Jurnal Rekam Medik & Manajemen Informasi Kesehatan
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Analisis Kelengkapan Pengisian Formulir Informed Consent Pada Pasien Rawat Inap Di RS Pusat Pertamina
Full text linkThe completeness of filling out the informed consent form at Pertamina Central Hospital Jakarta is still less than the Hospital Minimum Service Standard, which is 100%. This is based on the researcher's preliminary study that the completeness of filling out the informed consent form at Pertamina Central Hospital Jakarta was recorded at 73%, while the remaining 27% were incomplete. The purpose of this study was to review the completeness of filling out the informed consent form at Pertamina Central Hospital. This research uses quantitative research with descriptive approach method. Data collection was carried out by observing and documenting the informed consent form as well as interviews with medical record officers. The results showed that the analysis component with the highest completeness was 98%, namely the patient's/guardian's name and patient's signature, while the analysis component with the lowest completeness was 38%, namely the signatures and names of witnesses I and II. The cause of the incomplete informed consent form is the lack of explanation and emphasis by PPA officers on the patient or patient's family to fill out and complete the data that is part of it to be filled and completed
Evaluasi Keakuratan Kodifikasi Diagnosis Penyakit Mata Menggunakan Aplikasi Kodifikasi Diagnosis Penyakit Mata Berbasis Dekstop Di Klinik Malang Eye Center
Full text linkAn accuration code of diagnosis disease should match ICD-10 classification. The accuration of diagnosis code of eye diseases at Malang Eye Center Clinic by using code list in excel program was 30%. The purpose of this study was to determine the level of accuracy of the coding of eye diseases before and after using the application of Desktop-based Eye Disease Codes, at Malang Eye Center Clinic. The research design used the Research and Development (R&D) method with the One Group Pretest Posttest approach. This research used 200 outpatient medical record documents (MRD) of eye disease (100 MRD for pretest and 100 MRD for posttest), that were taken using simple random sampling method. The percentage result of the accuracy of the codification of eye disease diagnosis using a desktop-based application is 96%. The results showed that there was a difference in the accuration of diagnosis code of eye diseases before and after using the application of Desktop-based Eye Disease Codes (the Z calculated value was -4.76). This application can be used as a tool for coding officers to code eye diseases at the Malang Eye Center Clini
Keterlambatan Pelaksanaan Retensi Dokumen Rekam Medis di Rumah Sakit: Literature Review
Full text linkRetention of medical record documents in hospitals must be implemented to limit the number of documents that have been stored on storage shelves for five (five) years, so that they do not accumulate between active and inactive medical record documents. However, several variables contributed to the delay in the implementation of the medical record retention policy. The purpose of this study was to determine procedures, Standard Operating Procedures (SOP), and other factors that contributed to delays in retention of medical records in hospitals. The study was conducted with a literature review of searches on Google Scholar and Garuda. The literature data were analyzed according to the inclusion and exclusion criteria, namely through cross-sectional research methodologies, descriptive surveys, qualitative studies, and journals published between 2017 and 2021. Of all the journals that have been obtained, the procedure for implementing the retention of medical record documents in hospitals is still not implemented properly. The SOP that has been set does not fully explain the procedure for implementing the retention of medical record documents because there are no certain procedures. The delay in the implementation of retention of medical record documents in hospitals is due to differences in the characteristics of archiving officers, supporting facilities and infrastructure, and schedules for storing medical record documents. SOP is important to be made as a guideline to reduce officer errors, and there are several components that cause delays in the implementation of retention of medical record documents in hospitals
Analisis Singkatan Dan Simbol Terhadap Formulir Discharge Summary Rawat Inap Untuk Penilaian Akreditasi Snars Mirm (12) Periode Februari Di Rumah Sakit Pusat Pertamina Jakarta Selatan
