muhammad Yunus; Dony Setiawan Hendyca Putra
Jurnal Rekam Medik & Manajemen Informasi Kesehatan Vol. 4 No. 2 (2025): Oktober
Publisher : Indonesian Journal Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.47134/rmik.v4i2.1922

Abstract

The medical record at Umbulsari Jember Healthcare are still conducted manually leading to incomplete coding processes for patient diagnoses, with the completeness percentage falling below 100%, and the time required to provide medical records exceeding 10 minutes. This research aims to design and develop an electronic outpatient medical record system for Puskesmas Umbulsari Jember based on a web platform. Data collection was carried out through observation, interviews, documentation, and brainstorming. The system development method used is the prototype method, which includes the stages of requirement identification, prototype development, adjustment to user preferences, system development, and further adjustments. The first stage involves problem analysis, revealing that medical records are still handled manually. The next stage is prototype development, including the creation of Flowcharts, Data Flow Diagrams (DFD), Entity Relationship Diagrams (ERD), and interface designs. The system development process begins with gathering tools such as software, the Bootstrap 4 CSS Framework, the CodeIgniter Framework, and Visual Studio Code, followed by the system design phase. Once the system is complete, testing is conducted using the Black Box Testing approach, which shows that all system functions operate correctly
Pembuatan Tracer Elektronik Berbasis Web di Puskesmas Semboro Jember Nur Faiza Hardiyanti; Niyalatul Muna; Atma Deharja; Muhammad Yunus
Jurnal Rekam Medik & Manajemen Informasi Kesehatan Vol. 4 No. 2 (2025): Oktober
Publisher : Indonesian Journal Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.47134/rmik.v4i2.1923

Abstract

The activity of borrowing and returning medical records at the Semboro Jember Community Health Center experienced several obstacles, including the failure to implement a tracer to mark files that would leave the storage room, and the recording of borrowing and returns was still carried out manually in the expedition book. The aim of this research is to design a website-based electronic tracer system. The system development method uses waterfall. The result of this research is the creation of a website-based electronic tracer which has advantages including that police officers as loan officers can borrow medical record files by looking at the patient's name or medical record number to be borrowed and can print an electronic tracer accompanied by a QR Code to be handed over to the officer. medical record filling section. Meanwhile, medical record officers can add patient data, officer data, doctor data and verify the return of files that have been returned by police officers or loan officers, return notifications and late charts. The results of testing carried out on all features and forms are that they run well and meet user needss
Evaluasi Pelayanan Kesehatan Yang Diberikan Kepada Pasien Di Klinik Dokkes Polres Trenggalek Berdasarkan Aspek Service Quality Lusyta Hermawan; Untung Slamet Suhariyono; Anis Ansyori
Jurnal Rekam Medik & Manajemen Informasi Kesehatan Vol. 5 No. 1 (2026): April
Publisher : Indonesian Journal Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.47134/rmik.v5i1.1927

Abstract

Klinik Dokkes Polres Trenggalek is a primary healthcare facility serving police personnel, their families, and the general public under the National Health Insurance (JKN) scheme, which requires the clinic to maintain service quality amid a high volume of patient visits. Preliminary observations indicated that staff readiness in responding to patient needs and the perceived waiting time for services were not yet optimal. This study aims to evaluate the readiness of human resources, facilities and infrastructure, and service management, as well as to assess service quality based on the five dimensions of Service Quality (tangible, reliability, responsiveness, assurance, empathy). This research employed a descriptive qualitative approach involving six informants (the Clinic Head, a physician, a nurse, and three patients) through in-depth interviews, observation, and documentation, analyzed using the interactive model of Miles, Huberman, and Saldaña. The findings show that HR readiness and SOP implementation at the clinic have run well, although limited parking space and stock shortages of certain medicines, particularly vitamins, were identified as recurring obstacles, consistently confirmed by all informants through source and method triangulation. Service quality across all five Service Quality dimensions was rated positively by patients. This study recommends improving parking facility management and medicine availability toenhance the overall service quality of Klinik Dokkes Polres Trenggalek.
Pengembangan Sistem Informasi Ruang Rawat Jalan untuk Meningkatkan Kualitas Pelayanan Rumah Sakit X Ayu Indriya Ludhi Asmara; Sayidatun Nisa Rushdiya Nayyara; Anisa Munifatun Nabillah; Sabrina Rahma Sari; Nur Khamadiyatus Solica; Amira Rena Priyamita; Achmad Jaelani Rusdi; Untung Slamet Suhariyono; Moch. Noer Hoedan Ma’roef
Jurnal Rekam Medik & Manajemen Informasi Kesehatan Vol. 5 No. 1 (2026): April
Publisher : Indonesian Journal Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.47134/rmik.v5i1.1939

