Pub Date : 2022-02-26DOI: 10.52943/jipiki.v7i1.698
Niska Ramadani, Iin Desmiany Duri, Ni Komang Ummi Nur Gayatri, Ismail Arifin
Program KIA merupakan salah satu prioritas utama dalam rencana pembangunan jangka panjang nasional (RPJPN) di indonesia tahun 2005 – 2025, di puskesmas lingkar barat pengolahan data KIA masih menggunakan system manual dimana pengolahan data dicatat dibuku registrasi. Pencatatan manual membutuhkan waktu lebih dari 7 menit setiap pelayanan, dan sering terjadinya kesalahan dalam pencatatan dan pendataan serta membutukan waktu yang lama untuk melakukan pengolahan data pelaporan setiap bulannya, oleh karena itu perlu dikembangkannya system informasi KIA secara elektronik sehingga dapat membantu petugas dalam mengolah program KIA secara cepat, tepat, dan akurat. Tujuan dari penelitian ini adalah untuk menganalisis dan Merancang Sistem Informasi Kesehatan Ibu dan anak di Puskesmas Lingkar Barat guna mengatasi permasalahan yang ada pada saat ini Metode yang digunakan dalam perancangan dan membuat desain system aplikasi dengan memanfaatkan metode pengembangan perangkat lunak yaiu metode wartefal. Penelitian yang dilakukan adalah penelitian deskriptif yaitu mengumpulkan data dengan cara melakukan pengamatan secara langsung terhadap objek penelitian. Metode yang digunakan adalah metode wawancara dan observasi. Pengumpulan data menggunakan data primer dan sekunder. Hasil dari penelitian ini sendiri adalah terciptanya sebuah aplikasi untuk mempermudah pengolahan data menjadi sebuah laporan KIA yang dibutuhkan dan mengatasi masalah yang timbul karena sistem Informai Program Kesehatan Ibu dan Anak secara manual. Perancangan dan Pembuatan desain system Informasi dengan menggunakan Pemrograman Visual Basic 6.0 di Puskesmas Lingkar Barat Kota Bengkulu telah dibuat dengan hasil analisis sistem yang sudah ada dan sesuai metode yang digunakan, serta desain perancangan yang elah dibuat sesuai dengan buku registrasi dan formulir pelaporan manual atau kebutuhan pihak rumah sakit dan dapat mempermudah peroses pengolahan sisem KIA. keterbatasan dalam melakukan penelitian ini adalah sulitnya melakukan wawancara secara langsung , dikarenakan situasi pandemic covid 19 Kontribusi : Penelitian ini dapat berguna dan di Puskesmas Lingkar Barat Kota Bengkulu untuk membantu dalam mengolaha data Registrasi dan Pelaporan Kata Kunci : Sistem Informasi, Program kia, EHR
{"title":"Analisis Dan Perancangan Sistem Informasi Program Kesehatan Ibu Dan Anak Di Puskesmas Lingkar Barat Kota Bengkulu Tahun 2021","authors":"Niska Ramadani, Iin Desmiany Duri, Ni Komang Ummi Nur Gayatri, Ismail Arifin","doi":"10.52943/jipiki.v7i1.698","DOIUrl":"https://doi.org/10.52943/jipiki.v7i1.698","url":null,"abstract":"Program KIA merupakan salah satu prioritas utama dalam rencana pembangunan jangka panjang nasional (RPJPN) di indonesia tahun 2005 – 2025, di puskesmas lingkar barat pengolahan data KIA masih menggunakan system manual dimana pengolahan data dicatat dibuku registrasi. Pencatatan manual membutuhkan waktu lebih dari 7 menit setiap pelayanan, dan sering terjadinya kesalahan dalam pencatatan dan pendataan serta membutukan waktu yang lama untuk melakukan pengolahan data pelaporan setiap bulannya, oleh karena itu perlu dikembangkannya system informasi KIA secara elektronik sehingga dapat membantu petugas dalam mengolah program KIA secara cepat, tepat, dan akurat. \u0000Tujuan dari