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INDONESIA
Jurnal Rekam Medis dan Informasi Kesehatan Indonesia
Published by Institut Teknologi Sains dan Kesehatan RS dr. Soepraoen
ISSN : 2829341X     EISSN : 28285867     DOI : 10.62951
Core Subject : Health, Science,
Computer Science & IT Public Health
Jurmiki menerbitkan makalah asli, artikel ilmiah dan laporan singkat yang terkait dengan keilmuan terkait kesehatan (hukum, sistem informasi, manajemen dan klinis)
Arjuna Subject : Profesi Kesehatan - Menejmen Informasi Kesehatan
Articles 80 Documents
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ANALISIS EFEKTIVITAS IMPLEMENTASI REKAM MEDIS ELEKTRONIK TERHADAP WAKTU PENYEDIAAN REKAM MEDIS PASIEN RAWAT JALAN DI RUMAH SAKIT TINGKAT II UDAYANA DENPASAR Komang Cyntia Irene Imayana; I Wayan Widi Karsana; Rai Riska Resty Wasita
Jurnal Rekam Medis dan Informasi Kesehatan Indonesia Vol. 1 No. 2 (2022): Jurnal Rekam Medis dan Informasi Kesehatan Indonesia
Publisher : program studi Rekam Medis dan Infomasi Kesehatan ITSK RS dr Soepraoen Malang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.62951/jurmiki.v1i2.11

Abstract

Medical records for outpatients at Udayana Level II Hospital are still being carried out manually which affects the provision of medical record time. Based on the results of observations made during the provision of outpatient medical records, that is an average of 18 minutes. This is not in accordance with the minimum service standards of the Ministry of Health of the Republic of Indonesia No. 129 of 2008 with a set standard of 10 minutes.The research design was a quasi-experimental one-group pretest-posttest design. The system development analysis method applied is the System Development Life Cycle (SDLC) which consists of 5 stages, namely Analysis, Design, Implementation, Testing, and Maintenance.The results of the study used usability testing on this electronic medical record system and met the usability standard of 88% or can be classified as "very good". The Mann-Whitney test results get a Significance Asym value of 0.000. The significance value of 0.000 <0.05 indicates the influence of the use of electronic medical records on the provision of outpatient medical records at Udayana Level II Hospital in Denpasar with an average time of providing outpatient medical records is 25 seconds.
TINJAUAN KETIDAKLENGKAPAN PENGISIAN FORMULIR RINGKASAN MASUK DAN KELUAR REKAM MEDIS RAWAT INAP PADA PENYAKIT HIPERTENSI DI RSUD LUBUK BASUNG Yulfa Yulia; Oktamianiza Oktamianiza; Dian Sari; Kalasta Ayunda Putri; Vitratul Ilahi; Gopinda Deska Putra
Jurnal Rekam Medis dan Informasi Kesehatan Indonesia Vol. 1 No. 2 (2022): Jurnal Rekam Medis dan Informasi Kesehatan Indonesia
Publisher : program studi Rekam Medis dan Infomasi Kesehatan ITSK RS dr Soepraoen Malang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.62951/jurmiki.v1i2.12

Abstract

The admission and discharge summary is a medical record form that is used to record a summary of the course of the disease from the time the patient entered the hospital until the patient was discharged. The research used is quantitative research with a descriptive approach. Data collection was carried out at Lubuk Basung Regional Hospital from 27 May to 1 July 2023 and the sample consisted of 88 entry and discharge summary forms from the medical records of patients suffering from hypertension. Research through observation with a checklist table. Computerization is used to process data and carry out univariate analysis. The research results showed that there were still incomplete filling out of the entry and discharge summary forms on patient identification items (40.9%), important patient reports (20.5%), patient authentication (12.5%), good record keeping (15.9%). ), and scribbled and clearly legible (17.05%). The results showed that the summary form for admission and discharge for hypertensive patients was still incomplete. In conclusion, this shows that the summary form for admission and discharge for hypertensive patients is still incomplete. It is recommended to carry out evaluations and reviews, as well as outreach and evaluation with doctors, nurses and other related personnel. It mainly deals with the quantitative analysis of incoming and outgoing summary forms.
ANALISIS SWOT PELAPORAN MORTALITAS PASIEN RAWAT INAP SEBAGAI PENDUKUNG MUTU PELAYANAN DI RSU AMINAH KOTA BLITAR Intan Putri Maharani; Prima Soultoni Akbar; Ahmad Jaelani Rusdi
Jurnal Rekam Medis dan Informasi Kesehatan Indonesia Vol. 1 No. 2 (2022): Jurnal Rekam Medis dan Informasi Kesehatan Indonesia
Publisher : program studi Rekam Medis dan Infomasi Kesehatan ITSK RS dr Soepraoen Malang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.62951/jurmiki.v1i2.13

