147 research outputs found
Perancangan Sistem Informasi Peminjaman dan Pengembalian Rekam Medis Rawat Jalan di Rumah Sakit Muhammadiyah Bandung
Get PDFThis research was conducted based on the problem of managing the borrowing and returning outpatient medical records at the Muhammadiyah Hospital Bandung which aims to find solutions to these problems to support the effectiveness of medical record services. The research method used in this research is a qualitative method with a descriptive approach. The data collection techniques used were interviews, observation, and study approach. In making the software design the writer uses the waterfall method and the supporting applications used are Microsoft Visual Studio 2010 and Microsoft Access 2013. From the results of the research conducted, the authors found several problems in the management of borrowing and returning outpatient medical records, namely: (1). There were no medical records found on the storage shelf; (2). Recording of borrowing and returning medical records still uses a manual system; (3). The absence of reports on borrowing and returning medical records. The suggestions that can be given by the author, namely : (1). It is better if the borrowing of medical records is determined by the due date so that there are no more medical records that are late to be returned to the storage room; (2). An information system is needed on borrowing and returning medical records to support activities in the hospital, especially in making reports on borrowing and returning medical records. The result of this research is an information system for borrowing and returning medical record files at Muhammadiyah Hospital Bandung
Baba Sali rabbinic court notebook
No full textA handwritten manuscript from the rabbinic court of Yisrael Abuhatzeira in Morocco. This manuscript contains 88 entries or rabbinic rulings - numbers on side margins of pages refer to entry numbers rather than page numbers (there are some page numbers in upper corner, but most are unnumbered). Author Yisrael Abuhatzeira was known as Baba Sali both within and beyond Morroco's Jewish community. His funeral, in 1984, was attended by an estimated 100,000 people and his tomb has become a pilgrimage site to Moroccan Jews.64 unnumbered pagesDiaries, Journals, Notebooks, and other Handwritten Manuscript
Tinjauan Kelengkapan Pengisian Lembar Ringkasan Pulang Resume Pasien Rawat Inap Di Rs Permata Cibubur
Get PDFQuality medical documentation is the foundation of the healthcare system with a direct impact on continuity of care and clinical accountability. The medical resume as an integral component of the medical record serves as a holistic synthesis of therapeutic modalities during hospitalization. This investigation analyzes the completeness of the completion of medical resume documentation through a four-dimensional evaluation: identification modules, clinical reportage segments, authentication elements, and documentation aspects according to standards. This methodology applies a descriptive quantitative paradigm with a cross-sectional survey design on 60 samples of inpatient medical resume documents at Permata Cibubur Hospital during June 2025 using Simple Random Sampling. The research instrument consists of a structured checklist for systematic evaluation through direct observation of the medical resume form. The results of the analysis showed variations in the level of completeness: identification components 95% (5% deficiencies), critical report segments 88.87% (11.13% incomplete), authentication 92.22% (7.78% incompleteness), and proper documentation 93.4% (6.6% incompleteness). The findings show that although the majority of components meet good documentation standards, significant gaps still exist that require systematic optimization. Strategic implications for institutional management include the implementation of a continuous monitoring system and a structured training program for medical personnel to achieve 100% standards in accordance with the Regulation