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Jurnal Health Information Management and Medical Record
Published by Poltekkes Kemenkes Yogyakarta
ISSN : 31632696     EISSN : 31632696     DOI : https://doi.org/10.29238/himmr.v2i1.3281
Core Subject :
The Journal of Health Information Management and Medical Record is an national peer-reviewed scientific journal that includes publications containing research on medical records and health information. All activities that have a relationship with medical records work unit management, workload analysis, disease and medical treatment coding, health service facility statistics, electronic medical records, health financing, and others. This journal aims to enrich the knowledge of medical records and health information for both academics and practitioners. The journal accepts manuscripts in the following categories: 1. Medical records work unit management 2. Workload analysis 3. Medical coding 4. Health service facility statistics 5. Electronic medical records 6. Health financing 7. Other fields related to medical records and health information management This journal also accepts articles from research results and community service activities
Arjuna Subject : -
Articles 15 Documents
 1   2 
Perancangan Standar Prosedur Operasional (SPO) Pelaksanaan Kegiatan Pendaftaran Klinik Adhe Irma Ayuningtyas; Arif Nugroho Triutomo; Margono Margono
Journal of Health Information Management and Medical Record Vol. 1 No. 1 (2025): Vol 1. No. 1 (Juni) 2025
Publisher : Poltekkes Kemenkes Yogyakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.29238/himmr.v1i1.2139

Abstract

Yogyakarta Ministry of Health's Pratama Poltekkes Clinic, especially the Patient Registration Unit, does not yet have Standard Operational Procedures (SPO) for patient registration. The absence of Standard Operational Procedures (SPO) for patient registration has of course caused patient queues, long waiting times and unclear information at the Yogyakarta Ministry of Health's Pratama Poltekkes Clinic. Designing and Designing Standard Operating Procedures (SPO) for Patient Registration at the Pratama Clinic Poltekkes Kemenkes Yogyakarta using the Borg and Gall development stage method, by adopting only the initial 5 stages. This research produced 5 Standard Operational Procedures (SPO) and conducted trials at the Pratama Polytechnic Clinic, Ministry of Health, Yogyakarta with the subject of 2 registration officers and the object of Standard Operating Procedures (SPO) for patient registration at the Pratama Poltekkes Clinic, Ministry of Health, Yogyakarta and the results of the SPO design trial. This research was presented in a qualitative descriptive manner with 3 informants, namely two registration officers in this study and one clinic head as triangulation. Standard Operational Procedures (SPO), which have been tried for 12 days at the Pratama Clinic, Poltekkes Kemenkes Yogyakarta, are running well, can be accepted and well digested by officers. carry out registration activities.
Menuju Rekam Medis Elektronik: Seberapa Jauh Kesiapan Klinik? Aryanti Desty Ramadhani; Anton Kristijono; Niko Tesni Saputra
Journal of Health Information Management and Medical Record Vol. 1 No. 1 (2025): Vol 1. No. 1 (Juni) 2025
Publisher : Poltekkes Kemenkes Yogyakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.29238/himmr.v1i1.2153

