Novi Indriyani Gunawan, Meita Nurseha, Mei Hidayati
Medical record retention is an activity of transferring medical record documents from an active storage room to an inactive storage room. Based on a preliminary survey at UPT Puskesmas Sukarasa, it is known that the puskesmas has retained outpatient medical record files 2 times in 2018 and 2019. But the retention is not done according to the SOP. The purpose of the study was to determine the implementation of outpatient medical record file retention at UPT Puskesmas Sukarasa. This type of research is descriptive with a retrospective approach. The research instrument was carried out by observation, interviews and checklist forms. The object of the research is the implementation of active to inactive outpatient medical record retention at UPT Puskesmas Sukarasa. The research subjects are the officer in charge of medical records and the person in charge of registration who performs retention of outpatient medical records.It is also known that the UPT Puskesmas Sukarasa already has an SOP on retention of medical records, but the SOP has not been implemented due to the lack of special staff for retention and the accumulation of medical record files on active storage shelves. Files that are retained are files for 2016-2018 without looking at the last date of treatment but based on the year number in the medical record file. Then the file is immediately moved to the inactive storage rack. It can be concluded that the implementation of retention at UPT Puskesmas Sukarasa is not in accordance with the SOP. It would be better if the retention is carried out according to the SOP with special and scheduled officers so that there is no accumulation of medical record files.
{"title":"Analisis Retensi Rekam Medis Rawat Jalan Aktif ke Inaktif di UPT Puskesmas Sukarasa","authors":"Novi Indriyani Gunawan, Meita Nurseha, Mei Hidayati","doi":"10.2411/JIPIKI.V6I2.569","DOIUrl":"https://doi.org/10.2411/JIPIKI.V6I2.569","url":null,"abstract":"Medical record retention is an activity of transferring medical record documents from an active storage room to an inactive storage room. Based on a preliminary survey at UPT Puskesmas Sukarasa, it is known that the puskesmas has retained outpatient medical record files 2 times in 2018 and 2019. But the retention is not done according to the SOP. The purpose of the study was to determine the implementation of outpatient medical record file retention at UPT Puskesmas Sukarasa. This type of research is descriptive with a retrospective approach. The research instrument was carried out by observation, interviews and checklist forms. The object of the research is the implementation of active to inactive outpatient medical record retention at UPT Puskesmas Sukarasa. The research subjects are the officer in charge of medical records and the person in charge of registration who performs retention of outpatient medical records.It is also known that the UPT Puskesmas Sukarasa already has an SOP on retention of medical records, but the SOP has not been implemented due to the lack of special staff for retention and the accumulation of medical record files on active storage shelves. Files that are retained are files for 2016-2018 without looking at the last date of treatment but based on the year number in the medical record file. Then the file is immediately moved to the inactive storage rack. It can be concluded that the implementation of retention at UPT Puskesmas Sukarasa is not in accordance with the SOP. It would be better if the retention is carried out according to the SOP with special and scheduled officers so that there is no accumulation of medical record files.","PeriodicalId":261208,"journal":{"name":"Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI)","volume":"234 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":"131543723","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}
The Imelda Workers General Hospital of Indonesia does not yet have specific routines regarding the release of medical record information to third parties. however, they have used regular procedures for providing information and borrowing medical records in general, This study aims to determine the number of requests for medical record information. This type of research is descriptive, namely the research method carried out with the aim of making an objective state. The population was 4 people and the sample size was 4 people as the total sampling with the research methodology using quantitative methods. How to collect data by interview and observation. The results showed that the services of the Imelda Hospital for Indonesian Workers in Medan according to legalized death certificates amounted to 34 percent (0.56%), claims for raharja services amounted to 56 percent (0.92%), audits and insurance claims were 69 percent (1.14%) , research or education as much as 54 percent (0.89), post mortem as much as 28 percent (0.46%), BPJS as much as 5,790 percent (99.00%). Based on the results of the study, it is known that knowing the data on the number of requests for medical record information in January-June 2020 is 6,224 with a percentage (99.97%). As well as the absence of a special SPO on procedures and utilization of medical record information of deceased patients, however, they have used the permanent procedure of providing information and borrowing medical records in general. It is recommended that hospitals and medical record officers provide regular training or coaching to officers. And to health workers, especially medical records, in order to maintain the confidentiality of patient medical record information and carry out the established procedures properly.
