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INDONESIA
Jurnal manajemen informasi kesehatan
Published by Sekolah Tinggi Ilmu Kesehatan Sapta Bakti BENGKULU
ISSN : 2527368X     EISSN : 26214385     DOI : -
Core Subject : Health,
Public Health
JURNAL MANAJEMEN INFORMASI KESEHATAN is a journal that provides scientific writings for the exchange of ideas on theory, methodology and innovation related to the world of health, especially the scope of Medical Records and Health Information.
Arjuna Subject : Profesi Kesehatan - Profesi Kesehatan (Lain-Lain)
Articles 149 Documents
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valuation of the Hospital Service Indicator Reporting Application at Hospital X Arifin, Ismail; Heltiani, Nofri; Khairunnisyah
Jurnal Manajemen Informasi Kesehatan (Health Information Management) Vol. 10 No. 1 (2025): Health Information and Management
Publisher : Sekolah Tinggi Ilmu Kesehatan Sapta Bakti

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.51851/jmis.v10i1.742

Abstract

Regulation of the Minister of Health of the Republic of Indonesia Number 24 of 2022 concerning Medical Records states that every health service must conduct electronic medical record activities, one of which is reporting hospital service indicators. Hospital X's reporting application has not been fully implemented and utilized. This is because it only provides menus for BOR and AvLOS indicators, resulting in calculations using the application differing from manual calculations. The purpose of this study was to evaluate the Hospital Service Indicator Reporting Application at Hospital X in 2024. This study was qualitative with a phenomenological approach. The subjects were medical records and IT staff, as well as the reporting application participants. The data used in this study were primary data, using interview guidelines and observation sheets. The data were then processed and analyzed univariately. The results of this study show that there is a difference in the number of beds between the BOR and AvLOS indicator menus in the reporting application and the Decree of the Director of Hospital X, resulting in differences in the calculation results of Hospital service indicators based on the 2006 Indonesian Ministry of Health which can result in errors in decision making, while the TOI and BTO indicator menus are not yet available so it is necessary to develop a Hospital reporting system design.
Physical Examination Results and Medical Supporting Evidence Affect the Accuracy of Pneumonia Diagnosis Codes in Hospitals Heltiani, Nofri; Arifin, Ismail; Khairunnisyah
Jurnal Manajemen Informasi Kesehatan (Health Information Management) Vol. 10 No. 1 (2025): Health Information and Management
Publisher : Sekolah Tinggi Ilmu Kesehatan Sapta Bakti

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.51851/jmis.v10i1.743

Abstract

The Ministry of Health of the Republic of Indonesia, Decree No. HK.02.02/Menkes/514/2015, states that pneumonia is one of the diseases frequently leading to medical disputes, resulting in losses for hospitals. Based on an initial survey of 10 pneumonia medical records, five files contained missing supporting examination results (chest x-ray), two files contained incomplete physical examinations, and three files contained complete records (chest x-ray, physical examination), leading to doubts about the pneumonia diagnosis codes written in the medical records. This study aimed to determine the accuracy of pneumonia diagnosis codes by examining the results of physical examinations and medical support at Hospital X in 2024. This study was a quantitative descriptive study with a population and sample of 96 medical records of pneumonia cases. The data used in this study were primary and secondary data, using interview guidelines and observation sheets. The data were then processed and analyzed univariately using frequency distribution. The results of the study revealed that the completeness of the physical examination results and medical support was 38 (39%), the accuracy of the physical examination results and medical support was 35 (36%), and the accuracy of the pneumonia diagnosis code was 47 (49%). It is hoped that the Head of Medical Records will conduct a medical record audit through qualitative analysis to minimize the occurrence of medical disputes.
Tracing Diabetes Mellitus Readmission Incidence Through Medical Records at Bhayangkara Hospital, Bengkulu Budiarti, Anggia; Heltiani, Nofri
Jurnal Manajemen Informasi Kesehatan (Health Information Management) Vol. 10 No. 1 (2025): Health Information and Management
Publisher : Sekolah Tinggi Ilmu Kesehatan Sapta Bakti