penelitian ini adalah untuk menganalisis dan Merancang Sistem Informasi Kesehatan Ibu dan anak di Puskesmas Lingkar Barat guna mengatasi permasalahan yang ada pada saat ini Metode yang digunakan dalam perancangan dan membuat desain system aplikasi dengan memanfaatkan metode pengembangan perangkat lunak yaiu metode wartefal. \u0000Penelitian yang dilakukan adalah penelitian deskriptif yaitu mengumpulkan data dengan cara melakukan pengamatan secara langsung terhadap objek penelitian. Metode yang digunakan adalah metode wawancara dan observasi. Pengumpulan data menggunakan data primer dan sekunder. \u0000Hasil dari penelitian ini sendiri adalah terciptanya sebuah aplikasi untuk mempermudah pengolahan data menjadi sebuah laporan KIA yang dibutuhkan dan mengatasi masalah yang timbul karena sistem Informai Program Kesehatan Ibu dan Anak secara manual. Perancangan dan Pembuatan desain system Informasi dengan menggunakan Pemrograman Visual Basic 6.0 di Puskesmas Lingkar Barat Kota Bengkulu telah dibuat dengan hasil analisis sistem yang sudah ada dan sesuai metode yang digunakan, serta desain perancangan yang elah dibuat sesuai dengan buku registrasi dan formulir pelaporan manual atau kebutuhan pihak rumah sakit dan dapat mempermudah peroses pengolahan sisem KIA. \u0000keterbatasan dalam melakukan penelitian ini adalah sulitnya melakukan wawancara secara langsung , dikarenakan situasi pandemic covid 19 \u0000Kontribusi : Penelitian ini dapat berguna dan di Puskesmas Lingkar Barat Kota Bengkulu untuk membantu dalam mengolaha data Registrasi dan Pelaporan \u0000Kata Kunci : Sistem Informasi, Program kia, EHR","PeriodicalId":261208,"journal":{"name":"Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI)","volume":"1 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2022-02-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"128754325","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2022-02-26DOI: 10.52943/jipiki.v7i1.659
Angga Eko Pramono, Marko Ferdian Salim, Anita Wijayanti
The Covid-19 outbreak has been declared as a public health emergency of international concern by the World Health Organization (WHO). The pandemic has also changed the process of health services provided to patients, including medical record services. This study aimed to examine the process of medical record services at the Gondokusuman II Primary Health Center (PHC) in Yogyakarta City during the Covid-19 pandemic. This qualitative research explored medical record services during pandemics. Three staff were recruited as respondents using the purposive sampling technique. Data were collected through observation and interviews. There were differences in patient registration services before and after the pandemic. Before registering, patients will be screened first. If they show Covid-19 symptoms, the patients are directed to the infectious clinic and the provision of medical records will be prioritized. To support the implementation of health protocols, the primary health center provides personnel protective equipment adequately. However, the reference for health protocols related to medical record services at the PHC level is not yet available. So, reference issued by the Ministry of Health is used respectively. Therefore, specific regulations need to be immediately compiled and disseminated to ensure that the prevention of Covid-19 transmission can be carried out more precisely.