Abstract

As a reference for seeing the number of patients who died due to certain diseases, mortality reports are an important indicator for measuring the success of development in the health sector. Based on the results of research at Aminah General Hospital in Blitar City, it is known that mortality reporting is carried out using two methods, a manual method for processing reporting data and a computerized method for data acquisition. Data collection is written in the visit report in the medical records unit report. One of the efforts made to resolve this problem is to carry out a SWOT analysis of mortality reporting. The purpose of this research was to analyze the SWOT elements of reporting inpatient mortality as a support for the quality of service at RSU Aminah Blitar. This type of research is qualitative descriptive research using the SWOT approach. The results of the FGD (Focus Group Discussion)  show that the most dominant strategy is the WO (Weakness Opportunity) strategy, namely increasing effective communication with professional care provider and related units to minimize incomplete recording of the cause of patient death and to encourage reporting officers not to provide services at the patient registration when the time for reporting is approaching.
PERANCANGAN DAN PEMBUATAN ALUR PENDAFTARAN PASIEN RAWAT INAP DARI IGD MENGGUNAKAN MEDIA AKRILIK TENT HOLDER DI RSUD KABUPATEN JOMBANG Miftakhul Jannah; Dea Allan Karunia Sakti; Ahmad Fauzi
Jurnal Rekam Medis dan Informasi Kesehatan Indonesia Vol. 1 No. 2 (2022): Jurnal Rekam Medis dan Informasi Kesehatan Indonesia
Publisher : program studi Rekam Medis dan Infomasi Kesehatan ITSK RS dr Soepraoen Malang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.62951/jurmiki.v1i2.14

Abstract

Based on the results of observations, it is known that in the emergency room admission room there is no flow for registering inpatients, which causes the patient's family to be confused about the requirements and steps taken in registering an inpatient. The method used in this research is a qualitative method with a case study approach. The instruments used are interviews and observations. The results of the research show that the priority problem is problems related to the patient registration system, which is less than optimal. The results of the root cause analysis show that there are four factors causing the problem (man, method, machine, and environment). The design of the inpatient registration flow from the ER was made based on the results of interviews and observations and was based on the applicable SOP. The results of observing the implementation for two days revealed that there were 17 people in charge of patients who had observed the flow of inpatient registration from the ER. There needs to be socialization regarding the flow of registration of inpatients from the emergency room as well as monitoring and evaluation of the flow every three months.
PEMETAAN SEBARAN PENYAKIT FARINGITIS AKUT BERBASIS SISTEM INFORMASI GEOGRAFIS DI PUSKESMAS CANDILAMA TAHUN 2023 Shafira Berlian Tabroni; Setya Wijayanta; Asharul Fahyudi
Jurnal Rekam Medis dan Informasi Kesehatan Indonesia Vol. 1 No. 2 (2022): Jurnal Rekam Medis dan Informasi Kesehatan Indonesia
Publisher : program studi Rekam Medis dan Infomasi Kesehatan ITSK RS dr Soepraoen Malang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.62951/jurmiki.v1i2.15

Abstract

Acute pharyngitis is one of the diseases caused by viral bacterial infections. In the report of the top 10 diseases in the Candilama Health Center, acute pharyngitis disease was ranked first. In order to facilitate health surveillance, mapping based on Geographic Information Systems is carried out. However, at the Candilama Health Center, mapping the distribution of acute pharyngitis has never been carried out in the Candilam Health Center work area. This study used the method of document study and observation on the object of research and mapping the spread of acute pharyngitis in the working area of the Candilama Health Center, The data used in this study were data on visits of acute pharyngitis patients based on age group, gender, and based on work area. The results of this study show that based on mapping that has been carried out, the area with the most cases of acute pharyngitis is Jomblang sub-district, one of these factors in terms of population density, for the age group most suffered by toddlers in the toddler age group, they are usually susceptible to disease in the respiratory tract and for the sex group, many are suffered by women because women have a different respiratory structure from man.
RANCANGAN ALUR PENDAFTARAN PASIEN RAWAT INAP DARI POLIKLINIK MENGGUNAKAN MEDIA AKRILIK DINDING DI RSUD KABUPATEN JOMBANG Dwi Wulandari; Dea Allan Karunia Sakti; Honggo Dewanto
Jurnal Rekam Medis dan Informasi Kesehatan Indonesia Vol. 1 No. 2 (2022): Jurnal Rekam Medis dan Informasi Kesehatan Indonesia
Publisher : program studi Rekam Medis dan Infomasi Kesehatan ITSK RS dr Soepraoen Malang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.62951/jurmiki.v1i2.16