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.51851/jmis.v10i1.744

Abstract

Readmission can occur for all diseases, including diabetes mellitus. A preliminary survey showed an increase in readmission rates over the past three years. If readmissions occur more than once within a 30-day period, and within a short period of time, the hospital cannot claim funding. The BPJS (Social Security Agency) claims payment system for healthcare services is based on a per-case payment within a predetermined timeframe of ≤30 days. If the time limit is exceeded, the hospital bears the costs. The purpose of this study was to determine the incidence of diabetes mellitus readmissions at Bhayangkara Hospital, Bengkulu. This study was a descriptive quantitative study, with 25 medical records of inpatient diabetes mellitus readmissions collected from January to December 2023 as the population and sample. The data used in this study were secondary data using observation sheets. The data were then processed and analyzed univariately using frequency distribution. The results of the study showed that the incidence of readmission of diabetes mellitus was 100% with the majority being 48% in the 56 - ≥65 years age group, 64% female gender and 52% family history of the disease.
Tinjauan Keamanan Dokumen Rekam Medis Di Ruang Filling Rumah Sakit Sumber Waras mitta_24; Elfi; Subianto, Totok; Ismail Mohammad, Maulana
Jurnal Manajemen Informasi Kesehatan (Health Information Management) Vol. 10 No. 2 (2025): Health Information and Management
Publisher : Sekolah Tinggi Ilmu Kesehatan Sapta Bakti

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.51851/jmis.v10i2.705

Abstract

Latar Belakang :Keamanan memiliki peran penting dalam pengelolaan dokumen medis. Keamanan dokumen di Rumah Sakit Sumber Waras masih belum optimal. Tujuan dari penelitian ini untuk mengetahui keamanan dokumen rekam medis di ruang pengisian . Menjaga keamanan diperlukan ruang penyimpanan yang sesuai dengan standar keamanan yaitu mampu menjamin keamanan serta melindungi data dari risiko kehilangan, kelalaian, bencana, atau ancaman lain yang dapat membahayakan rekam medis. Metode Penelitian : Jenis metode yang digunakan adalah analisis deskriptif kualitatif dengan pendekatan cross-sectional. Teknik pengumpulan data yaitu melalui wawancara dan observasi. Subjek penelitian ini adalah 3 orang kepala yaitu rekam medis, Koordinator Rekam Medis dan Petugas Penanggung Jawab Rekam Medis di Ruang Filling . Hasil Penelitian : Hasil penelitian dengan 3 informan menunjukkan bahwa telah ada kebijakan yang berlaku dan SOP terkait keamanan dokumen rekam medis di pengisian ruang , serta pelaksanaannya sudah diterapkan. Namun, masih terdapat beberapa kekurangan dalam keamanan. Selain itu, hambatan dalam keamanannya meliputi kepadatan dokumen, keterbatasan ruang, dan keberadaan tikus. Simpulan : Keamanan dokumen rekam medis telah diterapkan dengan fasilitas pendukung, namun masih terdapat kekurangan seperti tidak adanya tanda peringatan “selain petugas dilarang masuk”, serta adanya petugas yang membawa makanan & minuman.
Tinjauan Pending Klaim BPJS Rawat Inap di RS X Cirebon Tahun 2024 Dwi Maharani, Sisilia; Aryani, Bhakti; Dewi Rahmawati , Fitria; Haryanto, Yanto
Jurnal Manajemen Informasi Kesehatan (Health Information Management) Vol. 10 No. 2 (2025): Health Information and Management
Publisher : Sekolah Tinggi Ilmu Kesehatan Sapta Bakti