{"title":"Tinjauan Pelepasan Informasi Rekam Medis Kepada Pihak Ketiga Di RSU Imelda Pekerja Indonesia Medan","authors":"Erlindai Purba, Hesty Afriani Sidabutar","doi":"10.2411/JIPIKI.V6I2.480","DOIUrl":"https://doi.org/10.2411/JIPIKI.V6I2.480","url":null,"abstract":"\u0000 \u0000 \u0000The Imelda Workers General Hospital of Indonesia does not yet have specific routines regarding the release of medical record information to third parties. however, they have used regular procedures for providing information and borrowing medical records in general, This study aims to determine the number of requests for medical record information. This type of research is descriptive, namely the research method carried out with the aim of making an objective state. The population was 4 people and the sample size was 4 people as the total sampling with the research methodology using quantitative methods. How to collect data by interview and observation. The results showed that the services of the Imelda Hospital for Indonesian Workers in Medan according to legalized death certificates amounted to 34 percent (0.56%), claims for raharja services amounted to 56 percent (0.92%), audits and insurance claims were 69 percent (1.14%) , research or education as much as 54 percent (0.89), post mortem as much as 28 percent (0.46%), BPJS as much as 5,790 percent (99.00%). Based on the results of the study, it is known that knowing the data on the number of requests for medical record information in January-June 2020 is 6,224 with a percentage (99.97%). As well as the absence of a special SPO on procedures and utilization of medical record information of deceased patients, however, they have used the permanent procedure of providing information and borrowing medical records in general. It is recommended that hospitals and medical record officers provide regular training or coaching to officers. And to health workers, especially medical records, in order to maintain the confidentiality of patient medical record information and carry out the established procedures properly. \u0000 \u0000 \u0000 \u0000 \u0000","PeriodicalId":261208,"journal":{"name":"Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI)","volume":"47 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":"134045820","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}
Puskesmas are required to maintain medical records containing data and information on patient care. Implementation according to accreditation standards, namely criteria 3.2 Registration Process and 3.8 Administration of medical records which are divided into 3.8.1 Coding, 3.8.2 Medical Record Access Rights 3.8.3 Clinical Information Filling and 3.8.4 Storage. The purpose of the study was to find out the implementation of the medical record management system according to the Puskesmas accreditation standards at the Pangkalan Berandan Health Center in 2020. This type of research was qualitative with a Phenomenology approach. The place of research was conducted at the Pangkalan Berandan Health Center. Time of study in July 2020. Research population is all medical record officers at the Pangkalan Berandan Health Center. The research sample is 5 officers. The research instrument was interview guide and check list sheet for observation. The results of the study revealed that the outpatient registration process had been carried out according to criteria 3.2 but there was no inpatient numbering of medical records. Coding was not carried out according to criteria 3.8.1, namely the absence of coding SOPs carried out by doctors using ICD 10, Medical Record Access Rights were carried out according to criteria 3.8. 2 but the implementation is not fully carried out in accordance with the SOP, the lending process is not recorded in the expedition book, Assembling is in accordance with criteria 3.8.3 but recording corrections are carried out using stip-ex and the storage process has been carried out according to criteria 3.8.4 but retention is not carried out according to the guidelines legislation. It is recommended for registration to give medical record numbers to inpatients, coding to make SOPs and given coding training, access rights to medical records to record loans in expedition books, assembling to be given socialization in terms of correcting recording of medical record files and storing tracers as well as in the retention process. given socialization about the implementation of retention.