Abstract

SIMRS is used in the patient registration process, one of which is the registration of the patient in the hospital. The stages of hospital patient registration are pre-admission, elective admission, and payment. The initial registration of patients in the hospital is only done through two doors: the Poliklinik and the UGD . (Unit Gawat Darurat). One of the problems with the registration of hospital patients is that (1) the absence of a hospital patient registration flow from the Poliklinik or IGD causes confusion for the patient or their family. (2) Patients and families complain about hospital registration at the polyclinic because there are frequent errors and long loadings on the SIMRS. (3) The hospital admission space is too small or closed. Methods used in research II are qualitative methods with case study approaches. The instruments used are interviews and observations. The study conducted analysis using the methods of ultrasound and fishbone to determine the priority of the problem, and the implementation of the hospital patient registration process was carried out by applying acrylic walls in the hospital admission section and conducting observations for 2 days that showed that there was a level of awareness or information given to the patient about the process and the course of hospital patient registration. Students can make a design of the patient's registration cycle from a poliklinic, and based on the results of observation over two days, it is known that there are 15–17 patients who are responsible for having observed the registry cycle of hospital patients from the poliklinic.
PENGARUH AKREDITASI RUMAH SAKIT TERHADAP MUTU PELAYANAN KESEHATAN: LITERATURE REVIEW Mochammad Malik Ibrahim; Azka Himatul Ulya; Cahya Arum Yuwantika; Muhammad Arika; Ria Irmanda Putri Melani; Rizkynieta Dwi Impiyani; Wulan Ayu Puspita
Jurnal Rekam Medis dan Informasi Kesehatan Indonesia Vol. 1 No. 2 (2022): Jurnal Rekam Medis dan Informasi Kesehatan Indonesia
Publisher : program studi Rekam Medis dan Infomasi Kesehatan ITSK RS dr Soepraoen Malang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.62951/jurmiki.v1i2.17

Abstract

The implementation of hospital accreditation is a policy used to measure whether the standards set by the government have been met by a hospital, besides that another function of hospital accreditation is that it can be used as an accountability for the quality of services provided. This study aims to determine whether there is an influence between hospital accreditation and the quality of health services. Literature Review design was chosen as the design to conduct this research, the databases used are Elsevier, google scholar, PubMed, and Sinta. Hospital accreditation has an influence on the quality of service in the hospital, where the higher the accreditation of a hospital, the better the quality of health services. There are several factors that can improve both variables, including the use of information technology, patient assessment, drug use management, patient and family education, control and prevention of infectious diseases, facility management.
TINJAUAN KELENGKAPAN INFORMASI PENUNJANG MEDIS PASIEN RAWAT JALAN DI RUMAH SAKIT TNI-AD BHIRAWA BHAKTI KOTA MALANG Sita Dwi Fahyanti; Chyntia Vicky Alvionita; Avid Wijaya
Jurnal Rekam Medis dan Informasi Kesehatan Indonesia Vol. 1 No. 2 (2022): Jurnal Rekam Medis dan Informasi Kesehatan Indonesia
Publisher : program studi Rekam Medis dan Infomasi Kesehatan ITSK RS dr Soepraoen Malang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.62951/jurmiki.v1i2.18

