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MEDICORDHIF Jurnal Rekam Medis
Published by Akademi Perekam Medis dan Informasi Kesehatan Bhumi Husada Jakarta
ISSN : 26558955     EISSN : 22529616     DOI : 10.59300/mjrm.v7i0
Core Subject : Health, Education,
Education Health Professions Public Health Other
MEDICORDHIF Jurnal Rekam Medis is a Scientific Electronic Journal of the Medical Recorder and Health Information Academy of Bhumi Husada Jakarta (APIKES BHJ) in order to accommodate the research results of APIKES BHJ lecturers and students as well as other authors outside the APIKES BHJ institutions, as one of the goals of higher education institutions in Indonesia.The Medicordhif e-journal provides the widest opportunity for lecturers, researchers and authors in the scientific fields of medical records, health information, public health, hospital management and also health management to join in as an author in our MEDICORDHIF e-journal.
Arjuna Subject : Profesi Kesehatan - Profesi Kesehatan (Lain-Lain)
Articles 96 Documents
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Tinjauan kebutuhan rak dan luas ruang penyimpanan rekam medis 5 tahun yang akan datang periode 2021 - 2025 di Rumah Sakit Ibu dan Anak ASIH Garis Gemilang; Ambarwati; Nur Soleh
MEDICORDHIF Jurnal Rekam Medis Vol 10 No 1 (2023): MEDICORDHIF Jurnal Rekam Medis
Publisher : APIKES Bhumi Husada Jakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (11.033 KB) | DOI: 10.59300/mjrm.v10i1.96

Abstract

Penyimpanan rekam medis bertujuan untuk mempercepat dan memudahkan petugas dalam pengambilan kembali rekam medis pada saat rekam medis dibutuhkan ,serta menjaga kerahasian rekam medis.oleh karena itu ,ruang penyimpanan rekam medis harus dilengkapi dengan fasilitas yang memadai untuk mencapai pelayan rekam medis yang baik. Tujuan penelitian ini adalah untuk mengetahui berapakah kebutuhan rak dan luas ruang penyimpanan rekam medis tahun 2021 – 2025 di Rumah Sakit ibu dan anak asih. Didalam penelitian ini penulis menggunakan metode penelitian deskriptif yaitu memperoleh gambaran dan melihat langsung kebutuhan rak rekam medis rumah sakit ibu dan anak asih tahun 2025. Berdasarkan hasil perhitungan didapatkan jumlah rekam medis pada tahun 2020 sebanyak 20.907 rekam medis dan jumlah rekam medis pada tahun 2025 sebanyak 24.603 rekam medis dengan rata-rata pertumbuhan volume rekam medis sebesar 3,31%. Rumah Sakit ibu dan anak asih saat ini memiliki 22 unit rak penyimpanan rekam medis dan luas ruang penyimpanan sebesar 10 m². Pada tahun dibutuhkan 42 unit rak penyimpanan rekam medis serta luas ruang penyimpanan sebesar 17,4 m², sehingga memerlukan tambahan 20 unit rak penyimpanan rekam medis serta ruangan tambahan sekitar 7,4 m².
Tinjauan ketepatan kode diagnosa diabetes melitus pasien rawat inap di Rumah Sakit Umum Universitas Kristen Indonesia Hudiyati Agustini; Atikah Ramadhani
MEDICORDHIF Jurnal Rekam Medis Vol 10 No 1 (2023): MEDICORDHIF Jurnal Rekam Medis
Publisher : APIKES Bhumi Husada Jakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (11.033 KB) | DOI: 10.59300/mjrm.v10i1.97

Abstract

Pemberian kode terhadap diagnosis pasien harus tepat, karena akan memengaruhi informasi laporan morbiditas dan mortalitas, serta administrasi rumah sakit termasuk data klaim biaya pengobatan. Penelitian ini bertujuan untuk mengetahui ketepatan kode diagnosa diabetes melitus di RSU UKI, sesuai dengan standar WHO berdasarkan ICD 10. Penelitian dimulai bulan April−Juni 2022, berdasarkan metode penelitian deskriptif kuantitatif dengan teknik pengumpulan data secara observasi, lembar checklist, dan wawancara. Penelitian ini mengambil sampel 75 ringkasan pulang dari pasien yang dirawat inap dengan diagnosis diabetes melitus. Hasil penelitian mendapatkan 25 kode tidak tepat (33,33%) dan 50 kode tepat (66,67%). Dapat disimpulkan bahwa RSU UKI sudah memiliki standar prosedur operasional pengkodean diagnosa. Namun, masih terdapat pengkodean yang tidak tepat. Faktor utama menjadi ketidaktepatan kode disebabkan oleh dokter yang tidak lengkap menulis diagnosa, dan petugas koding yang tidak tepat dalam menetapkan digit ke-4. Kata kunci: Ketepatan kode diagnosa, Diabetes Melitus, Ringkasan Pulang
TINJAUAN KEBUTUHAN TENAGA INSTALASI REKAM MEDIS BERDASARKAN ANALISIS BEBAN KERJA KESEHATAN DI RUMAH SAKIT PUSAT OTAK NASIONAL PROF. DR. dr. MAHAR MARDJONO JAKARTA Meliana; Adhe Ramadhan
MEDICORDHIF Jurnal Rekam Medis Vol 10 No 1 (2023): MEDICORDHIF Jurnal Rekam Medis
Publisher : APIKES Bhumi Husada Jakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (11.033 KB) | DOI: 10.59300/mjrm.v10i1.98