{"title":"Tinjauan Sistem Penyelenggaraan Rekam Medis Menurut Standart Akreditasi Puskesmas di Puskesmas Pangakalan Berandan Tahun 2020","authors":"Esraida Simanjuntak, F. Insani","doi":"10.2411/JIPIKI.V6I2.587","DOIUrl":"https://doi.org/10.2411/JIPIKI.V6I2.587","url":null,"abstract":"Puskesmas are required to maintain medical records containing data and information on patient care. Implementation according to accreditation standards, namely criteria 3.2 Registration Process and 3.8 Administration of medical records which are divided into 3.8.1 Coding, 3.8.2 Medical Record Access Rights 3.8.3 Clinical Information Filling and 3.8.4 Storage. The purpose of the study was to find out the implementation of the medical record management system according to the Puskesmas accreditation standards at the Pangkalan Berandan Health Center in 2020. This type of research was qualitative with a Phenomenology approach. The place of research was conducted at the Pangkalan Berandan Health Center. Time of study in July 2020. Research population is all medical record officers at the Pangkalan Berandan Health Center. The research sample is 5 officers. The research instrument was interview guide and check list sheet for observation. The results of the study revealed that the outpatient registration process had been carried out according to criteria 3.2 but there was no inpatient numbering of medical records. Coding was not carried out according to criteria 3.8.1, namely the absence of coding SOPs carried out by doctors using ICD 10, Medical Record Access Rights were carried out according to criteria 3.8. 2 but the implementation is not fully carried out in accordance with the SOP, the lending process is not recorded in the expedition book, Assembling is in accordance with criteria 3.8.3 but recording corrections are carried out using stip-ex and the storage process has been carried out according to criteria 3.8.4 but retention is not carried out according to the guidelines legislation. It is recommended for registration to give medical record numbers to inpatients, coding to make SOPs and given coding training, access rights to medical records to record loans in expedition books, assembling to be given socialization in terms of correcting recording of medical record files and storing tracers as well as in the retention process. given socialization about the implementation of retention.","PeriodicalId":261208,"journal":{"name":"Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI)","volume":"112 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":"128942136","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}
Trend analysis is a statistical analysis method used for planning and evaluating efforts to minimize risk for the better. The purpose of this study was to analyze trends and barber johnson charts on the efficiency of bed use at X Hospital, Bandung City. This type of research is a qualitative method with a descriptive approach. Observations and interviews were carried out with data processing officers and medical record reporting officers, while secondary data was obtained from RL3 Year 2020 at Hospital X Bandung City. Data analysis using least square trend method and Barber Johnson chart. The results showed that the trend of BOR and BTO in Quarter I-IV of 2020 decreased. The trend of AvLOS and TOI in Quarter I and II increased, while in Quarter III and IV it decreased. Based on the results of the study, it can be analyzed that the use of beds at Hospital X Bandung City in 2020 has not been efficient, only reaching 20-60% while the standard value according to Barber Johnson is 75-85%, but it can be predicted that the TOI indicator will be more efficient, while the BOR indicator , AvLOS, and BTO are increasingly inefficient because their values are getting further away from the predetermined standard values. To increase efficiency in the use of beds, the hospital should evaluate the beds and improve the quality of service.
{"title":"Analisis Trend Dan Grafik Barber Johnson Pada Efisiensi Tempat Tidur Di Rumah Sakit X Kota Bandung","authors":"Rd. Sekar Putri Defiyanti, Sali Setiatin, Aris Susanto","doi":"10.52943/jipiki.v6i2.576","DOIUrl":"https://doi.org/10.52943/jipiki.v6i2.576","url":null,"abstract":"Trend analysis is a statistical analysis method used for planning and evaluating efforts to minimize risk for the better. The purpose of this study was to analyze trends and barber johnson charts on the efficiency of bed use at X Hospital, Bandung City. This type of research is a qualitative method with a descriptive approach. Observations and interviews were carried out with data processing officers and medical record reporting officers, while secondary data was obtained from RL3 Year 2020 at Hospital X Bandung City. Data analysis using least square trend method and Barber Johnson chart. The results showed that the trend of BOR and BTO in Quarter I-IV of 2020 decreased. The trend of AvLOS and TOI in Quarter I and II increased, while in Quarter III and IV it decreased. Based on the results of the study, it can be analyzed that the use of beds at Hospital X Bandung City in 2020 has not been efficient, only reaching 20-60% while the standard value according to Barber Johnson is 75-85%, but it can be predicted that the TOI indicator will be more efficient, while the BOR indicator , AvLOS, and BTO are increasingly inefficient because their values are getting further away from the predetermined standard values. To increase efficiency in the use of beds, the hospital should evaluate the beds and improve the quality of service.","PeriodicalId":261208,"journal":{"name":"Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI)","volume":"6 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":"114772620","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}
This 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.
