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Journal : J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan

Analisis Aspek Kompetensi Individu dalam Duplikasi Nomor Rekam Medis di Puskesmas Ida Nurmawati; Kurnia Arofah
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 1 (2019): December
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v1i1.1928

Abstract

Duplication of medical record number is one of the problems in medical record section. Duplication that occurred in the Labruk Kidul Public Health Center was 10,3% consist of 7,6% duplicate one medical record number owned by some head of families, and 2,7% duplicated one head of family with some medical record numbers. The purpose of this research is to analyze the priority causes of duplication medical record of numbers in the Labruk Kidul Public Health Center Lumajang. It was a qualitative research and the data collection techniques used interviews,and observations. The subject of this research was registration officer, head of the medical record and head of the public health center. The results showed that the cause of duplication from individual competency factors was that the officer could not make KIUP, the officer did not write the. The solution is to socialize the system of numbering and additional time and labor in finding duplicate medical record number and merging files.
Faktor Penyebab Ketidaklengkapan Pengisian Kode Diagnosa Rawat Jalan di RS Husada Utama Nabiilah Qurrota A'yun; Rossalina Adi Wijayanti; Gilang Nur Permana; Ida Nurmawati
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 2 No 1 (2020): December
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v2i1.2001

Abstract

At present hospitals and paramedics prone to demands that demands the quality of service , lawsuits from a patient and the competitors in the same because of that required to improve the quality and keep the quality of health services at the hospital .One parameter to determine the quality of health services at the hospital is data or information from medical record good and complete , both the contents , accurate , timely and working persayaratan legal aspects .Based on working practices roomy implemented in february to march obtained hasill that incomplete filling out of code diagnose on medical record outpatient husada surabaya hospital main reach 100 % it is not in line with permenkes 269 year 2008 stating that document completeness medical record must be fully 100 %. A journal aims to understand the factors causing the incomplete filling out of the diagnosis code .Incompleteness this researched use the undirected behavior lawrence green with a variable presdiposing factors , enabling options factors , reinforcing factors .Incomplete filling out of the diagnosis code was conducted by interviews is not structured and observation activities directly when performing my roomy .The result of the report is affecting behavior because of the incomplete on charging the diagnosis code outpatient medical record husada hospital as much as the main the hospitals are required to carry out socialization of standard operating procedures aimed at the paramedics to be the remembrance of the content and doing the work of in accordance with the sop.
Evaluasi Sistem Pendaftaran Online dengan Metode Technology Acceptance Model di Rumah Sakit Umum Daerah K.R.M.T Wongsonegoro Kota Semarang Finno Harta Dinata; Ida Nurmawati; Indah Muflihatin
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 3 (2020): June
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v1i3.2048

Abstract

The online registration system is important component to improve hospital service quality. Regional GeneralHospital K.R.M.T. Wongsonegoro City of Semarang has implemented online registration system since 2017and never been evaluated. An online registration system that is often used by patients is via the MYRSWNapplication, can be downloaded at the play store and app store. Online registration system users in 2019totaling 15,437 users from 199,188 patients. Based on data, it can be seen that users of the online registrationsystem are only 8% of the total number of patients. This shows the user's interest in using the onlineregistration system is very lacking. This research was aimed to analyze the acceptance of an onlineregistration system. The research showed that overview of the online registration system based on aspects ofperceived ease of use can be assessed as easy to learn, quite flexible and easy to use, aspects of perceivedusefulness is considered to have considerable benefits in increasing productivity, making work effective andfast, last aspects of behavioural intention to use tend to be satisfied using the online registration system.Based on aspects of perceived ease of use, perceived usefulness,and behavioural intention to use applicationof an online registration system has been running according to user needs, but it is not free from variousproblems, so there needs a efforts to improvement and development of online registration system through therecommendation of researchers so that online registration system can maintain quality and improve servicequality to patients.
Identifikasi Penyebab Keterlambatan Penyediaan Dokumen Rekam Medis Rawat Jalan di Rumah Sakit Husada Utama Surabaya Tahun 2020 Astrid Kartika Dewi Aprilia; Ida Nurmawati; Rossalina Adi Wijayanti
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 4 (2020): September
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v1i4.2130