Abstract

The complexity of hospital layouts with numerous outpatient clinics can make it difficult for patients to locate healthcare services, particularly new and older patients. This study aimed to develop an interactive digital map of outpatient services at Rumah Sakit X Kabupaten Blitar as an information medium for service locations and routes. A descriptive qualitative method with a case study approach was used. The study was conducted in the outpatient service area, which consists of 31 clinics distributed across two floors. Data were collected through field observations, interviews, focused discussions, and validation with relevant parties. The development stages included identifying the existing map, identifying information needs, designing the media, validating location and route information, revising the design, and testing media functions. The results showed that the existing map had limitations in typography size, color differentiation, visualization of public facilities, route presentation, and inter-page navigation. The map was developed by grouping information by floor, adding supporting facilities, providing location and route markers, presenting the service flow, and integrating hyperlinks into an interactive PDF format. Validation results showed that information on clinic locations, facilities, and routes was adjusted to field conditions. Technical testing showed that buttons, hyperlinks, page transitions, and navigation functions operated as designed. This study produced an interactive digital map that technically functions as an information medium for outpatient service locations and routes. However, its effectiveness in improving patient navigation cannot yet be established because user testing has not been conducted.
Evaluasi Ruang Rekam Medis Berdasarkan Teori Ergonomi di Puskesmas Pamotan Sayidatun Nisa Rushdiya Nayyara; Fikri Rahmat Maulana; Mohammad Arfianova Febri Nashuha; Anisa Munifatun Nabillah; Sabrina Rahma Sari; Dwi Trisnawati; Achmad Jaelani Rusdi; Zahrotul Mufida Fauzi
Jurnal Rekam Medik & Manajemen Informasi Kesehatan Vol. 5 No. 2 (2026): October
Publisher : Indonesian Journal Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.47134/rmik.v5i2.1940

Abstract

The medical records room plays an important role in supporting the storage and management of medical record documents. Initial observations at Pamotan Public Health Center indicated that several aspects of the room were not fully consistent with ergonomic principles, including limited storage facilities, uneven lighting, inadequate work facilities, and suboptimal room layout and workflow. This study aimed to evaluate the ergonomic conditions of the medical records room and develop a workplace design based on ergonomic principles. A descriptive qualitative approach was employed through the stages of problem identification, needs analysis, design development, and design evaluation. Data were collected through direct observation, interviews, literature review, ergonomic standards, staff anthropometric data, and the Regulation of the Minister of Health of the Republic of Indonesia Number 24 of 2022 concerning Medical Records. The results showed that the storage rack had a height of 106.4 cm and a width of 73.2 cm, with the rack width not meeting the ideal dimension used in this study. Natural lighting was limited, while artificial lighting was unevenly distributed. In addition, appropriate desks and chairs were not available for assembling, checking, and grouping medical record documents. Based on the analysis, a development design was proposed, including rearrangement of storage racks, addition of work desks and chairs, and adjustment of the room layout and workflow based on staff needs and anthropometric data. In conclusion, the proposed design can serve as a recommendation for Pamotan Public Health Center to develop a medical records room that better supports staff activities and applies ergonomic principles.
Optimalisasi Standar Operasional Prosedur Koding di Rumah Sakit Pindad Turen Malang Sayidatun Nisa Rushdiya Nayyara; Bella Ayu Rosyita Sari; Dania Putri Ramadani; Hanum Salsabillah Reka Aulia; Maghfirina Nawinda Putri; Nia Ariska; Nuril Fauziyah Febriyani; Sabrina Widad Nur Fauziah; Achmad Jaelani Rusdi; Agus Syukron Ma’ruf; Mochammad Yusril Rizkyawan
Jurnal Rekam Medik & Manajemen Informasi Kesehatan Vol. 5 No. 2 (2026): October
Publisher : Indonesian Journal Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.47134/rmik.v5i2.1941