of the Minister of Health Number 24 of 2022.Dokumentasi medis berkualitas merupakan fondasi sistem layanan kesehatan dengan dampak langsung pada kelangsungan perawatan dan akuntabilitas klinis. Resume medis sebagai komponen integral dari rekam medis berfungsi sebagai sintesis holistik dari modalitas terapeutik selama rawat inap. Investigasi ini menganalisis kelengkapan penyelesaian dokumentasi resume medis melalui evaluasi empat dimensi: modul identifikasi, segmen reportase klinis, elemen otentikasi, dan aspek dokumentasi sesuai standar. Metodologi ini menerapkan paradigma kuantitatif deskriptif dengan desain survei cross-sectional pada 60 sampel dokumen resume medis rawat inap di RS Permata Cibubur selama Juni 2025 menggunakan Simple Random Sampling. Instrumen penelitian terdiri dari daftar periksa terstruktur untuk evaluasi sistematis melalui pengamatan langsung formulir resume medis. Hasil analisis menunjukkan variasi tingkat kelengkapan: komponen identifikasi 95% (kekurangan 5%), segmen laporan penting 88,87% (ketidaklengkapan 11,13%), otentikasi 92,2% (ketidaklengkapan 7,8%), dan dokumentasi yang tepat 93,4% (ketidaklengkapan 6,6%). Temuan menunjukkan bahwa meskipun komponen mayoritas memenuhi standar dokumentasi yang baik, kesenjangan signifikan masih ada yang membutuhkan pengoptimalan sistematis. Implikasi strategis bagi manajemen kelembagaan antara lain penerapan sistem pemantauan berkelanjutan dan program pelatihan terstruktur bagi tenaga medis untuk mencapai standar 100% sesuai Peraturan Menteri Kesehatan Nomor 24 Tahun 202
Analisis Luas Ruangan Berdasarkan Kebutuhan Rak di Ruang Penyimpanan Berkas Rekam Medis Rawat Jalan di Puskesmas Cangkuang
Get PDFStorage racks are needed to maintain the confidentiality of medical records, maintain medical records from physical damage, and make it easier for officers to retrieve medical records and return medical records. In addition, sufficient storage space is also needed so that the shelves needed can be arranged properly and neatly. Based on initial observations, the medical record file storage space at the Cangkuang Health Center is still narrow and insufficient, as evidenced by the large number of medical record files scattered on the floor and difficult access for officers. This study aims to determine the area of medical file storage space based on the need for storage racks. The research method used is a quantitative descriptive method by describing the results of the research as they are and comparing them with the theory which then draws conclusions. The subject in this study is the outpatient medical record file storage room. The object of this research is the outpatient medical record file and the outpatient medical record file storage rack. The results showed that the number of storage racks at the Cangkuang Health Center was 5 units with a storage area of 5.39 m². If currently there are only 5 shelves, Cangkuang Health Center needs to provide 5 more shelves, and expand the storage space to 13.63 m² so that all current medical record files can be neatly arranged in the shelves and make it easier for officers to retrieve and return them. medical record file.Rak penyimpanan dibutuhkan dalam menjaga kerahasiaan rekam medis, memelihara rekam medis dari kerusakan fisik, dan memudahkan petugas dalam mengambil rekam medis serta pengembalian kembali rekam medis. Disamping itu, dibutuhkan juga ruang penyimpanan yang memadai agar rak yang dibutuhkan dapat tertata dengan baik dan rapi. Berdasarkan hasil pengamatan awal, ruang penyimpanan berkas rekam medis di Puskesmas Cangkuang masih sempit dan belum memadai, terbukti dengan banyaknya berkas rekam medis yang tercecer di lantai dan akses yang sulit untuk petugas. Penelitian ini bertujuan untuk menentukan luas ruangan penyimpanan berkas rekam medis berdasarkan kebutuhan rak penyimpanan. Metode penelitian yang digunakan adalah metode deskriptif kuantitatif dengan menggambarkan hasil penelitian apa adanya dan membandingkan dengan teori kemudian ditarik kesimpulan. Subjek