Abstract

Fast and precise services are the desire of consumers. The speed of document provision of medical records to the PDS can be an indicator in measuring satisfaction. Based on the SPM of the hospital when providing outpatient medical records is ≤ 10 minutes. Husada Utama Surabaya Hospital has implemented medical records management, but there are problems in the implementation, in the provision of medical record documents less than the maximum and delayed. The aim of this research is to determine the factors causing delays in the provision of patient medical record documents in outpatient services based on 7M (man, money, method, material, machine, motivation, and media). This type of research is qualitative. Data collection used observation sheets and interview guidelines to 4 respondents. The results showed that the education, knowledge, and training of employee about the science of medical records is still lacking, the budget was managed by the financial management and there were no details for the needs of the medical record unit, there is no SOP about the provision of outpatient medical record documents, the medical record file is only a thin sheet of HVS paper, the folder used is easily damaged, outpatient medical records employee never get a reward from the leadership, room and rack filling cannot store medical records medical records properly. In conclusion, the factors that caused the delay in providing medical record documents are man, money, method, material, motivation, and media. The results of this study can be an evaluation material for Husada Utama Hospital to improve the service provision of medical records for outpatients.
Perancangan Sistem Informasi Peminjaman dan Pengembalian BRM Rawat Jalan di Rumah Sakit Husada Utama Lidya Nur Fatimatuz Zuhro; Ida Nurmawati; Rossalina Adi Wijayanti; Gilang Nur Permana
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 4 (2020): September
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v1i4.2136

Abstract

Borrow and return outpatient medical records at the Husada Utama Hospital in Surabaya still uses manuals by referring to the date of discharge from the hospital to search for files that have not been returned or for file tracking so that it can cause difficulties for officers in tracking outpatient medical records. Data of delay in the return of outpatient medical records in February-March 2020 counted for 117 (14.88%) of the total files late from the 786 total outgoing files. SOP (Standard Operational Procedure) that applies at Husada Utama Hospital regarding hospital service standards is explained by the medical records of Specialist Practices which are returned within 1X24 hours on the same day. While the medical record file in the inpatient room is submitted no later than 2X24 hours after the date the patient is discharged from the hospital. This research  was aimed to design a web-based outpatient medical records and loan information system at the Husada Utama Hospital in Surabaya. The type of research is qualitative research with data collection methods of observation and interviews. The subjects of this research were the head of the medical record and the outpatient medical record officer. The method used by researchers is the waterfall method. The results of this research can be seen that the design of information systems for borrowing and returning outpatient medical record files are made according to the needs of users, making the system starts from the needs analysis so it produce a system design that suits your needs.
Analisis Penerapan RME Pada Unit Coding Rawat Jalan RSUD K.R.M.T Wongsonegoro Semarang Amaliya Nikmatul Rohmah; Ida Nurmawati; Indah Muflihatin; Syaifuddin Syaifuddin
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 4 (2020): September
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v1i4.2137

Abstract

RSUD K.R.M.T Wongsonegoro Semarang City is one of the hospitals that have implemented an electronic medical record at the end of December 2017. Information systems that support management and service to patients are electronic medical records, especially in outpatient coding units. One factor that plays an important role in the successful application and use of information technology is the user factor. The level of user readiness to accept information technology has a major influence in determining the success or failure of the application of the technology. The purpose of this study was to evaluate the application of electronic medical records in outpatient coding units based on the Technology Acceptance Model (TAM) method. This type of research is qualitative research with the data collection methods, namely interviews, observation and documentation. The subjects of this study were outpatient coding officers. The results showed that based on the aspects of usefulness in the use of electronic medical records in outpatient coding units be very beneficial for officers. Based on the aspect of ease in showing the acceptance of electronic medical records, it is considered easy to understand, flexible enough with the work of officers and easy to used to assist with work. Based on the aspect of interest, it is obtained that outpatient coding officers also show their interest in the system, and plan to use the system in the future, although there are some obstacles. The solution obtained from the problem is making guidelines for the use of electronic medical records, adding electronic signature features to electronic medical records for patient medical resume forms, striving for electricity and electricity networks to remain stable, making updates or updating electronic medical records.
Evaluasi Rekam Medis Elektronik di Tempat Pendaftaran Pasien Gawat Darurat dan Rawat Inap RSUD K.R.M.T Wongsonegoro Kota Semarang Eka Cintiya Febrianti; Ida Nurmawati; Indah Muflihatin
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 4 (2020): September
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v1i4.2145