{"title":"Studi Kasus Pelayanan Rekam Medis pada Masa Pandemi Covid-19 Di Puskesmas Gondokusuman II Kota Yogyakarta","authors":"Angga Eko Pramono, Marko Ferdian Salim, Anita Wijayanti","doi":"10.52943/jipiki.v7i1.659","DOIUrl":"https://doi.org/10.52943/jipiki.v7i1.659","url":null,"abstract":"The Covid-19 outbreak has been declared as a public health emergency of international concern by the World Health Organization (WHO). The pandemic has also changed the process of health services provided to patients, including medical record services. This study aimed to examine the process of medical record services at the Gondokusuman II Primary Health Center (PHC) in Yogyakarta City during the Covid-19 pandemic. This qualitative research explored medical record services during pandemics. Three staff were recruited as respondents using the purposive sampling technique. Data were collected through observation and interviews. There were differences in patient registration services before and after the pandemic. Before registering, patients will be screened first. If they show Covid-19 symptoms, the patients are directed to the infectious clinic and the provision of medical records will be prioritized. To support the implementation of health protocols, the primary health center provides personnel protective equipment adequately. However, the reference for health protocols related to medical record services at the PHC level is not yet available. So, reference issued by the Ministry of Health is used respectively. Therefore, specific regulations need to be immediately compiled and disseminated to ensure that the prevention of Covid-19 transmission can be carried out more precisely.","PeriodicalId":261208,"journal":{"name":"Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI)","volume":"84 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2022-02-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"131314531","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2022-02-26DOI: 10.52943/jipiki.v7i1.695
Valentina, Mita Sari, T. Sandika
Rejection of claims is one of the obstacles in the BPJS Kesehatan claim collection process. The purpose of this study was to determine the description of administrative verification on the rejection of BPJS Kesehatan patient claims at Tanjung Pura Hospital. This type of research is descriptive qualitative. The population is all BPJS patient medical record files that were rejected in June 2021 counted 135 files and BPJS Kesehatan claiming officers at Tanjung Pura Hospital, totaling 2 people. The samples of this study were the medical record files of BPJS patients who were rejected in June 2021 and the BPJS claiming officers who were taken by saturated sampling. The instruments used are check list sheets and interview guidelines. Data was collected by using documentation, observation and interview methods. Data analysis was done descriptively. The results showed that there were 123 claim files (2.9%) which were rejected by BPJS Kesehatan from 4,253 claim files submitted. The reason for the rejection of the claim file was because all of them did not pass the verification of the service administration which consisted of the absence of a DPJP signature on the resume and proof of service, no referral letter attached, no inpatient indication/order sheet, and no indication of anesthesia attached to the operation report. This incompleteness is due to the lack of thorough examination of the completeness of the medical record file by the data analysis section and the absence of SOPs in the implementation of the claim process. It is recommended to the hospital director to make an SOP for claiming BPJS Kesehatan and to the claims officer and data analysis to be more thorough in checking the completeness of the BPJS Kesehatan claim file.
{"title":"Tinjauan Penolakan Pada Klaim Pasien BPJS Kesehatan di RSUD Tanjung Pura","authors":"Valentina, Mita Sari, T. Sandika","doi":"10.52943/jipiki.v7i1.695","DOIUrl":"https://doi.org/10.52943/jipiki.v7i1.695","url":null,"abstract":"Rejection of claims is one of the obstacles in the BPJS Kesehatan claim collection process. The purpose of this study was to determine the description of administrative verification on the rejection of BPJS Kesehatan patient claims at Tanjung Pura Hospital. This type of research is descriptive qualitative. The population is all BPJS patient medical record files that were rejected in June 2021 counted 135 files and BPJS Kesehatan claiming officers at Tanjung Pura Hospital, totaling 2 people. The samples of this study were the medical record files of BPJS patients who were rejected in June 2021 and the BPJS claiming officers who were taken by saturated sampling. The instruments used are check list sheets and interview guidelines. Data was collected by using documentation, observation and interview methods. Data analysis was done descriptively. The results showed that there were 123 claim files (2.9%) which were rejected by BPJS Kesehatan from 4,253 claim files submitted. The reason for the rejection of the claim file was because all of them did not pass the verification of the service administration which consisted of the absence of a DPJP signature on the resume and proof of service, no referral letter attached, no inpatient indication/order sheet, and no indication of anesthesia attached to the operation report. This incompleteness is due to the lack of thorough examination of the completeness of the medical record file by the data analysis section and the absence of SOPs in the implementation of the claim process. It is recommended to the hospital director to make an SOP for claiming BPJS Kesehatan and to the claims officer and data analysis to be more thorough in checking the completeness of the BPJS Kesehatan claim file.","PeriodicalId":261208,"journal":{"name":"Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI)","volume":"63 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2022-02-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"114640031","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2022-02-26DOI: 10.52943/jipiki.v7i1.599
Rika Andriani, Dewi Septiana Wulandari, Rizka Siwi Margianti
Electronic Medical Records (EMR) is a digital repository of administrative and medical data to support integrated health services. EMR can be used to support case management activities such as identification, care coordination, patient progress monitoring, and provide cost-effective interventions. One of main factor in information system implementation is users. Based on users’ perceptions, recommendations can be made. It’s used to maximize the adoption and development of EMR. The purpose of this study to explore the users’ perceived benefits of EMR implementation to support case management. This research is a qualitative research with a case study design. Informants were EMR users, namely doctors, nurse, pharmacist, medical record officer, and laboratory assistant. They were selected through purposive sampling technique. We conducted face-to-face semi-structured interviews and observation. This research used an interview guide with open-ended questions and an observation guide. Results showed benefits of EMR were support patient safety, reduce duplicate examinations, continuity of care, patient care efficiency, and collaboration among health professionals. It is suggested to develop a patient reminder feature and periodic staff training.