Abstract

The completeness of medical supporting information for outpatients at the TNI-AD Bhirawa Bhakti Hospital, Malang City, was still found to be incomplete, which affected the filling out of forms in medical record documents. In the research, it was discovered that 19 documents had a percentage of 21% (incomplete) and 71 documents had a percentage of 79% (complete). The aim of this research is to analyze the completeness of medical supporting information for outpatients at the Bhirawa Bhakti TNI-AD Hospital, Malang City. This type of research uses quantitative data collection in the form of observations and interviews, while the research instrument uses a checklist sheet. The number of samples used was 90 medical records from April-June 2023 for outpatients. In this study, the average completeness of patient identification results was 80 (88.8%), the average component of important reports was 70 (77.7%), the average component of good records was 66 (73.3%) , and the authentication review component was 69 (76.6%). From the 4 components, the total results of the recapitulation of completeness of medical supporting information obtained a complete total of 71 (79%). Conclusion: factors that influence incompleteness in medical record documents are incompleteness in the Dpjp's signature, the Dpjp's name, and the readability of the doctor's writing which is less understandable.
FAKTOR PENYEBAB KETIDAKTEPATAN KODE DIAGNOSIS PADA DOKUMEN REKAM MEDIS RAWAT INAP DI RUMAH SAKIT ISLAM AISYIYAH MALANG Fakhrur Rozi; Elystia Vidia Marselina
Jurnal Rekam Medis dan Informasi Kesehatan Indonesia Vol. 1 No. 2 (2022): Jurnal Rekam Medis dan Informasi Kesehatan Indonesia
Publisher : program studi Rekam Medis dan Infomasi Kesehatan ITSK RS dr Soepraoen Malang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.62951/jurmiki.v1i2.19

Abstract

One of the competencies of a medical recorder is being able to carry out coding of diseases and actions in accordance with applicable regulations. Errors in determining codes can cause losses to health service facilities. Based on the results of the observations that have been made, it was found that the activity of giving diagnosis codes at Aisyiyah Islamic Hospital still contains errors, namely there is a mismatch between the diagnosis and the diagnosis code. This occurs because the coder is not careful, thus causing errors in coding. The aim of this research is to determine the factors that cause inaccurate diagnosis codes in inpatient medical record documents at the Aisyiyah Islamic Hospital, Malang. This research method uses a qualitative descriptive method. By analyzing the elements that produce inaccuracies in coding based on the man and method elements. This study aims to develop a plan to solve coding errors from patient medical records. Qualitative research was used, with data collection techniques in the form of informant interviews and observational research. Conformity of diagnoses and diagnosis codes at Aisyiyah Islamic Hospital Malang for the 2023 period from a total of 52 samples taken, there were 13.4% incorrect diagnosis codes according to ICD 10 and 86.6% correct diagnosis codes according to ICD 10. The results of the study showed that the cause of inaccuracy in coding Inpatient patient medical record files include unclear doctor's writing, non-standard writing of diagnosis abbreviations, medical record officers are less thorough in coding diagnoses and medical record officers rarely open ICD-10 to ensure the code is accurate or inaccurate.
PREDIKSI KEBUTUHAN RAK DOKUMEN REKAM MEDIS DI RUMAH SAKIT PERMATA BUNDA TAHUN 2022-2026 Gunawan Gunawan; Karina Permata Devi
Jurnal Rekam Medis dan Informasi Kesehatan Indonesia Vol. 2 No. 1 (2022): Jurnal Rekam Medis dan Informasi Kesehatan Indonesia
Publisher : program studi Rekam Medis dan Infomasi Kesehatan ITSK RS dr Soepraoen Malang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.62951/jurmiki.v2i1.20

Abstract

Medical record documents (DRM) at Permata Bunda Hospital are added every year, especially new DRM. The addition of new DRM causes the shelves to be full and exceed the storage capacity so that there are 2600 active DRM stored in cardboard. The addition of DRM causes less storage space. The process of shrinking and destroying DRM at Permata Bunda Hospital has not been carried out routinely so that inactive files accumulate in the storage room. The narrowing of storage space makes it difficult for medical record officers in the return and retrieval process. A fast and accurate return and retrieval process is needed to maintain the quality of DRM services. Planning for five-year (2022-2026) DRM storage rack requirements is very important. This study aims to determine the prediction of the need for DRM shelves at Permata Bunda Hospital in 2022-2026. The type of research used is descriptive quantitative. There are 73,575 (2019-2021) medical DRM as the population and 100 DRM used as the sample. Collecting data by direct observation and calculation on the specified variable. Analysis of calculations with linear equations trend of the last 3 years. The results of the study were 29,452 new DRM and 44,123 old DRM in the 2019-2021 period. The average thickness of the DRM is 0.235 cm. The results of the calculation of the prediction of DRM shelf needs in 2022-2026 are that 18 additional shelves are needed and an area of 8.4 m x 8.7 m = 73 m2

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