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.51851/jmis.v10i2.706

Abstract

Abstrak Latar Belakang: Permasalahan pending klaim BPJS Kesehatan masih menjadi tantangan utama yang dapat mengganggu stabilitas keuangan dan pelayanan rumah sakit. kondisi ini tidak hanya berdampak pada keterlambatan pembayaran, tetapi juga berpotensi menurunkan efisiensi operasional rumah sakit. Penelitian ini bertujuan untuk meninjau penyebab pending klaim BPJS rawat inap Triwulan III Tahun 2024 di RS X Cirebon, dengan fokus pada aspek koding, medis, dan administratif. Metode Penelitian: Penelitian ini menggunakan metode kuantitatif deskriptif dengan sampel sebanyak 93 dokumen pending klaim yang diperoleh melalui perhitungan menggunakan rumus Slovin dengan tingkat toleransi kesalahan 10% dari total 1.418 pending klaim. Data dikumpulkan melalui observasi dokumen klaim dan berita acara hasil verifikasi (BAHV) dari BPJS Kesehatan Hasil Penelitian: Hasil penelitian menunjukkan bahwa 54,83% pending klaim disebabkan oleh aspek koding, 24,73% oleh aspek administratif, dan 20,43% oleh aspek medis. Perubahan kode diagnosis primer menjadi penyumbang terbesar kasus pending klaim, diikuti oleh perubahan kode diagnosis sekunder dan tindakan medis. Sebagian besar kasus disebabkan oleh perbedaan persepsi antara koder rumah sakit dan verifikator BPJS, serta ketidaksesuaian dengan pedoman pengkodean yang berlaku. Simpulan: Penelitian ini menekankan pentingnya peningkatan akurasi pengkodean, kelengkapan dokumen medis, serta keselarasan pemahaman antara pihak rumah sakit dan BPJS. Diperlukan sosialisasi dan pelatihan secara berkala bagi koder serta verifikator internal terkait aturan kodifikasi yang mengacu pada pedoman klaim terbaru dan ketentuan pada ICD-10, sera menerapkan sistem reward dan punishment.
Literature Review: Analisis Keamanan Data Rekam Medis Elektronik di Fasilitas Kesehatan Fita Rusdian Ikawati; Anis Ansyori; dewi anggih surya permatasari
Jurnal Manajemen Informasi Kesehatan (Health Information Management) Vol. 10 No. 2 (2025): Health Information and Management
Publisher : Sekolah Tinggi Ilmu Kesehatan Sapta Bakti

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.51851/jmis.v10i2.673

Abstract

Keamanan dan privasi data rekam medis elektronik (RME) merupakan aspek yang sangat penting dalam sistem layanan kesehatan digital. Penelitian ini bertujuan untuk menganalisis aspek keamanan informasi RME pada fasilitas kesehatan melalui tinjauan literatur. Penelitian ini menggunakan metode tinjauan literatur, dengan mencari penelitian-penelitian terdahulu yang relevan di database Google Scholar. Dari 226 artikel yang ditemukan, 10 artikel dipilih berdasarkan kriteria inklusi dan eksklusi. Analisis difokuskan pada empat aspek utama keamanan informasi, yaitu privasi, integritas, otentikasi, dan kontrol akses. Hasil penelitian menunjukkan bahwa beberapa fasilitas kesehatan masih menghadapi tantangan dalam melindungi privasi pasien, seperti lemahnya sistem otentikasi dan akses yang tidak terkontrol. Selain itu, integritas data belum sepenuhnya terjamin karena kurangnya sistem pencatatan perubahan data. Beberapa rumah sakit telah menerapkan tanda tangan elektronik dan enkripsi untuk meningkatkan keamanan, namun masih ditemukan celah keamanan, sehingga penelitian ini menekankan pentingnya meningkatkan kebijakan keamanan, menggunakan metode otentikasi yang lebih kuat, dan menerapkan teknologi enkripsi untuk melindungi data pasien. Kolaborasi antara tenaga kesehatan dan ahli teknologi informasi sangat diperlukan untuk mengembangkan sistem RME yang lebih aman dan handal.
Literature Review: Tantangan Interoperabilitas Rekam Medis Elektronik di Fasilitas Kesehatan Widasari, Immaculata Vettha Sarasvati; Ikawati, Fita Rusdian; Ma’ruf, Agus Syukron
Jurnal Manajemen Informasi Kesehatan (Health Information Management) Vol. 10 No. 2 (2025): Health Information and Management
Publisher : Sekolah Tinggi Ilmu Kesehatan Sapta Bakti