dalam penelitian ini adalah ruang penyimpanan berkas rekam medis rawat jalan. Objek dalam penelitian ini adalah berkas rekam medis rawat jalan dan rak penyimpanan berkas rekam medis rawat jalan. Hasil dari penelitian menunjukkan jumlah rak penyimpanan di Puskesmas Cangkuang adalah 5 unit rak dengan luas ruang penyimpanan 5.39 m². Jika saat ini hanya terdapat 5 unit rak, Puskesmas Cangkuang perlu menyediakan 5 unit rak lagi, dan memperluas ruang penyimpanan menjadi 13.63 m² sehingga semua berkas rekam medis saat ini dapat tersusun rapi di dalam rak serta memudahkan akses bagi petugas untuk mengambil dan mengembalikan kembali berkas rekam medi
PENANGAN BERKAS REKAM MEDIS TERKAIT COVID-19 DI RS X
Get PDFABSTRAK
Virus Corona atau serve acute respiratory syndrome coronavirus 2 (SARS-CoV-2) adalah infeksi virus yang menyebabkan gangguan pada sistem pernafasan. Dengan laju penyebaran yang cepat, virus corona tentunya juga berisiko tinggi menginfeksi para tenaga medis yang merawat pasien COVID-19. Oleh karenanya para tenaga medis dan tenaga kesehatan khususnya perekam medis perlu menggunakan Alat Perlindungan Diri (APD) untuk menghindari penularan virus corona yang bisa bertahan pada media kertas selama 4-5 hari. Tempat pelayanan pendaftaran baik di rawat jalan maupun gawat darurat merupakan titik rawan penularan COVID-19 karena di tempat itulah pertama kali pasien datang, baik pasien negatif, positif maupun pasien yang belum terkonfirmasi kondisi tubuhnya. Tetapi penularan juga masih dapat terjadi antar petugas medis (dokter dan perawat) yang menangani pasien positif COVID-19 dengan petugas rekam medis meskipun tidak kontak langsung dengan pasien. Maka dari itu dibutuhkan strategi penanganan dokumen berkas rekam medis pasien agar tidak menularkan berbagai macam virus terhadap para petugas medis khususnya petugas rekam medis selama pandemi COVID-19 di semua fasilitas pelayanan kesehatan. Tujuan penelitian ini adalah untuk mengetahui bagaimana pengelolaan berkas rekam medis pasien COVID-19 dan pemulihan berkas rekam medis setelah pelayanan pasien COVID-19 khususnya di Rumah Sakit X. Metode yang digunakan dalam penelitin ini adalah kualitatif analisis deskriptif dan wawancara dengan petugas rekam medis. Dapat disimpulkan bahwa sebaiknya perekam medis membuat strategi untuk membedakan antara berkas pasien COVID-19 dan non COVID-19.
Kata kunci : COVID-19, Virus, Berkas, Rekam Medis
ABSTRACT
Coronavirus or serve acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a viral infection that causes disorders of the respiratory system. With the rapid rate of spread, coronavirus is certainly also at high risk of infecting medical personnel treating COVID-19 patients. Therefore, medical personnel and health workers, especially medical recorders need to use Personal Protection Equipment (PPE) to avoid the transmission of coronavirus that can survive on paper media for 4-5 days. Place of registration services both outpatient and emergency is a vulnerable point of transmission of COVID-19 because that is where the patient first came, both negative, positive and unconfirmed patients. But transmission can also still occur between medical personnel (doctors and nurses) who treat COVID-19 positive patients with medical records officers even if there is no direct contact with the patient. Therefore, it is necessary to handle the strategy of handling patient medical record file documents so as not to transmit various viruses to medical personnel, especially medical record personnel during the COVID-19 pandemic in all health care facilities. The purpose of this study is to find out how to manage the medical record file of COVID-19 patients and the recovery of medical record files after COVID-19 patient services, especially in Hospital X. The method used in this research is qualitative descriptive analysis and interviews with medical record officers. It can be concluded that it is recommended that medical recorders make strategies to distinguish between COVID-19 and non-COVID-19 patient files.
