Jurnal Rekam Medik & Manajemen Informasi Kesehatan
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Analisis Berkas Rekam Medis Rawat Inap Pada Kasus Operasi Di Rumah Sakit Pusat Pertamina Jakarta Selatan
No full textBased on the results of observations made at Pertamina Central Hospital, it was found that several inpatient medical record file forms, especially in cases of surgery, were related to filling out forms that were not 100% complete and there was no evaluation of the completeness of inpatient medical record files in surgical cases. The purpose of this study was to analyze the completeness of inpatient medical record files, especially cases of surgery at Pertamina Central Hospital in February 2022. This research method used qualitative descriptive. Sampling using the Slovin formula with a population of 200 and the sample results obtained 67 samples. The results of this study obtained that the completeness of filling out the medical record file operation form in the complete category was 43 medical record files (64%) and 24 medical record files were incomplete (36%). The conclusion of this study is that the completeness of inpatient medical record files in surgical cases, especially related to filling out forms at Pertamina Central Hospital is categorized as incomplete because filling out forms is not 100% complete
Analisis Faktor Penyebab Ketidaklengkapan Resume Medis Rawat Inap di Puskesmas Cermee Bondowoso
Full text linkThe patient's medical resume form is a summary of the entire period of patient care and treatment as has been attempted by health workers and related parties. Based on a preliminary study in March 2021, researchers obtained data information on incomplete medical resume forms, the highest incompleteness was found in the identification component, which was 86.7%, the next incompleteness was in the Authentication component, which was 80%, the next incompleteness was in the Authentication component. important reports that is equal to 56.7%. The purpose of this study was to analyze the factors causing the incomplete filling of the patient's medical resume form. This type of research uses qualitative research, the subject of this research consists of 1 head of puskesmas, 3 inpatient doctors, and 1 medical record officer, the object of this research is to use an inpatient medical resume form to determine the factors that cause incomplete medical resume forms. inpatient. The results found in this study are that the first priority is that there is no SOP (Standard Operational Procedure) regarding filling out medical resumes, so it is determined efforts to make SOPs for filling out medical resumes in accordance with medical record service standard
Pencatatan dan Pelaporan Vaksinasi COVID-19 dengan Aplikasi PCare Vaksinasi di Puskesmas Seputih Banyak
Full text linkCOVID-19 has spread throughout the world, so it has a pandemic status. One of the countries infected with the COVID-19 pandemic is Indonesia. The Indonesian government's efforts to stop the spread of COVID-19 are through the COVID-19 vaccination. Every health service facility that carries out the COVID-19 vaccination must record and report the results of the COVID-19 vaccination service through the Vaccination PCare application. The obstacles found at the Seputih Banyak Health Center were data that numbered in the thousands so that the officers were overwhelmed when entering data. This study aims to determine the implementation of recording and reporting of COVID-19 vaccination using the Vaccination PCare application. Data collection in this study was carried out by observing the input, process, and output of the recording and reporting of COVID-19 vaccination using the Vaccination PCare application. . The data analysis used descriptive analysis. The results showed that during the recording and reporting of COVID-19 vaccination, regulations, human resources, process and output were by the provisions, while the facilities are not entirely appropriate. Facilities that are not appropriate are the unavailability of wifi and printers