Full text linkRecording in SNARS Edition 1 is included in the Hospital Management Standards group on Information and Record Management (MIRM), one of the medical standards in MIRM, namely the standardization of diagnosis codes, procedure/action codes, symbols, abbreviations, and their meanings contained in the MIRM 12 standard. Where in the assessment element, the hospital must have regulations on standardizing diagnosis codes, procedure/action codes, definitions, symbols used and which should not be used, abbreviations used and which should not be used, and monitored their implementation. Pertamina Central Hospital is a referral hospital and accredited B. Where this hospital becomes the Presidential Hospital. Medical Records used in the form of Electronic and Manual Medical Records. On the Medical Record Form in the application there are abbreviations and symbols. In the use of abbreviations and symbols, socialization has been carried out which contains a guideline entitled "The RSPP abbreviation list book" but in its implementation no evaluation has been carried out. And also there are SOPs that state the existence of abbreviations, symbols, actions and diagnostic codes. In the period of February, there were 463 hospitalized patients. And researchers took samples of medical record number 132 medical records from 30% of the number of inpatients using the formula of slovin. This is a qualitative research using direct observation and documentation methods. The results of observation and study documentation show that the abbreviations that are not appropriate are 45%, 67% for symbols and 55% appropriate for summary form releases, The book of abbreviations and symbols belonging to Pertamina Central Hospital has not yet been legalized and socialized legally. And there is no SOP in accordance with SNARS MIRM 12 for abbreviations and symbols at Pertamina Central Hospital. There is also no evaluation in the implementation of the use of abbreviations and symbols as well as the books used, there are still not several symbols and abbreviations listed in the abbreviation and symbol guidelines in the Rspp
Analisis Kebutuhan Tenaga Rekam Medis dengan Metode Workload Indicator Staffing Need (WISN)
Full text linkAs the enacment of National Healt Coverage (JKN), certaintly the number of patients who seek treatment in hospitals has increase due to the patient no longer think about the cost of an expensive problem. The occurrence of the coopertion between the BPJS Paru Hospital Surabaya, certainly made a number of cisits increases it can be seen in the increase in the number of cisits the patient in Paru Hospitals Surabaya years 2014 to 2016. Calculatio of the new workforce needs in the unit procedures is indispensable in order to improve the quality of service. If the increasing number of visits certainly have an effect on basic tasks performed by officers of the procedures. Therefore required the calculation of labbor needs on the Unit Procedures Paru Hospital Surabaya.
Type of this research is descriptive, by describing the calculation of labor needs medical record on the Unit Procedures tah the Paru Hospital Surabaya. Data collection methods used in this study. Interview Procedures and observations officer to find out the acerage time taken at each activity.
From the results of research on workforce needs calculation Unit Procedures Paru Hospital Surabaya found to shift the morning amoun ted to 3 officers. Ther result is greater compared to the number of staff available at this time. If the number of officers alreay according to needs will facilitate the pro cess of service to patients and improven the quality of work
Analisis Kebutuhan Tempat Tidur Di Bangsal Merak RSUP Dr. Kariadi Semarang Tahun 2022-2024
Full text linkThe hospital as a complete health service unit is currently undergoing development where various standards are used to see the effectiveness and efficiency of health services, some of which are. are BOR and LOS. This research was conducted at RSUSP Dr. Kariadi Semarang, namely in three wards; Basic Peacock, Peacock 1, and Peacock 2. The data used in this study are data from 2017 to 2019. The method used in this study is a quantitative descriptive research method. It is known that the number of bed capacities in Dr. Kariadi did not experience an increase in the study year. In addition, the number of effective days in the three wards varied with the condition that the number of treatment days was predicted to decrease. On the other hand, the BOR is too high so it is necessary to add more beds
Analisis Hubungan Ketepatan Penulisan Diagnosis dengan Keakuratan Kode Diagnosis pada Kasus Obstetri dan Ginekologi di Rumah Sakit Tk. IV DKT Kediri