Abstract

Workload analysis is a method used to determine the amount of time, effort and resources required to carry out organizational tasks and functions. The results of the initial observations. Researchers took the example of a monthly report in October, November, December 2021, it was found that the monthly report for that month experienced a delay in completion. The report that was supposed to be completed at the beginning of the following month was only completed in the middle of the following month, because some work from the medical record installation had not been completed, such as from the coding and analysis of the completeness of the medical record. Research objectives is To calculate the need for personnel in the medical record installation at the Rumah Sakit Pusat Otak Nasional Prof. Dr, dr. Mahar Mardjono Jakarta. Research methodology is Descriptive with a quantitative approach with research subjects 11 medical record officers and the object of research is a review of the needs of medical record installation personnel based on workload analysis. The results of the study Every job in the medical record installation already has an SOP, the available working time is 5 working days in 72000 minutes / year, the result of calculating the number of Human Resouce Health needed is 12 people.Human Resouce Healt needs in medical record installations are 12 people., Keywords : Medical Record , Work Loard Analysis , Human Resouce Health
TINJAUAN KELENGKAPAN PENGISIAN CATATAN PERKEMBANGAN PASIEN TERINTEGRASI ( CPPT ) DALAM MENINGKATKAN KOMUNIKASI EFEKTIF ANTAR TENAGA KESEHATAN DI RUANG RAWAT OBGYN RUMAH SAKIT UMUM UNIVER Meliana; Kanjeng Gamas Brajamusti
MEDICORDHIF Jurnal Rekam Medis Vol 10 No 1 (2023): MEDICORDHIF Jurnal Rekam Medis
Publisher : APIKES Bhumi Husada Jakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (11.033 KB) | DOI: 10.59300/mjrm.v10i1.99

Abstract

The integrated patient progress record (CPPT) form contains information about the patient's identity, important notes, authentication, and good notes in the form of writings on the health services that have been provided to the patient. To coordinate or collaborate between health workers in documenting health services for patients in all polys / clinics in the Hospital, one of which is the Obgyn Room. This study aims to get an overview of the Completeness of Filling in the Integrity Patient Development Record (CPPT) in the Obgyn Inpatient Room of UKI Hospital. The study starts in June – August 2022. The research design used, namely the descriptive method, is to describe the research by conducting interviews and observations with Qualitative and Quantitative approaches. In this scientific paper study, researchers sampled 77 CPPT forms. The results of the study obtained 77 samples studied, obtained complete as many as 27 (35%) CPPT forms and incomplete ones as many as 50 (69.9%) CPPT forms. It can be concluded that UKI General Hospital already has Standard Operating Procedures for filling cppt. We recommend that the doctor again check the instructions that have been given to find out if it has gone right Keywords : Effective Communication, Completeness, Integrated Patient Development Record.
PLANNING ANALYSIS OF HEALTH HUMAN RESOURCES USING THE ABK KES METHOD IN THE OUTBOARD MEDICAL RECORD UNIT AT UPTD PUSKESMAS JATIROTO WONOGIRI Arifatun Nisaa Nisaa
MEDICORDHIF Jurnal Rekam Medis Vol 10 No 2 (2023): MEDICORDHIF Jurnal Rekam Medis
Publisher : APIKES Bhumi Husada Jakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.59300/mjrm.v10i2.87