Abstract

Medical records have been urged by requiring health care facilities, including clinics, to organize electronic medical records. The implementation of Electronic Medical Records needs to be done by analyzing readiness first. The analysis can be done using the DOQ-IT method. Readiness analysis is needed before implementing RME to determine the level of RME readiness at the Primary Clinic of the Poltekkes Kemenkes Yogyakarta based on the Docto's office quality-information technology (DOQ-IT) method. This type of research is descriptive with a quantitative approach accompanied by qualitative. Research data were collected through questionnaires using googleform and in-depth interview guidelines. The sample used was total sampling of 15 respondents and 1 informant. Primary Clinic of Poltekkes Kemenkes Yogyakarta is very ready (119.71) in implementing RME. Judging from human resources, the clinic is quite ready, with an average score of 3.78. Judging from the organizational work culture, the clinic is very ready, with an average score of 4.31. In terms of leadership, the clinic is very well prepared with an average score of 4.03. In addition, seen from the infrastructure, with an average score of 4.23. Of the four components, the HR component has a fairly low value so that in-depth exploration is needed. The Primary Clinic of the Poltekkes Kemenkes Yogyakarta obtained a score of 119.71, which is said to be very ready. The strategy in dealing with Electronic Medical Records in the conditions of the Primary Clinic of the Poltekkes Kemenkes Yogyakarta is to take advantage of the internship program with third parties and form a special team responsible for supporting the implementation of electronic medical records.
Tinjauan Pelaksanaan Sistem Informasi Pendaftaran Rawat Jalan Menggunakan Metode PIECES di Fasilitas Kesehatan Tingkat Lanjut Aida Nur Arrifah Aida; Nanik Setiyawati; Sumarah Sumarah
Journal of Health Information Management and Medical Record Vol. 1 No. 1 (2025): Vol 1. No. 1 (Juni) 2025
Publisher : Poltekkes Kemenkes Yogyakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.29238/himmr.v1i1.2154

Abstract

The Hospital Information System is a subsystem of the entire Hospital technique consisting of information processing used by individuals according to their roles. The use of this system supports patient care starting from outpatient registration to being processed as hospital reporting material by considering aspects of patient data security. Analyzing weaknesses in information systems can use the PIECES framework, namely Performance, Information, Economy, Control, Efficiency and Service. Purpose : Identifying the implementation of the information system based on the PIECES aspect in the Outpatient Registration section of Nyi Ageng Serang Kulon Progo Hospital. Methods : This study uses a qualitative descriptive method with a case study approach. Data was collected through interviews and observation. The research was conducted in April-May 2023. The research informants were 3 outpatient registration officers, 1 IT officer, and 1 head of medical records. Results: From the results of the study, information was obtained that the results of the performance aspect of the Information System were running according to user needs even though there were incomplete data items on general consent, the information aspect generated by the information system on information data according to user needs even though duplication of medical records is caused by the inconsistency of officers when inputting data; the economics aspect has not yet produced economic value because it is not completely paperless; the control aspect is already running with the control of access rights and security restrictions in the system using passwords and usernames; the efficiency aspect of the information system provides convenience in work; Information system service aspects can be relied upon because they provide convenience for users. Conclusion: Aspects of control, efficiency, service have been fulfilled. while in the performance aspect there are no general consent data items, the information aspect still occurs with double medical records, the economic aspect still has paper forms and medical record folder
Analisis Risiko Keselamatan dan Kesehatan Kerja Bagi Petugas Filing di Fasilitas Kesehatan Tingkat Lanjut Rifa Windy Choirunnisak Rifa; Nanik Setiyawati; Anton Kristijono
Journal of Health Information Management and Medical Record Vol. 1 No. 1 (2025): Vol 1. No. 1 (Juni) 2025
Publisher : Poltekkes Kemenkes Yogyakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.29238/himmr.v1i1.2155

Abstract

Filing room that does not pay attention to and does not apply anthropometric ergonomics aspects can pose a risk to Occupational Safety and Health. The risk factors in the filing room are direct and indirect factors. The direct factors are the area of ??the room, the distance between the storage shelves, the size of the storage shelves, temperature, humidity, noise and lighting. While the indirect factors are SOPs and work instructions for filing officers. Identification of Occupational Safety and Health policies in the form of SOPs, filing room infrastructure and K3 risk analysis in the filing room of Nur Hidayah Hospital, Bantul. This research is a qualitative research with observation, interview, documentation, and Focus Group Discussion methods and uses descriptive data analysis. The results of this study explain that Occupational Safety and Health policies in the form of guidelines, manuals, SOPs, and general work instructions already exist in written form. However, they do not yet have SOPs that regulate Occupational Safety and Health in the filing room. The availability of equipment in the filing room is incomplete, but the condition of the equipment is still suitable for use. Air temperature and humidity in the filing room have not met the ideal standard. The results of the work risk analysis in the filing room show that the highest score for the risk of work accidents is falling and slipping. The SOP for Occupational Safety and Health for the filing room does not yet exist, so hospitals need to make this SOP. The facilities and infrastructure in the filing room are incomplete. The highest work accident risk is 140 and is included in the substantial criteria.
Analisis Desain Ulang Formulir General Consent di Bagian Pendaftaran Rawat Jalan Azkiya Salsabilla Setyaputra Salsa; Anton Kristijono; Yuliantisari Retnaningsih
Journal of Health Information Management and Medical Record Vol. 1 No. 1 (2025): Vol 1. No. 1 (Juni) 2025
Publisher : Poltekkes Kemenkes Yogyakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.29238/himmr.v1i1.2156