本研究是根据万隆穆罕默迪亚医院门诊病历借阅和归还管理问题进行的，旨在找到解决这些问题的办法，以支持病历服务的有效性。本研究采用的研究方法是定性方法与描述性方法相结合。数据收集技术采用访谈法、观察法和研究法。在软件设计中，作者采用了瀑布法，使用的支持软件是Microsoft Visual Studio 2010和Microsoft Access 2013。通过调研发现，门诊病历借还管理中存在以下几个问题:(1)病历存放架上无病历;(2)病历借还记录仍采用人工系统;(三)病历借用、归还未作报告的。笔者可以给出的建议是:(1)以病历的借阅期限确定为好，这样就不会再出现病历逾期归还储藏室的情况;(2)建立病案借还信息系统，以支持医院的各项工作，特别是建立病案借还报告。这项研究的结果是万隆穆罕默迪亚医院的病历文件借阅和归还信息系统。
{"title":"Perancangan Sistem Informasi Peminjaman dan Pengembalian Rekam Medis Rawat Jalan di Rumah Sakit Muhammadiyah Bandung","authors":"Israwati, Sali Setiatin, Falaah Abdussalaam","doi":"10.2411/JIPIKI.V6I2.575","DOIUrl":"https://doi.org/10.2411/JIPIKI.V6I2.575","url":null,"abstract":"This 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.","PeriodicalId":261208,"journal":{"name":"Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI)","volume":"9 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":"122242216","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}
Syafira Nulia, Ian Rahmadhani, Ary Kuncoro, Azundha Rahmadani, Salshabilla Fitri, S. LilisMasyfufahA., S. DiahWijayanti
Work stress is a state of physical and psychological imbalance that can interfere with the implementation of tasks in achieving work performance. The purpose of this study was to determine the description of the work stress of medical record officers, for that a survey was conducted and questionnaires were distributed to obtain data. The population in this study were medical record officers with a sample size of 40 people, using the non-probability sampling technique with the quota sampling method. The three variables studied were the work environment, technological developments and work motivation. The number of questionnaires used in this study were 40 questionnaires. Then quantitative data analysis was carried out categorizing the scores on a high, medium and low scale with the help of the SPSS version 25 application program. According to statistical calculations, the results of the assessment of work environment variables were 52.5% in the high category. While the variable of technological development is 57.5% in the high category and work motivation is 72.5% in the medium category.