Abstract

Abstrak Di Puskesmas Jatiroto Wonogiri terdapat 2 petugas pendaftaran rawat jalan yang sudah memasuki masa purna kerja sehingga diperlukan perencanaan sumber daya manusia (SDM) agar kegiatan pengelolaan rekam medis optimal.Tujuan penelitian ini yaitu menetapkan fasilitas pelayanan kesehatan, menghitung waktu kerja tersedia, komponen beban kerja, standar beban kerja, standar tugas penunjang dan kebutuhan jumlah SDM kesehatan di UPTD Puskesmas Jatiroto. Jenis Penelitian yang digunakan adalah deskriptif kualitatif. Subjek penelitian ini yaitu kepala rekam medis dan kepala puskesmas, sedangkan objeknya adalah kegiatan tenaga rekam medis. Pengumpulan data dilakukan dengan observasi dan wawancara terhadap subyek penelitian. Hasil perhitungan ABK Kes diketahui waktu kerja tersedia 1.200 jam/tahun atau 72.000 menit/ tahun, kebutuhan beban kerja rekam medis rawat jalan untuk tugas pokoknya 432.000 menit/tahun dan untuk tugas penunjang adalah 600 menit/tahun dan penghitungan kebutuhan SDMK rekam medis sebanyak 5 tenaga di unit rekam medis rawat jalan UPTD Puskesmas Jatiroto. Kata Kunci : ABK Kes, Beban Kerja, Perencanaan kebutuhan SDMK Abstract At the Jatiroto Wonogiri Health Center there are 2 outpatient registration officers who have entered their retirement period so that human resource planning is needed so that medical record management activities are optimal. workload standards, supporting task standards and the need for the number of health human resources at the Jatiroto Health Center UPTD. The type of research used is descriptive qualitative. The subjects of this study were the head of medical records and the head of the puskesmas, while the object was the activities of the medical record personnel. Data was collected by observation and interviews with research subjects. The results of the calculation of ABK Kes show that the available working time is 1,200 hours/year or 72,000 minutes/year, the need for outpatient medical record workload for the main task is 432,000 minutes/year and for supporting tasks is 600 minutes/year and the calculation of HRK needs for medical records is 5 workers. in the outpatient medical record unit UPTD Jatiroto Health Center. Keywords: ABK Kes, Workload, Need for medical record personnel
TINJAUAN KETIDAKTEPATAN KODE DIAGNOSIS PENYAKIT DAN TINDAKAN MEDIS KASUS GIGI DAN MULUT RAWAT JALAN DI RUMAH SAKIT X JAKARTA Indah Kristina; Rani Rahmayanti
MEDICORDHIF Jurnal Rekam Medis Vol 10 No 2 (2023): MEDICORDHIF Jurnal Rekam Medis
Publisher : APIKES Bhumi Husada Jakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.59300/mjrm.v10i2.101

Abstract

ABSTRACT This research is to identify the Standard Operating Procedure (SPO) coding, calculate the number of inaccuracies in the disease diagnosis code and medical treatment in outpatient dental and oral cases and the factors causing the code inaccuracy. The research method used is descriptive analysis research method with data collection techniques by observation and interviews. The population of this study amounted to 2141 medical records, especially in the clinical summary in November 2021-April 2022, samples taken as many as 96 clinical summaries. The results of the study: the SOP has been carried out but is in the process of being revised and not yet perfect, the inaccuracy rate of the incorrect disease diagnosis code is 29 (30.20%) and the correct one is 67 (69.80%), while the inaccurate medical code of action is 18 (18.75%) and the correct one is 78 (81.25%), Causing factors: SOP steps are not perfect, the competence of coding officers is still lacking, identification of medical diagnoses and actions is less detailed, and lack of evaluation, especially periodic coding audits. Bibliography : 17 (2006 – 2020) Keywords : Code, Diagnosis, Medical Action, Clinical Summary, Dental, Oral
Analisis Implementasi Komunikasi Efektif Pada Petugas Pendaftaran Terhadap Pasien Baru Rawat Jalan Di Rumah Sakit Setia Mitra Yayah Sya'diah,SST,MKes.; Nadisa Sabrina Kevinita Sabrina Kevinita
MEDICORDHIF Jurnal Rekam Medis Vol 10 No 2 (2023): MEDICORDHIF Jurnal Rekam Medis
Publisher : APIKES Bhumi Husada Jakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.59300/mjrm.v10i2.102