{"title":"Rekam Medis Elektronik sebagai Pendukung Manajemen Pelayanan Pasien di RS Universitas Gadjah Mada","authors":"Rika Andriani, Dewi Septiana Wulandari, Rizka Siwi Margianti","doi":"10.52943/jipiki.v7i1.599","DOIUrl":"https://doi.org/10.52943/jipiki.v7i1.599","url":null,"abstract":"Electronic Medical Records (EMR) is a digital repository of administrative and medical data to support integrated health services. EMR can be used to support case management activities such as identification, care coordination, patient progress monitoring, and provide cost-effective interventions. One of main factor in information system implementation is users. Based on users’ perceptions, recommendations can be made. It’s used to maximize the adoption and development of EMR. The purpose of this study to explore the users’ perceived benefits of EMR implementation to support case management. This research is a qualitative research with a case study design. Informants were EMR users, namely doctors, nurse, pharmacist, medical record officer, and laboratory assistant. They were selected through purposive sampling technique. We conducted face-to-face semi-structured interviews and observation. This research used an interview guide with open-ended questions and an observation guide. Results showed benefits of EMR were support patient safety, reduce duplicate examinations, continuity of care, patient care efficiency, and collaboration among health professionals. It is suggested to develop a patient reminder feature and periodic staff training.","PeriodicalId":261208,"journal":{"name":"Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI)","volume":"54 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2022-02-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"128339540","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2022-02-26DOI: 10.52943/jipiki.v7i1.694
Yeyi Gusla Nengsih
Dokumen rekam medis merupakan alat untuk mencatat terjadinya transaksi pelayanan sehingga harus dijaga keamanan serta kerahasiaannya dari bahaya kerusakan. Tujuan penelitian ini untuk mengetahui bagaimana pelaksanaan pemeliharaan dokumen rekam medis diruang penyimpanan Puskesmas Polonia Medan. Penelitian bersifat deskriptif dan populasi yang digunakan adalah seluruh dokumen rekam medis diruang penyimpanan Puskesmas Polonia dengan sampel berjumlah 100 berkas. Dari hasil penelitian diperoleh kerusakan dokumen rekam medis diruang penyimpanan Puskesmas Polonia Medan sebesar 56%. Faktor intrinsik yang mempengaruhi yaitu kualitas kertas, tinta dan sampul berkas. Sedangkan faktor ektrinsik yang mempengaruhi yaitu kabel listrik tidak tersusun rapi, rak terlalu penuh dan sempit, kelembapan udara mencapai 16oC, jamur, serangga, debu yang menjadi penyebab kerusakan dokumen rekam medis di ruang penyimpanan Puskesmas Polonia Medan. Disarankan kepada Puskesmas Polonia Medan agar dokumen rekam medis menggunakan sampul plastik dengan rak penyimpanan terbuat dari besi sehingga dokumen rekam medis tidak terkena jamur dan rayap yang dapat merusak dokumen rekam medis.