Keywords : COVID-19, Virus, File, Medical Recor
Analisis Desain Formulir Asesmen Awal Rawat Jalan Terkait SNARS Edisi 1.1 Elemen Penilaian AP 1.2 di RSBSA Bandung
Get PDFThe initial assessment was identified for new patients who came for outpatient treatment as basic information to determine the patient's condition and for follow-up care. Based on the results of observations at RSBSA Bandung that the initial outpatient assessment form is still less effective and efficient. So the hospital needs to review the initial outpatient assessment form, so that it can fulfill SNARS Edition 1.1 Assessment Elements of AP 1.2. The purpose of this study was to design an outpatient initial assessment form at RSBSA Bandung form based on SNARS Edition 1.1 Assessment Elements of AP 1.2. This study uses a qualitative case study approach. The subjects of this study included dentists, nurses and heads of medical records. The object of this research is the outpatient initial assessment form. Research data collection techniques by interview and observation. From the physical aspect, the form design uses white with A4 size cardboard, paper weight is 190grams and is rectangular in shape. From the anatomical aspect, there is no edition number and page number heading, no introduction and instructions, no body and no close notes. From the aspect of content, identity data already exists, patient medical data is not suitable for SNARS Edition 1.1 Elements of AP 1.2. Based on the results of research, it is necessary to design an outpatient initial assessment form based on SNARS Edition 1.1 related to AP 1.2 Assessment Elements.Asesmen awal diidentifikasi untuk pasien baru yang datang pengobatan rawat jalan sebagai informasi dasar untuk mengetahui keadaan pasien dan untuk tindak lanjut perawatan. Berdasarkan hasil observasi di RSBSA Bandung bahwa formulir asesmen awal rawat jalan masih kurang efektif dan efisien. Sehingga pihak rumah sakit perlu mengkaji ulang terkait formulir asesmen awal rawat jalan, agar dapat memenuhi SNARS Edisi 1.1 Elemen Penilaian AP 1.2. Tujuan dari penelitian ini yaitu menganalisis dan mendesain formulir asesmen awal rawat jalan di RSBSA Bandung agar sesuai SNARS Edisi 1.1 Elemen Penilaian AP 1.2. Penelitian ini menggunakan kualitatif dengan pendekatan studi kasus. Subjek penelitian meliputi dokter, perawat dan kepala rekam medis. Objek yang diambil dalam penelitian yaitu formulir asesmen awal rawat jalan. Teknik pengumpulan data penelitian dengan wawancara dan observasi. Dari aspek fisik, desain formulir menggunakan warna putih dengan kertas karton ukuran A4, berat kertas 190gram dan bentuk persegi panjang. Dari aspek anatomi, heading nomor edisi dan nomor halaman belum ada, introduction dan instruction belum ada, body sudah ada dan close catatan belum ada. Dari aspek isi, data identitas sudah ada, data medis pasien belum sesuai untuk SNARS Edisi 1.1 Elemen AP 1.2. Berdasarkan hasil penelitian, maka diperlukan desain formulir asesmen awal rawat jalan berdasarkan SNARS Edisi 1.1 terkait Elemen Penilaian AP 1.2
PENGARUH BEBAN KERJA PETUGAS PENDAFTARAN TERHADAP EFEKTIVITAS PELAYANAN DI RSU BINA SEHAT
No full textPenting melakukan analisis beban kerja petugas Rekam Medis yang menitik beratkan pada peningkatan efektivitas dalam bidang sumber daya manusia yang berkaitan dengan aktivitas kerja dan waktu yang dibutuhkan petugas untuk menyekesaikan tugasnya sesuai dengan unitnya masing–masing. Tujuan dari penelitian ini adalah untuk mengetahui jumlah kebutuhan tenaga rekam medis berdasarkan beban kerja di RSU Bina Sehat. Jenis penelitian yang digunakan adalah penelitian deskriptif dengan menggunakan pendekatan cross sectional yang bertujuan untuk mengetahui bagaimana kebutuhan petugas rekam medis berdasarkan beban kerja dengan metode analisis beban kerja kesehatan (ABK) di bagian pendaftaran. Dari hasil perhitungan jumlah minimal kebutuhan tenaga rekam medis di bagian pendaftaran di RSU Bina Sehat, dengan jumlah pasien pada tahun 2020 sebanyak 83349. Maka tenaga rekam medis yang dibutuhkan saat ini untuk melakukan kegiatan pendaftaran adalah 15 orang, sedangkan petugas di bagian pendaftaran saat ini sebanyak 13 orang.Dari hasil perhitungan tersebut petugas pendaftaran di RSU Bina Sehat harus menambah sebanyak 2 orang agar bisa menjalankan pekerjaannya sesuai dengan PMK NO.55 tahun 2013. Agar pekerjaannya menjadi lebih efektif sehingga beban kerja yang ada dapat cepat teratasi