{"title":"Gambaran Stres Kerja Petugas Rekam Medis di Rumah Sakit Kota Surabaya","authors":"Syafira Nulia, Ian Rahmadhani, Ary Kuncoro, Azundha Rahmadani, Salshabilla Fitri, S. LilisMasyfufahA., S. DiahWijayanti","doi":"10.2411/JIPIKI.V6I2.567","DOIUrl":"https://doi.org/10.2411/JIPIKI.V6I2.567","url":null,"abstract":"Work stress is a state of physical and psychological imbalance that can interfere with the implementation of tasks in achieving work performance. The purpose of this study was to determine the description of the work stress of medical record officers, for that a survey was conducted and questionnaires were distributed to obtain data. The population in this study were medical record officers with a sample size of 40 people, using the non-probability sampling technique with the quota sampling method. The three variables studied were the work environment, technological developments and work motivation. The number of questionnaires used in this study were 40 questionnaires. Then quantitative data analysis was carried out categorizing the scores on a high, medium and low scale with the help of the SPSS version 25 application program. According to statistical calculations, the results of the assessment of work environment variables were 52.5% in the high category. While the variable of technological development is 57.5% in the high category and work motivation is 72.5% in the medium category.","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":"114811053","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}
The implementation of medical records carried out at the puskesmas requires management in managing all existing activities with the aim of creating good health services, in accordance with procedures and guidelines. To achieve the goal of processing medical records, 5 elements of management are needed, namely man, money, material, machine, and method. The purpose of this study was to determine the management elements of man, money, material, machine, and method in the implementation of medical records carried out at the Medan Johor Health Center. This type of research uses qualitative research methods with a phenomenological approach. The study was conducted from May to July 2020. The population was all medical record officers at the Medan Johor Health Center. The research sample amounted to 5 people who were taken by saturated sampling. The research instrument is an interview guide and recorded using an audio recorder and a check list sheet for observation. The results showed that the man element was 5 people and none of them had a medical record background and had never received training, the money element was the funding obtained from JKN and APBD, the material element was that a family folder was used to store all patient forms, while the use of tracers and register books has not been used to control the borrowed files out of the storage rack, and the filling cabinet is used as a tool to store medical record files, the machine element is a primary care application to register patients, the SIMPUS application is used for reporting, the method element is Not all SOPs in medical records exist. The advice given is to provide training to medical record officers so that their officers better understand the importance of medical records.
{"title":"Pelaksanaan Penyimpanan Rekam Medis Berdasarkan Unsur Manjemen 5M di Puskesmas Medan Johor","authors":"Valentina, Winda Andryani Sinaga","doi":"10.2411/JIPIKI.V6I2.590","DOIUrl":"https://doi.org/10.2411/JIPIKI.V6I2.590","url":null,"abstract":"The implementation of medical records carried out at the puskesmas requires management in managing all existing activities with the aim of creating good health services, in accordance with procedures and guidelines. To achieve the goal of processing medical records, 5 elements of management are needed, namely man, money, material, machine, and method. The purpose of this study was to determine the management elements of man, money, material, machine, and method in the implementation of medical records carried out at the Medan Johor Health Center. This type of research uses qualitative research methods with a phenomenological approach. The study was conducted from May to July 2020. The population was all medical record officers at the Medan Johor Health Center. The research sample amounted to 5 people who were taken by saturated sampling. The research instrument is an interview guide and recorded using an audio recorder and a check list sheet for observation. The results showed that the man element was 5 people and none of them had a medical record background and had never received training, the money element was the funding obtained from JKN and APBD, the material element was that a family folder was used to store all patient forms, while the use of tracers and register books has not been used to control the borrowed files out of the storage rack, and the filling cabinet is used as a tool to store medical record files, the machine element is a primary care application to register patients, the SIMPUS application is used for reporting, the method element is Not all SOPs in medical records exist. The advice given is to provide training to medical record officers so that their officers better understand the importance of medical records.","PeriodicalId":261208,"journal":{"name":"Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI)","volume":"101 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":"122027953","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}
One of the parameters for determining the quality of health services in the hospital is data or information from good and complete medical records. Medical records are an important part of helping the implementation of service delivery to patients at the hospital. Standards relating to medical records in SNARS Edition 1 are in the group of hospital management standards, namely Medical Record Information Management (MIRM) regarding medical record document processing including provision, filling of medical records and reviewing medical records. This research method is descriptive with the method of observation. When this research was conducted in July 2020 at the Imelda Hospital Worker Indonesia Medan. The population taken was 705 medical record documents while the sample in this study was 87 medical record documents. Based on the results of the study, in the review the accuracy of returning medical record documents was 57.4% and 42.5% were incorrect. Readability review of ER assessment as much as 63.2%, assessment of Inpatient as much as 56.3%, CPPT as much as 60.9%, approval for action as much as 77%, reports of anesthesia as much as 68.9%. 3 forms of completeness review are complete, namely Education Assessment, rejection and education form (100%). Suggestions in this study are that review officers must be more assertive to remind every doctor or other medical personnel to pay attention to the accuracy of the restoration, the legibility of medical record files and the completeness of medical record documents. As well as regularly socializing the elements of the MIRM 13.4 assessment.