{"title":"Pelaksanaan Pemeliharaan Dokumen Rekam Medis Di Ruang Penyimpanan Puskesmas Polonia Medan Tahun 2021","authors":"Yeyi Gusla Nengsih","doi":"10.52943/jipiki.v7i1.694","DOIUrl":"https://doi.org/10.52943/jipiki.v7i1.694","url":null,"abstract":"Dokumen rekam medis merupakan alat untuk mencatat terjadinya transaksi pelayanan sehingga harus dijaga keamanan serta kerahasiaannya dari bahaya kerusakan. Tujuan penelitian ini untuk mengetahui bagaimana pelaksanaan pemeliharaan dokumen rekam medis diruang penyimpanan Puskesmas Polonia Medan. Penelitian bersifat deskriptif dan populasi yang digunakan adalah seluruh dokumen rekam medis diruang penyimpanan Puskesmas Polonia dengan sampel berjumlah 100 berkas. Dari hasil penelitian diperoleh kerusakan dokumen rekam medis diruang penyimpanan Puskesmas Polonia Medan sebesar 56%. Faktor intrinsik yang mempengaruhi yaitu kualitas kertas, tinta dan sampul berkas. Sedangkan faktor ektrinsik yang mempengaruhi yaitu kabel listrik tidak tersusun rapi, rak terlalu penuh dan sempit, kelembapan udara mencapai 16oC, jamur, serangga, debu yang menjadi penyebab kerusakan dokumen rekam medis di ruang penyimpanan Puskesmas Polonia Medan. Disarankan kepada Puskesmas Polonia Medan agar dokumen rekam medis menggunakan sampul plastik dengan rak penyimpanan terbuat dari besi sehingga dokumen rekam medis tidak terkena jamur dan rayap yang dapat merusak dokumen rekam medis.","PeriodicalId":261208,"journal":{"name":"Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI)","volume":"1 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2022-02-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"130968345","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2022-02-26DOI: 10.52943/jipiki.v7i1.721
Lutfi Rinaldi Syahbana, Indang Trihandini
The completeness of medical records is very important to affect the process of services provided by health workers and impact on the quality of services of a hospital. Preliminary study results conducted at RSDC Wisma Atlet Kemayoran, filling out medical resume form 5 out of 10 files no signature name of medical resume form. Also found, 3 out of 10 files have no outgoing diagnostic information. The purpose of this study is to identify the completeness of the patient's identity, review of important reports, authenticity review and review of the correct completeness of the medical resume form at RSDC Wisma Atlet Kemayoran. This research is qualitative research. The study subject consisted of 2 doctors who filled out a medical resume. The object of the study was a sample of inpatient medical records from June 7-21, 2021 based on slovin formula as many as 98 files. The results of the study on the completeness of filling a medical resume seen from 4 aspects have not been high enough. Incomplete filling of medical resume forms is influenced by several factors, namely man, methode, material, and machine factors.
{"title":"Analisis Kelengkapan Pengisian Resume Medis Rawat Inap di RS Darurat Covid-19 Wisma Atlet Kemayoran","authors":"Lutfi Rinaldi Syahbana, Indang Trihandini","doi":"10.52943/jipiki.v7i1.721","DOIUrl":"https://doi.org/10.52943/jipiki.v7i1.721","url":null,"abstract":"The completeness of medical records is very important to affect the process of services provided by health workers and impact on the quality of services of a hospital. Preliminary study results conducted at RSDC Wisma Atlet Kemayoran, filling out medical resume form 5 out of 10 files no signature name of medical resume form. Also found, 3 out of 10 files have no outgoing diagnostic information. The purpose of this study is to identify the completeness of the patient's identity, review of important reports, authenticity review and review of the correct completeness of the medical resume form at RSDC Wisma Atlet Kemayoran. This research is qualitative research. The study subject consisted of 2 doctors who filled out a medical resume. The object of the study was a sample of inpatient medical records from June 7-21, 2021 based on slovin formula as many as 98 files. The results of the study on the completeness of filling a medical resume seen from 4 aspects have not been high enough. Incomplete filling of medical resume forms is influenced by several factors, namely man, methode, material, and machine factors.","PeriodicalId":261208,"journal":{"name":"Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI)","volume":"140 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2022-02-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"123520612","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2022-02-26DOI: 10.52943/jipiki.v7i1.733