Full text linkActivity of determining the disease code and writing the diagnosis must be in accordance with the correct medical terminology and the classification rules that apply in Indonesia, namely ICD-10 in order to get the right and accurate code. This study aims to analyze the relationship between the accuracy of writing a diagnosis and the accuracy of the diagnosis code in obstetrics and gynecology cases at Rumah Sakit Tk. IV DKT Kediri. The method used in this research is analytic research with cross sectional approach. Based on Slovin's formula, the sample used was 100 medical record documents of inpatients. The sampling technique used is simple random sampling. The data collection technique used observation with a checklist instrument. Data on the accuracy of writing the diagnosis and the accuracy of the diagnosis code were analyzed univariately, while the relationship between the accuracy of writing the diagnosis and the accuracy of the diagnosis code was analyzed using SPSS with Chi-Square test. The results showed that the accuracy of writing the diagnosis was 56%, the accuracy of the diagnosis code was 43%, and there was a relationship between the accuracy of writing the diagnosis and the accuracy of the diagnostic code for obstetrics and gynecology cases at Rumah Sakit Tk. IV DKT Kediri (p < 0.025)
Analisis Aspek Keamanan Informasi Data Pasien Pada Penerapan RME di Fasilitas Kesehatan
No full textData security issues are becoming increasingly serious as the trend of data theft is increasing. This causes not only material losses but also psychological victims. The purpose of this study was to determine how the information security of patient data in the application of RME in terms of information security aspects. The method used is a literature review by analyzing 20 articles from various sources. The results of the study show that from the articles reviewed in terms of 6 security aspects, namely username and password, changes or deletions of data by administrators, electronic signatures and the use of PINs, aspects of using data backup processes to anticipate patient data hacking, restrictions on access rights by using user id & password for each user, as well as log file usage. Overall, health facilities basically have carried out data security on the information systems they use, but in practice there are still health facilities that do not fully meet the data security aspect or are not optimal in using the techniques used. System managers need to develop techniques or ways to secure data more optimally that can fulfill 6 aspects of information security in electronic medical records
Analisis Kelengkapan Berkas Rekam Medis Elektronik Pada Pasien Covid-19 Di Rumah Sakit
Full text linkThe medical record as a record of the patient's illness is a file that must be filled in completely. The incomplete filling of the medical record file will result in the notes contained being out of sync and difficult to identify the previous patient's health information. Therefore, the completeness of filling out the medical record file must reach 100% for 1x24 hours after the patient leaves the hospital. This study aims to determine the level of completeness of filling out electronic medical records in Covid-19 patients at PKU Muhammadiyah Gamping Hospital. The design of this research is descriptive quantitative. The sample in this study was the medical record file for Covid-19 patients in a period of one month as many as 155 medical records. The method of data collection is in the form of a checklist. The results showed that 100% of the electronic medical record files were incomplete. The most complete indicators are the results of supporting the diagnosis (100%), nursing actions (98.9), and pain assessment (93.5%)
Determinan Ketepatan Kode Diagnosis Utama di RS Pusat Pertamina Jakarta Selatan
Full text linkThe inaccuracy of the main diagnosis code will have an impact on the hospital in terms of financing and the quality of the information produced. This can also be influenced by the accuracy of writing the main diagnosis. The purpose of this study was to determinants of the accuracy of the main diagnosis code in the discharged summary of inpatient in February 2022 at Pertamina Central Hospital by paying attention to several components, namely the clarity of writing the main diagnosis and the accuracy of the main diagnosis code. The method used is descriptive qualitative. The total sample is 130 of inpatient discharged summary sheets from a total of 463 medical record files in February 2022. The results showed that 42% discharge summary sheets were not clear in writing the main diagnosis and 86% the main diagnosis code did not correct. It is suggested that the hospital can improve the evaluation of the accuracy of filling in the code and writing the main diagnosis in the summary of discharge, holding training and seminars related to doctor's compliance with the ICD-10 code, and socializing how to enforce the code and write a diagnosis according to the ICD-10 rules