{"title":"Tinjauan Pelaksanaan Review Berkas Rekam Medis Sesuai Standar Manajemen Informasi Dan Rekam Medik (MIRM 13.4) Di Rumah Sakit Imelda Pekerja Indonesia Tahun 2020","authors":"Esraida Simanjuntak, Mustamil Alwi Dasopang","doi":"10.2411/JIPIKI.V6I1.476","DOIUrl":"https://doi.org/10.2411/JIPIKI.V6I1.476","url":null,"abstract":" \u0000One of the parameters for determining the quality of health services in the hospital is data or information from good and complete medical records. Medical records are an important part of helping the implementation of service delivery to patients at the hospital. Standards relating to medical records in SNARS Edition 1 are in the group of hospital management standards, namely Medical Record Information Management (MIRM) regarding medical record document processing including provision, filling of medical records and reviewing medical records. This research method is descriptive with the method of observation. When this research was conducted in July 2020 at the Imelda Hospital Worker Indonesia Medan. The population taken was 705 medical record documents while the sample in this study was 87 medical record documents. Based on the results of the study, in the review the accuracy of returning medical record documents was 57.4% and 42.5% were incorrect. Readability review of ER assessment as much as 63.2%, assessment of Inpatient as much as 56.3%, CPPT as much as 60.9%, approval for action as much as 77%, reports of anesthesia as much as 68.9%. 3 forms of completeness review are complete, namely Education Assessment, rejection and education form (100%). Suggestions in this study are that review officers must be more assertive to remind every doctor or other medical personnel to pay attention to the accuracy of the restoration, the legibility of medical record files and the completeness of medical record documents. As well as regularly socializing the elements of the MIRM 13.4 assessment.","PeriodicalId":261208,"journal":{"name":"Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI)","volume":"5 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2021-02-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"125470795","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}
Storage of medical records is one of the assessments in puskesmas accreditation standards. The medical record file storage system is very important to do in health care institutions, because the storage system can make it easier for medical record files to be stored in storage racks, speed up the recovery or retrieval of medical record files stored on storage racks, easy to return, and protect record files. from theft, physical, chemical and biological damage. The purpose of this study was to determine how the implementation of a medical record storage system based on puskesmas accreditation standards, which was carried out in August 2020. The research method used was descriptive research with a qualitative approach. The number of research informants was 4 people. Storage of medical records had not used tracers and expedition book as a means of replacing medical record files and notes in and out of borrowed medical record files. Meanwhile, tracer and expedition books can assist officers in searching for missing / out of place medical record files. This can hamper the provision of patient medical record files that are needed. It is hoped that the UPTD Puskesmas Kotanopan will provide regular training or debriefing to medical record officers
{"title":"Tinjauan Pelaksanaan Sistem Penyimpanan Rekam Medis Berdasarkan Standar Akreditasi Di UPTD Puskesmas Kotanopan Mandailing Natal","authors":"Zulham Andi Ritonga, Hasran Ependi Lubis","doi":"10.2411/JIPIKI.V6I1.485","DOIUrl":"https://doi.org/10.2411/JIPIKI.V6I1.485","url":null,"abstract":"Storage of medical records is one of the assessments in puskesmas accreditation standards. The medical record file storage system is very important to do in health care institutions, because the storage system can make it easier for medical record files to be stored in storage racks, speed up the recovery or retrieval of medical record files stored on storage racks, easy to return, and protect record files. from theft, physical, chemical and biological damage. The purpose of this study was to determine how the implementation of a medical record storage system based on puskesmas accreditation standards, which was carried out in August 2020. The research method used was descriptive research with a qualitative approach. The number of research informants was 4 people. Storage of medical records had not used tracers and expedition book as a means of replacing medical record files and notes in and out of borrowed medical record files. Meanwhile, tracer and expedition books can assist officers in searching for missing / out of place medical record files. This can hamper the provision of patient medical record files that are needed. It is hoped that the UPTD Puskesmas Kotanopan will provide regular training or debriefing to medical record officers","PeriodicalId":261208,"journal":{"name":"Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI)","volume":"141 2 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2021-02-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"133954414","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}