Kuswanto Hardjo, Eniyati, Kori Puspita ningsih
Recording and Reporting are parts of the Medical Record. According to Law No. 29 of 2004 on The Practice of Medicine, Medical Record is a file containing records and documents about the patient's identity, examination, treatment, actions, and other services given to the patient. Good data collection tools can produce accurate and valuable health information. Posyandu elderly Congkrang Village Muntilan District Magelang has been done regularly, but there is no good documentation of examination results. Documentation is written in books, but Posyandu participants can not access it. Forms have not available yet, so participants can not monitor the results of their examinations. The purpose of this study is the creation of health record forms and health examinations documentation of the elderly on an ongoing basis. This research is a development research or Research and Development (R&D) with a qualitative approach. The study results in health record forms in Posyandu elderly "As Syifa" Congkrang Village Muntilan District Magelang Regency based on aspects of form design, namely anatomical aspects, physical aspects, and aspects of content. The final result of creating the health record form is using 80 grams HVS paper size 22 cm x 34 cm with black ink. Based on the validation of the Posyandu elderly that the form design is good and immediately applied because they do not have a health record form.
{"title":"Desain Formulir Posyandu Lansia Desa Congkrang Kecamatan Muntilan Kabupaten Magelang Jawa Tengah","authors":"Kuswanto Hardjo, Eniyati, Kori Puspita ningsih","doi":"10.52943/jipiki.v7i1.733","DOIUrl":"https://doi.org/10.52943/jipiki.v7i1.733","url":null,"abstract":"Recording and Reporting are parts of the Medical Record. According to Law No. 29 of 2004 on The Practice of Medicine, Medical Record is a file containing records and documents about the patient's identity, examination, treatment, actions, and other services given to the patient. Good data collection tools can produce accurate and valuable health information. Posyandu elderly Congkrang Village Muntilan District Magelang has been done regularly, but there is no good documentation of examination results. Documentation is written in books, but Posyandu participants can not access it. Forms have not available yet, so participants can not monitor the results of their examinations. The purpose of this study is the creation of health record forms and health examinations documentation of the elderly on an ongoing basis. This research is a development research or Research and Development (R&D) with a qualitative approach. The study results in health record forms in Posyandu elderly \"As Syifa\" Congkrang Village Muntilan District Magelang Regency based on aspects of form design, namely anatomical aspects, physical aspects, and aspects of content. The final result of creating the health record form is using 80 grams HVS paper size 22 cm x 34 cm with black ink. Based on the validation of the Posyandu elderly that the form design is good and immediately applied because they do not have a health record form.","PeriodicalId":261208,"journal":{"name":"Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI)","volume":"23 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2022-02-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"124161168","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
In SNARS edition 1, it is known that medical record documents in paper or electronic form must be kept safe and confidential so they must be stored in a location that is protected from water, fire, heat, and other damage and protected from interference with access and unauthorized use. The purpose of this study was to determine the ergonomics aspect based on the National Standard for Hospital Accreditation (SNARS) Edition 1. The method used was observation and interviews with a descriptive type of research located at Tere Margareth General Hospital Medan in July 2020. The population in this study was the physical aspect. Ergonomics and medical records officers in the storage room as many as 2 people using the total sampling technique. is the storage room for medical record files at the Tere Margareth hospital that does not meet accreditation standards because there are still problems that occur related to room security which can be assessed based on the standard of ergonomic aspects. Ask the hospital to pay more attention to the state of the medical record storage room in order to meet the standard assessment elements of information management and medical records in SNARS Edition 1.