Abstract

The use of data items in the outpatient registration general consent form at Nyi Ageng Serang Hospital Kulon Progo is not in accordance with the data items contained in the Decree of the Minister of Health of the Republic of Indonesia Number HK.01.07/MENKES/1423/2022. Regarding Guidelines for Variables and Metadata in the Implementation of Electronic Medical Records The impact of incomplete data is that when there is case of malpractice, the data cannot be used as means of protection for both the hospital and the patient, so it was necessary to redesign the general consent form. The purpose of this research was Identify, analyze, design, and describe the acceptability of redesigning general consent forms from paper to electronic at Nyi Ageng Serang Hospital, Kulon Progo. This research used qualitative descriptive study with a case study approach. This research was conducted in April–May 2023. Respondents in this study were 2 registration officers, 1 IT team, 1 DPJP person, 1 education and training employee, 1 HPK working group team, and 1 head of medical records at Nyi Ageng Serang Hospital Kulon Progo. The results of the identification and analysis show that the anatomical aspects and the contents of the general consent form at Nyi Ageng Serang Kulon Progo General Hospital are not in accordance with the form design standards. When the redesign was carried out, there were changes to the form material, headings, instructions, margins, rules, font and size, way of recording, closing, and completeness of data items. Based on the description of the acceptance of the general consent redesign, the average score of the seven respondents was 81%-100%, so it was included in the "very good" criteria. The conclusion of this research was the redesign of the general consent form obtained a "very good" rating, so it was feasible to use.
Gambaran Ketepatan Penentuan Penyebab Dasar Kematian Pada Formulir Keterangan Penyebab Kematian di RSPAU dr. Suhardi Hardjolukito Syinta Yulia Niswah Nadhiroh
Journal of Health Information Management and Medical Record Vol. 1 No. 2 (2025): Vol 1. No 2 ( Desember ) 2025
Publisher : Poltekkes Kemenkes Yogyakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.29238/himmr.v2i1.3003

Abstract

Formulir Keterangan Penyebab Kematian (FKPK) merupakan dokumen penting dalam rekam medis yang berfungsi sebagai sumber data utama mortalitas di rumah sakit. Ketepatan penentuan penyebab dasar kematian atau UCoD sangat diperlukan untuk menghasilkan data kesehatan yang akurat dalam perencanaan dan evaluasi program kesehatan masyarakat. Pada FKPK ditemukan ketidaktepatan dalam penentuan UcoD akibat kurangnya pemahaman dan penerapan prinsip-prinsip pengisian FKPK yang sesuai standarnya. Metode deskriptif dengan pendekatan kuantitatif digunakan untuk membandingkan hasil UCoD rumah sakit, peneliti, dan expert judgement dengan pedoman ICD-10 dan tabel MMDS. Sampel penelitian berupa FKPK elektronik periode Januari-Februari 2025 dengan usia pasien >7 hari yang dikumpulkan melalui observasi dan dilakukan wawancara untuk mengidentifikasi faktor penyebab ketidaktepatan. Ketidaktepatan pengambilan keputusan UCoD sebesar 87.50% dari 80 FKPK elektronik. Ketidaktepatan diidentifikasi dengan unsur faktor 5M yang meliputi belum adanya pembagian tugas koder yang secara spesifik bertanggung jawab mengenai reseleksi FKPK elektronik, pengisian FKPK belum sesuai dengan standar pada ICD-10 volume 2, belum terdapat SPO penentuan UCoD pada FKPK elektronik, belum digunakannya ICD-10 volume 2 dan tabel MMDS dan belum adanya alokasi anggaran pelatihan terkait penentuan UCoD pada FKPK elektronik. Hasil analisis ketidaktepatan yang sangat tinggi dalam penentuan penyebab dasar kematian pada FKPK elektronik di RSPAU karena belum dilakukan reseleksi kode oleh koder.
Gambaran Pelaksanaan Keselamatan Kesehatan Kerja dan Produktivitas Kerja Petugas Rekam Medis di Rumah Sakit XYZ: Overview of Occupational Health and Safety Implementation and Work Productivity of Medical Record Officers at XYZ Hospital Zahra Fauziyyah; Fery Fadly
Journal of Health Information Management and Medical Record Vol. 1 No. 2 (2025): Vol 1. No 2 ( Desember ) 2025
Publisher : Poltekkes Kemenkes Yogyakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.29238/himmr.v2i1.3010