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.51851/jmis.v10i2.676

Abstract

Interoperabilitas Rekam Medis Elektronik (RME) menjadi tantangan utama dalam transformasi digital sektor kesehatan. Meskipun bertujuan meningkatkan efektivitas pengelolaan data pasien dan mutu layanan, implementasinya masih terkendala ketidakcocokan standar data, keterbatasan infrastruktur teknologi, serta kurangnya tenaga ahli. Selain itu, belum adanya regulasi nasional yang jelas menyebabkan sulitnya integrasi data antar fasilitas kesehatan, yang berdampak pada keterlambatan akses informasi medis dan pengambilan keputusan klinis yang kurang optimal. Rumusan masalah dalam penelitian ini menganalisis faktor penghambat interoperabilitas RME, dampaknya terhadap layanan kesehatan, serta strategi untuk meningkatkan integrasi sistem informasi kesehatan. Metode yang digunakan adalah tinjauan literatur terhadap jurnal nasional dan internasional yang diterbitkan antara 2021–2025 melalui Google Scholar dan SpringerLink. Hasil penelitian menunjukkan bahwa ketidakcocokan standar data, keterbatasan infrastruktur, serta regulasi yang belum optimal menjadi kendala utama. Selain itu, kurangnya pelatihan tenaga medis dan minimnya tenaga ahli memperlambat adopsi RME. Kesimpulannya, strategi yang diperlukan meliputi standarisasi data, penerapan API terbuka, peningkatan infrastruktur TI, penguatan regulasi, serta pelatihan tenaga medis dan administrator rumah sakit. Dengan strategi yang tepat, sistem RME di Indonesia dapat lebih terintegrasi, meningkatkan efektivitas layanan kesehatan, mempercepat akses informasi medis, serta meningkatkan keamanan dan mutu pelayanan pasien.
LITERATURE REVIEW: ANALYSIS OF THE SYSTEM FOR RECORDING AND REPORTING EXTRAORDINARY EVENTS (KLB) IN HEALTH CARE FACILITIES Amellia, Elsa Andara Dita Amellia; Fita Rusdian Ikawati; Achmad Jaelani Rusdi
Jurnal Manajemen Informasi Kesehatan (Health Information Management) Vol. 10 No. 2 (2025): Health Information and Management
Publisher : Sekolah Tinggi Ilmu Kesehatan Sapta Bakti

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.51851/jmis.v10i2.677

Abstract

Health service facilities (Fasyankes) play an important role in recording and reporting extraordinary events (KLB) as part of the national health system. However, there are still various obstacles in the recording and reporting system, such as discrepancies in patient identity, data duplication, reporting delays due to manual recording, and lack of digital infrastructure and training of health workers. This study aims to analyze the recording and reporting system of outbreak cases in health facilities based on a literature review of various previous studies. The method used was a literature review by analyzing relevant research results from 2019 to 2024. The results showed that implementing a digital system can improve the accuracy and efficiency of recording and reporting outbreak cases, enable early detection, and accelerate health interventions. However, obstacles such as limited human resources, high workload, and suboptimal coordination between agencies are still a challenge in implementing the system. Therefore, strengthening digital infrastructure, increasing the capacity of health workers, and optimizing coordination between agencies are needed to improve the effectiveness of the outbreak recording and reporting system in health facilities.
Literature Review: Security of Electronic Medical Record Patient Data Based on ISO27001 in Healthcare Facilities Jannah, syahfira nur jannah; Untung Slamet; Achmad Jaelani Rusdi
Jurnal Manajemen Informasi Kesehatan (Health Information Management) Vol. 10 No. 2 (2025): Health Information and Management
Publisher : Sekolah Tinggi Ilmu Kesehatan Sapta Bakti

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.51851/jmis.v10i2.680

Abstract

Patient data security in electronic medical records (EMR) is a major concern in healthcare facilities. This study aims to analyze EMR data security based on the ISO 27001 standard through a literature review method. Data were collected from various previous studies that discussed aspects of information security in the implementation of EMR. The results of the study indicate that although security mechanisms such as authentication, encryption, and access control have been implemented, weaknesses are still found in the management of access rights, recording user activities, and security policies. Several healthcare facilities have not fully met the ISO 27001 standard, especially in the aspects of risk management documentation and security evaluation. Therefore, it is necessary to improve security policies, train medical personnel, and provide periodic evaluations to ensure better protection of patient data.

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