{"title":"Tinjauan Aspek Ergonomi Pada Ruang Penyimpanan Berdasarkan Standart Nasional Akreditasi Rumah Sakit (SNARS) Edisi 1 Di RSU Tere Margareth Medan Tahun 2020","authors":"Esraida Simanjuntak, Ermas Estiyana, Septi Anastasya","doi":"10.52943/jipiki.v7i1.693","DOIUrl":"https://doi.org/10.52943/jipiki.v7i1.693","url":null,"abstract":"In SNARS edition 1, it is known that medical record documents in paper or electronic form must be kept safe and confidential so they must be stored in a location that is protected from water, fire, heat, and other damage and protected from interference with access and unauthorized use. The purpose of this study was to determine the ergonomics aspect based on the National Standard for Hospital Accreditation (SNARS) Edition 1. The method used was observation and interviews with a descriptive type of research located at Tere Margareth General Hospital Medan in July 2020. The population in this study was the physical aspect. Ergonomics and medical records officers in the storage room as many as 2 people using the total sampling technique. is the storage room for medical record files at the Tere Margareth hospital that does not meet accreditation standards because there are still problems that occur related to room security which can be assessed based on the standard of ergonomic aspects. Ask the hospital to pay more attention to the state of the medical record storage room in order to meet the standard assessment elements of information management and medical records in SNARS Edition 1.","PeriodicalId":261208,"journal":{"name":"Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI)","volume":"7 14","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2022-02-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"113954501","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Z. Purbobinuko, Ratna Prahesti, Kori Puspita Ningsih
Adanya tuntutan rumah sakit untuk menjamin kelengkapan rekam medis, perlu didukung dengan upaya rumah sakit melalui suatu regulasi dan edukasi kepada para PPA dalam proses pendokumentasian rekam medis. Lebih lanjut bahwa paradigma faktor manusia, dalam hal ini adalah PPA dalam menjaga kualitas rekam medis cukup berpengaruh langsung dalam keselamatan pasien. Tujuan dari penelitian ini adalah mengeksplorasi upaya rumah sakit dalam meningkatkan kepatuhan PPA pada dokumentasi rekam medis Penelitian ini merupakan penelitian deskriptif dengan pendekatan kualitatif. Rancangan penelitian menggunakan metode cross sectional. Penelitian ini dilaksanakan di RSUD Panembahan Senopati Bantul. Hasil penelitian menunjuukan RSUD Panembahan Senopati Bantul telah berupaya meningkatkan kepatuhan PPA dengan menetapkan regulasi berupa Pedoman Pelayanan Rekam Medis dan SPO Pengisian Rekam Medis. Upaya dari aspek material dilakukan dengan menyediakan formulir rekam medis berbahan kertas ukuran A4 berat 80 gram berbentuk persegi panjang dengan beberapa warna sesuai kebutuhan pengguna dan diberikan nomor formulir rekam medis. RSUD Panembahan Senopati Bantul telah melakukan penilaian kinerja setiap tahun sekali di akhir tahun, akan tetapi penilai kinerja berkaitan dengan kepatuhan PPA dalam dokumentasi rekam medis belum tertuang dalam SKP. Dalam upaya meningkatkan kepatuhan PPA dalam dokumentasi rekam medis, maka Tim KMKP menetapkan angka ketidaklengkapan assesmen awal medis dalam 24 jam pada pasien rawat inap melalui Instalasi Gawat Darurat (IGD) sebagai indikator mutu prioritas di RSUD Panembahan Senopati Bantul. Sebaiknya dalam upaya meningkatkan motivasi, budaya kerja dan kepatuhan PPA dalam dokumentasi medis, maka RSUD Panembahan Senopati Bantul dapat menerapkan reward dan punishment, sehingga tercapai kepuasan kerja karyawan
{"title":"Upaya Meningkatkan Kepatuhan Profesional Pemberi Asuhan Pasien Dalam Dokumentasi Rekam Medis","authors":"Z. Purbobinuko, Ratna Prahesti, Kori Puspita Ningsih","doi":"10.2411/JIPIKI.V6I2.607","DOIUrl":"https://doi.org/10.2411/JIPIKI.V6I2.607","url":null,"abstract":"Adanya tuntutan rumah sakit untuk menjamin kelengkapan rekam medis, perlu didukung dengan upaya rumah sakit melalui suatu regulasi dan edukasi kepada para PPA dalam proses pendokumentasian rekam medis. Lebih lanjut bahwa paradigma faktor manusia, dalam hal ini adalah PPA dalam menjaga kualitas rekam medis cukup berpengaruh langsung dalam keselamatan pasien. Tujuan dari penelitian