Abstract

ABSTRACT Effective communication of officers is very important to give a good impression at the beginning of service at the hospital. Problems related to effective communication in registration services are that officers do not receive training and seminars. The study was conducted to determine the implementation of effective communication of outpatient registration officers at Setia Mitra Hospital. The research was conducted using qualitative and quantitative descriptive analysis methods with data collection techniques by observation, interviewing officers, and patient surveys. The research sample consisted of 10 registration officers and 94 new patients. The results of the study were the highest compliance rate of 100% when the officers asked for patient visits and identity interviews. The compliance rate is 40% when officers provide 3S and are quick to respond. The compliance rate is 30% when officers provide clear, friendly, and pleasant information, providing a comfortable and conducive situation. The lowest compliance rate was 20% when the officer thanked him in a friendly manner. Officers have consistently implemented SOPs, but there are several SOPs that have not been implemented.
Tinjauan Ketepatan Kode Diagnosa Gastroenteritis pada Pasien Rawat Inap di Rumah Sakit Umum Daerah Budhi Asih Hudiyati Agustini; Fathirsa Ariya Wirayuda; Indah Kristina
MEDICORDHIF Jurnal Rekam Medis Vol 10 No 2 (2023): MEDICORDHIF Jurnal Rekam Medis
Publisher : APIKES Bhumi Husada Jakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.59300/mjrm.v10i2.104

Abstract

The results of early observations at the Budhi Asih Hospital, on the medical record files of inpatients with a diagnosis of gastroenteritis, found that there were still coding errors. The Gastroenteric Code is divided into two, namely infectious gastroenteritis and non-infectious gastroenteritis. Infectious gastroenteritis can be coded A09.0 (acute infectious gastroenteritis) or A09.9 (unspecified infectious gastroenteritis). Meanwhile, non-infectious gastroenteritis can be coded K52.- and non-infectious gastroenteritis in neonates is coded P78.3. The completeness and accuracy of gastroenteritis coding comes from doctors and nurses who record information on the patient's condition, as well as coding officers providing coding. The purpose of this study was to determine the completeness and accuracy of coding in cases of gastroenteritis in hospitalized patients based on ICD-10. Keywords: Diagnostic code accuracy, Gastroenteritis, Discharge Summary.
Analisis Waktu Penyediaan Berkas Rekam Medis Rawat Jalan di Rumah Sakit Setia Mitra Jakarta Selatan Hudiyati Agustini; Ririn Sri Lestari; Joko Asmoro W
MEDICORDHIF Jurnal Rekam Medis Vol 10 No 2 (2023): MEDICORDHIF Jurnal Rekam Medis
Publisher : APIKES Bhumi Husada Jakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.59300/mjrm.v10i2.105

Abstract

Provision of medical record files must be able to support health services, including outpatient services at hospitals. The time for providing medical record files since the old patient registered has a service standard of 10 minutes or less. The purpose of this study was to find out when to provide outpatient medical record files at Setia Mitra Hospital. The research design used was observative and quantitative descriptive, with a total sample of 98 medical record files taken by random sampling. The results showed that the average provision of outpatient medical record files was 11 minutes, of which 0 files (0%) within 1−5 minutes, 43 files (43.9%) within 6−10 minutes, 49 files (50.0%) within 11−15%, and 6 files (6.1%) within 16−20 minutes. Factors causing this delay include disruption to the network connection on the TMU printer machine and registration computer, misplaced files (miss files), and the lack of socialization and evaluation of the SPO which regulates the time for providing medical record files. Keywords : delays, provision, time line, outpatient medical record file.
TINJAUAN PENERAPAN REKAM MEDIS ELEKTRONIK DI DALAM REGISTRASI PASIEN RAWAT JALAN UPTD PUSKESMAS CIPAYUNG DEPOK Garis Gemilang; Reza Kurniawan
MEDICORDHIF Jurnal Rekam Medis Vol 10 No 2 (2023): MEDICORDHIF Jurnal Rekam Medis
Publisher : APIKES Bhumi Husada Jakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.59300/mjrm.v10i2.106

Abstract

Based on observations of SIMPUS at the UPTD Puskesmas Cipayung Depok, the new patient registration module already running quite well, but it is not yet in accordance with the variable guidelines and meta data for electronic medical records, in which the variable guidelines and meta data for electric medical records are meant to be used as standard data elements for ease of compatibility and/or interoperability of data in electronic systems developed by health care facilities. This journal is based on research data collected on January 2023 with a descriptive research method and by collecting data by observation and interviews. With the results of the research conducted, it was found that the early development of the electronic medical record system at the Cipayung Health Center UPTD was started at the end of 2014 and continued with the development of online registration in 2018. Obstacles that still occur frequently and have not been resolved to date are bugs that have appeared, and there is yet a standardization in the application of variables and metadata used in accordance with the guidelines for variables and metadata of electronic medical records. The suggestions given is to adjust the standard variables and metadata, improve the system to avoid bugs, and standardizing variables.

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