Abstract

Standar Operasional Prosedur (SOP) coding rekam medis merupakan pedoman penting dalam menjamin akurasi, konsistensi, dan kelengkapan proses pengkodean diagnosis serta tindakan medis di rumah sakit. Penelitian ini bertujuan untuk mengevaluasi pelaksanaan SOP coding yang sedang berjalan serta mengoptimalkan alur kerja coding di Rumah Sakit Umum Pindad Turen Malang agar sesuai dengan standar ICD-10 dan ICD-9-CM. Metode penelitian menggunakan pendekatan deskriptif kualitatif melalui observasi langsung terhadap proses coding serta wawancara dengan petugas rekam medis. Hasil menunjukkan bahwa sebagian besar prosedur coding telah dilaksanakan sesuai standar, meliputi pemeriksaan kelengkapan berkas, identifikasi diagnosis dan tindakan, penentuan kode, hingga proses verifikasi. Namun, masih ditemukan beberapa hambatan seperti ketidaklengkapan dokumentasi medis, penggunaan singkatan yang tidak baku, serta perbedaan pemahaman antarpetugas coding. Melalui kegiatan sosialisasi, penyusunan ulang SOP, dan peningkatan pelatihan petugas, optimalisasi SOP coding mampu meningkatkan akurasi hasil kode, memperlancar proses klaim, serta mendukung kualitas data rekam medis. Kesimpulannya, SOP coding perlu dievaluasi secara berkala dan didukung koordinasi yang baik antarpetugas untuk mencapai kualitas coding yang lebih optimal dan sesuai standar pelayanan kesehatan.
Himbauan Membawa Dokumen Identitas Dalam Mengakses Pelayanan Kesehatan Di Pukesmas Kalipare Malang Amanda Eka Kurnia; Sayidatun Nisa Rushdiya Nayyara; Maghfirina Nawinda Putri; Nur Khamdiyatus Solicha; Fita Rusdian Ikawati; Lilik Afifah; Christian Eka Putra Joel
Jurnal Rekam Medik & Manajemen Informasi Kesehatan Vol. 5 No. 2 (2026): October
Publisher : Indonesian Journal Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.47134/rmik.v5i2.1942

Abstract

Completeness of patient identity documents is an important aspect in supporting smooth administrative processes and healthcare services at community health centers (Puskesmas). Incomplete documents may hinder the registration, identification, verification, and recording of patient data. This study aims to analyze the importance of reminding patients about the obligation to bring identity documents when accessing healthcare services at Kalipare Community Health Center, Malang. This descriptive qualitative study used survey and field observation approaches over three months. Primary data were collected through a survey of 200 puskesmas visitors selected by purposive sampling and interviews with 15 health workers, while secondary data came from administrative records, outreach reports, and literature. Data were analyzed descriptively using percentages and cross-tabulation, and interview data were analyzed thematically. Observations showed that reminders were delivered through a pamphlet listing the required documents (KTP/KIA, KK, BPJS/KIS card, and referral letter when required) and their benefits: faster registration, easier service, more accurate data recording, and better use of BPJS facilities. Patients who brought complete documents went through administration more easily, whereas incomplete documents added staff tasks such as data searching, confirmation, and re-checking of requirements, making registration less efficient. Interviews indicated that patients who knew the requirements were better prepared, while those who forgot needed additional explanation. In conclusion, continuous reminders serve as a preventive effort that supports orderly administration and efficient services and should become part of the registration flow. Puskesmas are advised to add reminder channels, such as digital media, and future studies should evaluate their effectiveness quantitatively.

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