ini adalah mengeksplorasi upaya rumah sakit dalam meningkatkan kepatuhan PPA pada dokumentasi rekam medis Penelitian ini merupakan penelitian deskriptif dengan pendekatan kualitatif. Rancangan penelitian menggunakan metode cross sectional. Penelitian ini dilaksanakan di RSUD Panembahan Senopati Bantul. Hasil penelitian menunjuukan RSUD Panembahan Senopati Bantul telah berupaya meningkatkan kepatuhan PPA dengan menetapkan regulasi berupa Pedoman Pelayanan Rekam Medis dan SPO Pengisian Rekam Medis. Upaya dari aspek material dilakukan dengan menyediakan formulir rekam medis berbahan kertas ukuran A4 berat 80 gram berbentuk persegi panjang dengan beberapa warna sesuai kebutuhan pengguna dan diberikan nomor formulir rekam medis. RSUD Panembahan Senopati Bantul telah melakukan penilaian kinerja setiap tahun sekali di akhir tahun, akan tetapi penilai kinerja berkaitan dengan kepatuhan PPA dalam dokumentasi rekam medis belum tertuang dalam SKP. Dalam upaya meningkatkan kepatuhan PPA dalam dokumentasi rekam medis, maka Tim KMKP menetapkan angka ketidaklengkapan assesmen awal medis dalam 24 jam pada pasien rawat inap melalui Instalasi Gawat Darurat (IGD) sebagai indikator mutu prioritas di RSUD Panembahan Senopati Bantul. Sebaiknya dalam upaya meningkatkan motivasi, budaya kerja dan kepatuhan PPA dalam dokumentasi medis, maka RSUD Panembahan Senopati Bantul dapat menerapkan reward dan punishment, sehingga tercapai kepuasan kerja karyawan","PeriodicalId":261208,"journal":{"name":"Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI)","volume":"47 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2021-08-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"127133597","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2021-08-26DOI: 10.52943/jipiki.v6i2.574
Deni Gunawan
A Medical records are files containing notes and documents regarding the patient's identity, examination, treatment, actions and other services that have been provided to patients. So that a medical file is strictly protected so that it is not damaged or lost.Based on observations, it was found that there were several files of medical records that were interchanged or not in the normal filling rack. Medical record files can be exchanged due to the large number of regional shelf columns so that alternatives and innovations are needed to increase the accuracy of returning and retrieving medical record files correctly.Troubleshooting efforts are being made, namely by providing a regional color code in the medical record file folder so that errors in taking and returning medical record files can be minimized.Based on the results of observations made by the author, it was found that there was an effect before and after color coding the region in the medical record file folder.
{"title":"Pengaruh Pemberian Kode Warna Wilayah Pada Folder Terhadap Ketepatan Penyimpanan Berkas Rekam Medis Di Puskesmas Wadaslintang 1","authors":"Deni Gunawan","doi":"10.52943/jipiki.v6i2.574","DOIUrl":"https://doi.org/10.52943/jipiki.v6i2.574","url":null,"abstract":"A Medical records are files containing notes and documents regarding the patient's identity, examination, treatment, actions and other services that have been provided to patients. So that a medical file is strictly protected so that it is not damaged or lost.Based on observations, it was found that there were several files of medical records that were interchanged or not in the normal filling rack. Medical record files can be exchanged due to the large number of regional shelf columns so that alternatives and innovations are needed to increase the accuracy of returning and retrieving medical record files correctly.Troubleshooting efforts are being made, namely by providing a regional color code in the medical record file folder so that errors in taking and returning medical record files can be minimized.Based on the results of observations made by the author, it was found that there was an effect before and after color coding the region in the medical record file folder.","PeriodicalId":261208,"journal":{"name":"Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI)","volume":"8 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2021-08-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"115418885","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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