ANALISIS EFEKTIVITAS PENGGUNAAAN REKAM MEDIS ELEKTRONIK MENINGKATKAN EFISIENSI DAN AKURASI DATA PASIEN RAWAT JALAN DI RSUD WELAS ASIH
Get PDFPerkembangan transformasi digital di sektor kesehatan menjadi strategi penting untuk memperbaiki mutu layanan, efisiensi proses, serta ketepatan data pasien. Penelitian ini bertujuan untuk menilai tingkat efektivitas penerapan Rekam Medis Elektronik (RME) dalam upaya meningkatkan efisiensi dan keakuratan data pasien rawat jalan di RSUD Welas Asih. Pendekatan penelitian yang digunakan bersifat deskriptif kuantitatif, dengan teknik pengumpulan data melalui kuesioner berbasis skala Likert (1–5) yang diberikan kepada petugas rekam medis dan tenaga kesehatan pengguna sistem RME. Analisis data dilakukan dengan menghitung rata-rata dari setiap indikator kemudian dikonversi menjadi persentase efektivitas. Hasil penelitian memperlihatkan bahwa penerapan RME berada pada kategori sangat efektif, dengan rata-rata efektivitas melebihi 90%. Nilai rata-rata variabel efisiensi sebesar 4,79 (95,82%), akurasi data sebesar 4,83 (96,55%), dan kemudahan penggunaan sebesar 4,63 (92,55%). Temuan tersebut menegaskan bahwa sistem RME mampu mempercepat proses pengelolaan data, meminimalkan kesalahan pencatatan, serta mempermudah petugas dalam mengakses dan memperbarui informasi pasien. Dengan demikian, dapat disimpulkan bahwa implementasi RME di RSUD Welas Asih berhasil meningkatkan efisiensi pelayanan dan akurasi data pasien rawat jalan. Penelitian ini merekomendasikan peningkatan kualitas infrastruktur jaringan, penyelenggaraan pelatihan rutin bagi pengguna, serta pengembangan fitur integrasi sistem untuk mengoptimalkan kinerja RME di masa mendatang
TINJAUAN PENGGUNAAN MOBILE JKN DALAM MENINGKATKAN EFISIENSI PROSES PENDAFTARAN PASIEN RAWAT JALAN DI RSUD BANDUNG KIWARI
Get PDFDigitalisasi layanan kesehatan mendorong hadirnya aplikasi Mobile JKN sebagai inovasi BPJS Kesehatan untuk mempermudah pendaftaran pasien rawat jalan. Penelitian ini meninjau efektivitas Mobile JKN dalam meningkatkan efisiensi pendaftaran, menggambarkan prosedur, serta mengidentifikasi hambatan implementasi di RSUD Bandung Kiwari. Metode penelitian menggunakan pendekatan kualitatif deskriptif melalui wawancara dan observasi dengan petugas pendaftaran. Hasil penelitian menunjukkan bahwa Mobile JKN cukup sering digunakan karena dianggap cepat, praktis, dan mampu memberikan kepastian kuota dokter. Aplikasi ini memangkas alur pendaftaran manual melalui check-in di Anjungan Pendaftaran Mandiri (APM). Hambatan yang muncul meliputi keterbatasan integrasi dengan Surat Eligibilitas Peserta (SEP), kendala biometrik, perbedaan informasi jadwal layanan, rendahnya literasi digital pasien, serta resistensi sebagian tenaga medis. Mobile JKN terbukti berkontribusi positif terhadap efisiensi, namun masih diperlukan peningkatan integrasi sistem, edukasi pasien, dan dukungan internal rumah sakit
Mišljenje studenata o ulozi medicinske sestre instrumentarke u operacijskoj sali
No full textUVOD: Medicinske sestre instrumentarke imaju višestruku ulogu u operacijskoj sali prije, za vrijeme i nakon operativnog zahvata, a ona uključuje održavanje sterilnih uvjeta tijekom operativnog zahvata, pripremu kirurških instrumenata i asistiranje kirurgu tijekom izvođenja operativnog zahvata. Kako bi medicinska sestra instrumentarka mogla kvalitetno izvršavati svoju zadaću u operacijskoj sali, mora poznavati cijeli tijek operativnog zahvata, razlikovati kirurške instrumente te biti pripremljena na brze i adekvatne reakcije s obzirom da su operacijske sale često nestabilna okruženja u kojima se stanje pacijenta može promijeniti iz minute u minutu.