Abstract

Hospitals are recognized as high-risk work environments due to the potential for occupational accidents and work-related illnesses. To mitigate these risks, hospitals are required to implement comprehensive Occupational Health and Safety (OHS) programs. Effective implementation of OHS measures not only ensures the safety and well-being of staff but also contributes to increased work productivity. However, in practice, some hospital staff still experience occupational hazards. For instance, medical record staff have reported injuries such as cuts from new medical record folders, and limitations such as cramped workspace conditions, which hinder their performance and reduce overall productivity. This study aims to provide an overview of the implementation of occupational health and safety measures and the work productivity of medical record staff in a hospital setting. This research employed a quantitative descriptive method. Data were collected through questionnaires, direct observations, and documentation review. The implementation of OHS was assessed based on several indicators, including the physical work environment, availability of health facilities, and general health maintenance of workers. The findings revealed that 26 respondents (76%) rated the implementation of occupational health and safety as “good.” In contrast, the assessment of work productivity—measured through indicators such as employee capability, output improvement, work motivation, self-development, work quality, and efficiency—showed that 19 respondents (56%) were categorized as “less productive.”
Hubungan Mutu Pelayanan Kesehatan dan Kepuasan Pasien BPJS Rawat Jalan Puskesmas Kejaksan Kota Cirebon karina utami
Journal of Health Information Management and Medical Record Vol. 1 No. 2 (2025): Vol 1. No 2 ( Desember ) 2025
Publisher : Poltekkes Kemenkes Yogyakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.29238/himmr.v2i1.3011

Abstract

This research was conducted at the Kejaksan Public Health Center (Puskesmas Kejaksan) in Cirebon City, with a total sample of 40 respondents in August 2025. The samples were selected using the total random sampling technique, based on Roscoe’s opinion in Research Methods for Business (1982:253) as cited in Sugiyono (2020:90), which states that the minimum sample size for research should be 30 samples.This study was based on preliminary observations and interviews with several patients, which revealed that some were still dissatisfied with the services provided by Puskesmas Kejaksan, Cirebon City.The purpose of this study was to determine whether there is a relationship between the quality of health services and the satisfaction of BPJS outpatient patients at Puskesmas Kejaksan, Cirebon City. Data were collected through observation, questionnaires, and literature study, while data analysis employed validity tests, reliability tests, and simple regression analysis.The results of the data analysis showed that the variables of health service quality and patient satisfaction had a validity test value lower than the r-table value (0.004), and using the Chi-Square Test, it was found that Ho was rejected and H1 was accepted. Therefore, there is a significant relationship between the quality of health services and the satisfaction of BPJS patients at Puskesmas Kejaksan, Cirebon City. It is thus necessary to improve the quality of health services to further enhance patient satisfaction among those seeking treatment at Puskesmas Kejaksan, Cirebon City
Tinjauan Peran Rekam Medis Elektronik dalam Mendukung Deteksi Dini dan Pengawasan Penyakit Menular di RS PKU Muhammadiyah Gamping Sleman: Tinjauan Peran Rekam Medis Elektronik dalam Mendukung Deteksi Dini dan Pengawasan Penyakit Menular di RS PKU Muhammadiyah Gamping Sleman SITI LAILA TUSNIA TUSNIA
Journal of Health Information Management and Medical Record Vol. 1 No. 2 (2025): Vol 1. No 2 ( Desember ) 2025
Publisher : Poltekkes Kemenkes Yogyakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.29238/himmr.v2i1.3014