Welly Satria Dewi, Daniel Ginting, Rumondang Gultom
Based on the regulations of the Act – Act number 44-year 2009 about hospitals, where each hospital is obligated to do the recording and reporting of all activities of the Organization of the hospital in the form of hospital management information system (SIMRS). Therefore, every hospital is obligated to run SIMRS with the use of open source as has been set in the Year 2013 No. 82 Permenkes about SIMRS. The purpose of the study in order to evaluate the management information system in hospital medical record Installation was RSUP. Adam Malik. Quantitative research method withcross sectional design to measure the research variables model HOT Fit: Human (the use of the system, user satisfaction), Technology (quality system, the quality of information and service quality), Organization (structure), against a Net benefit. Population is the entire staff of medical record that uses SIMRS of 69 people, sampling techniques are the total sampling. The data analysis done in a multiple regression. The purpose of the study to find out the influence of the factor of human technology is preferred, and the organization 's response to the net benefit. The results of the research there is the influence of human factors and technology against a net benefit to mean Ho denied and Ha was accepted, while to factor the organization has no influence on the net benefit, meaning that Ho and Ha accepted rejected. Simultaneously all the independent variables have significant effects on the dependent variable i.e. factors human, technology and organization, the impact on the net benefit. The R-squared value of 0.635 which means all variables the dependent variable may affect independent of 63.5%. Conclusion the research need to craft a careful planning for the development of SIMRS in order to get a quality system, quality of information and service quality, and poured in the master plan, and strategic plan of the hospital.
{"title":"Evaluasi Sistem Informasi Manajemen Rumah Sakit Di Instalasi Rekam Medis RSUP H. Adam Malik Dengan Metode Human Organization Technology Fit (HOT-FIT) Tahun 2019","authors":"Welly Satria Dewi, Daniel Ginting, Rumondang Gultom","doi":"10.2411/JIPIKI.V6I1.510","DOIUrl":"https://doi.org/10.2411/JIPIKI.V6I1.510","url":null,"abstract":"Based on the regulations of the Act – Act number 44-year 2009 about hospitals, where each hospital is obligated to do the recording and reporting of all activities of the Organization of the hospital in the form of hospital management information system (SIMRS). Therefore, every hospital is obligated to run SIMRS with the use of open source as has been set in the Year 2013 No. 82 Permenkes about SIMRS. The purpose of the study in order to evaluate the management information system in hospital medical record Installation was RSUP. Adam Malik. Quantitative research method withcross sectional design to measure the research variables model HOT Fit: Human (the use of the system, user satisfaction), Technology (quality system, the quality of information and service quality), Organization (structure), against a Net benefit. Population is the entire staff of medical record that uses SIMRS of 69 people, sampling techniques are the total sampling. The data analysis done in a multiple regression. The purpose of the study to find out the influence of the factor of human technology is preferred, and the organization 's response to the net benefit. The results of the research there is the influence of human factors and technology against a net benefit to mean Ho denied and Ha was accepted, while to factor the organization has no influence on the net benefit, meaning that Ho and Ha accepted rejected. Simultaneously all the independent variables have significant effects on the dependent variable i.e. factors human, technology and organization, the impact on the net benefit. The R-squared value of 0.635 which means all variables the dependent variable may affect independent of 63.5%. Conclusion the research need to craft a careful planning for the development of SIMRS in order to get a quality system, quality of information and service quality, and poured in the master plan, and strategic plan of the hospital. ","PeriodicalId":261208,"journal":{"name":"Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI)","volume":"1 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2021-02-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"129740188","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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