CILJ: Cilj istraživanja bio je istražiti i prikazati mišljenje studenata sestrinstva na Preddiplomskom stručnom studiju sestrinstva o ulozi medicinske sestre instrumentarke u operacijskoj sali. Specifični ciljevi istraživanja su prikazati mišljenje studenata sestrinstva o timskom radu i odnosima unutar multidisciplinarnog tima u operacijskoj sali te mišljenje o razini edukacije potrebnoj za rad u istoj.
METODE: Podaci za istraživanje prikupljali su se putem online anketnog upitnika koji je osmišljen je od strane autorice rada. Prvim dijelom upitnika su se prikupljali sociodemografski podaci, a drugim dijelom mišljenja ispitanika o ulozi medicinske sestre instrumentarke u operacijskoj sali, timskom radu i razini edukacije medicinskih sestara/ tehničara potrebnoj za rad u operacijskoj sali. Prije ispunjavanja anketnog upitnika, svim ispitanicima bio je priložen obrazac za informirani pristanak. Rezultati su obrađeni metodama deskriptivne statistike.
REZULTATI: U istraživanju je sudjelovalo ukupno 53 ispitanika, od čega samo 2 ispitanika nisu bila u operacijskoj sali za vrijeme zahvata. 100% ispitanika smatra da je uloga medicinske sestre instrumentarke značajna, 98,1% ispitanika smatra da je u operacijskoj sali važan timski rad, no 56,6% ispitanika smatra da je uloga medicinske sestre instrumentarke zanemarena od drugih članova tima te 71,7% ispitanika smatra da unutar tima dolazi do sukoba. 54,7% ispitanika smatra da tijekom studija nisu stekli dovoljno kliničke prakse za rad u operacijskoj sali te da je za isto potrebna dodatna edukacija, što smatra 98,1% ispitanika.
ZAKLJUČAK: Studenti sestrinstva smatraju da medicinska sestra instrumentarka ima značajnu ulogu u operativnim zahvatima, no percepcija uloge medicinske sestre instrumentarke od strane studenata, odjelnih medicinskih sestara i drugih zdravstvenih djelatnika je nedovoljno istražena.INTRODUCTION: Instrument nurses have multiple roles in the operating room before, during, and after surgery, and it includes maintaining sterile conditions during surgery, preparing surgical instruments, and assisting the surgeon during surgery. For a nurse to perform her task in the operating room, she must know the entire course of the operation, differentiate surgical instruments, and be prepared for quick and adequate reactions, since operating rooms are often unstable environments where the patient's condition can change from minute to minute.
OBJECTIVE: The aim of the research was to investigate and present the opinion of nursing students at the Undergraduate Professional Study of Nursing on the role of an instrument nurse in the operating room. The specific objectives of the research are to present the opinion of nursing students on teamwork and relations within a multidisciplinary team in the operating room and the opinion on the level of education required to work in it.
METHODS: Data for the research were collected through an online survey questionnaire designed by the author for the purposes of writing the final paper. The first part of the questionnaire collected socio-demographic data of respondents, and the second part of respondents' opinions on the role of instrumental nurse in the operating room, teamwork, and the level of education of nurses / technicians required to work in the operating room. Prior to completing the questionnaire, all respondents were provided with an informed consent form. The results were processed by descriptive statistics methods.
RESULTS: A total of 53 subjects participated in the study, of which only 2 subjects were not in the operating room during the procedure. 100% of respondents believe that the role of instrumental nurse is important, 98.1% of respondents believe that teamwork is important in the operating room, but 56.6% of respondents believe that the role of instrumental nurse is neglected by other team members and 71.7% the respondent believes that there is a conflict within the team. 54.7% of respondents believe that during the studies they did not acquire enough clinical practice to work in the operating room and that the same requires additional education, which 98.1% of respondents believe.
CONCLUSION: Nursing students believe that the instrument nurse has a significant role in surgical interventions, but the perception of the role of the instrument nurse by students, ward nurses and other health professionals is insufficiently researche
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