Abstract

Latar Belakang: Penyelenggaraan rekam medis perlu didigitalisasi secara aman dan rahasia. Sebagai upaya preventif, penerapan Rekam Medis Elektronik (RME) memiliki potensi besar dalam mendukung deteksi dini dan pengawasan penyakit menular di rumah sakit. RME memungkinkan pengungkapan dan pelaporan cepat kasus penyakit menular kepada pihak yang berwenang untuk pencegahan dan pengendalian penyakit. RS PKU Muhammadiyah Gamping Sleman telah menerapkan rekam medis elektronik sejak tahun 2018. Selain itu, telah menggunakan sistem pelaporan untuk mendukung deteksi dini dan pengawasan penyakit menular. Sistem pelaporan menular penyakit belum terintegrasi dengan RME. Penelitian ini bertujuan untuk mengetahui peran rekam medis elektronik dalam mendukung deteksi dini dan pengawasan penyakit menular di RS PKU Muhammadiyah Gamping. Subjek dan Metode: Jenis penelitian ini adalah kualitatif dengan subjek penelitian 3 orang yaitu Kepala Rekam Medis, petugas pelaporan Kewaspadaan Dini Rumah Sakit, dan petugas pelaporan Surveilans Terpadu Penyakit. Teknik pengumpulan data dengan wawancara dan observasi. Hasil: Pengelolaan data RME untuk penyakit menular dimulai dari registrasi pasien, pendistribusian data, pengisian klinis hingga transfer isi RME. RME membantu dalam proses pelaporan penyakit menular. Terdapat beberapa kendala yaitu belum terdapat Early Warning System pada RME, dan error saat mengeluarkan data untuk pelaporan Surveilans Terpadu Penyakit (STP). Kesimpulan: Rekam medis elektronik memudahkan dalam akses cepat dan efisien untuk mencari data dan mengikuti perkembangan penyakit pasien. Hambatan yang dihadapi yaitu belum terdapat Early Warning System pada RME, dan error saat mengeluarkan data untuk pelaporan STP.
Perancangan Desain User Interface Formulir Serah Terima Pre & Post Operasi Elektronik dengan Metode UCD Salma Putri Rismayanti; Anton Kristijono; Nita Budiyanti
Journal of Health Information Management and Medical Record Vol. 1 No. 2 (2025): Vol 1. No 2 ( Desember ) 2025
Publisher : Poltekkes Kemenkes Yogyakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.29238/himmr.v2i1.3103

Abstract

Healthcare facilities are required to implement Electronic Medical Records to achieve integrated medical record management. RS TK III 04.06.03 Dr. Soetarto Yogyakarta has implemented EMR, but the pre and post operative handover forms used to transfer data between treatment rooms still use manual forms, which slow down the process of searching for patient data. This study aims to design a user interface for electronic pre and post operative handover forms. This is a qualitative study with a Research and Development (R&D) design that adopts the User Centered Design (UCD) method as the design method. Data collection was conducted through interviews with five health workers who use the pre and post operative handover forms and the completion of a System Usability Scale (SUS) questionnaire to evaluate the design results. This study produced a user interface design that includes a Login Page, Dashboard Page, OK Menu Page, Pre Operative Page, Post Operative Page, Print Page, and PDF of the Pre and Post Operative Handover Form Results. The evaluation results showed an average design acceptance score of 86.5, which falls within the “Acceptable” assessment criteria with a grade scale of ‘B’ and an adjective rating of “Best Imaginable”. The results of this study indicate that the user interface design of the electronic pre and post operative handover form is acceptable and accordance with user needs.

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