Abstract

Each hospital is required to hold records or records of all services provided to patients called medical records. Increasing the effectiveness of recording medical data that is accurate, fast, can take advantage of current technological advances through the implementation of the Electronic Medical Record (EMR) system in hospitals. RSUD K.R.M.T Wongsonegoro is one of the hospitals that has implemented an electronic medical record (EMR) especially in the inpatient and emergency department registration units. The application of this electronic medical record still has some flaws that must be evaluated. This study aims to evaluate the implementation of electronic medical records at the emergency and inpatient registrations of Wongsonegoro Hospital. Data collection in this study consisted of observations and interviews. Identification of problems using the TAM (Technology Acceptance Model) method by reviewing from 3 aspects namely perceived usefulness, perceived ease of use, and behavioral intention to use. This type of research is descriptive qualitative by narrating the results of research based on the data obtained. The results obtained from this study are based on the aspect of usefulness (perceived usefulness), namely the use of electronic medical records in TPPGD and TPPRI, making the registration officer work faster and more effective.The aspect of ease (perceived ease of use) obtained from the interview results is that it is able to make it easier to accelerate the registration process in the TPPGD and TPPRI. The behavioral intention to use obtained is that the users of this system really need this electronic medical record and the registration officer at TPPGD and TPPRI plans to use the EMR in the future.
Identifikasi Faktor Penyebab Penumpukan Berkas Rekam Medis Aktif di RS Husada Utama Nurul Kamilia; Rossalina Adi Wijayanti; Ida Nurmawati
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 4 (2020): September
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v1i4.2160

Abstract

Based on the results of a preliminary study conducted at the Husada Utama Hospital it is known that in 2018 there was an accumulation of active medical record files which were 310 files. The impact of the accumulation of medical record files is the provision of medical record files will take longer so that patients often complain, officers become fatigued quickly in doing their work so that it will also have an impact on the depreciation process that should be done every day, and officers also feel uncomfortable and disturbed because the accumulation of medical record files also interferes with access to filing officers when retrieving and returning medical record files. This study aims to identify the factors causing the accumulation of active medical record files in Husada Utama Hospital. This type of research uses qualitative and data collection by interview, observation, and documentation. The results obtained that the results showed that the cause of the accumulation of medical record files that affect from the Man side is that the officer has never attended medical records training, from the Money side that is still not getting a budget for storage shelves, from the Material side there is a medical record file that is not using a map, in terms of Machine that is the number of storage racks not according to needs and in terms of Method which is the implementation of a storage system, alignment, and retention that is not in accordance with the Standard Operating Procedure (SOP).
Evaluasi Rekam Medis Elektronik Bagian Coding Rawat Inap RSUD K.R.M.T Wongsonegoro Kota Semarang Septina Dwi Indrawati; Ida Nurmawati; Indah Muflihatin; Syaifuddin Syaifuddin
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 4 (2020): September
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v1i4.2164

Abstract

RSUD K.R.M. T Wongsonegoro The city of Semarang became one of the type B hospitals in the city of Semarang, which have applied the electronic medical record gradually the application of electronic medical records assessed as an effort to improve the quality of services increasing patient satisfaction improves the documentation accuracy reduces clinical error and speeds up patient data access. (Billy Maria in Andriani DKK 2017). One of the service units that require the speed, accuracy and accuracy of access to patient data is the coding part of the hospitalization of the person who handled the medical record and coding (PJRM). In its implementation, there were constraints that made the officers less satisfied with RME. The purpose of this research is to evaluate RME implementation using the PIECES method (performance, information, economic, control, efficiency, service). This type of research is qualitative research, by conducting observation methods and interviews to PJRM officers. The results of RME evaluation conducted using the PIECES method on the performance/performance aspect, RME has already produced a good performance. Based on information/information aspect, RME can provide accurate information quality, according to user needs, and easy to understand. Based on Economy/economy, RME has the value to be integrated with one hospital and have qualified resource. Based on Control/control aspect, RME has good integrity and security because it comes with username and password, has different permissions. Based on the Efficiency/data efficiency aspects of RME can be easily learned, operated, and processed. Based on the Service/service aspect: RME users feel that RME provides convenience for RME users. In conclusion, RME in the coding part of inpatient is good enough in terms of Performance, Information, Economy, Control, Efficiency and Control. The advice that can be given is to make improvements and development on RME to avoid errors, regulatory or regulation regarding steps when errors occur, as well as conducting socialization or training to RME users.
TINGKAT PENERIMAAN DAN PENGGUNAAN SISTEM INFORMASI MANAJEMEN PUSKESMAS KABUPATEN JEMBER Sedyo Pinerdi; Efri Tri Ardianto; Novita Nuraini; Ida Nurmawati
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 2 (2020): March
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v1i2.2242

Abstract

The district health office of Jember conducted a trial of operating SIMPUS in 20 puskesmas, but only 16puskesmas operated the SIMPUS. The district health office of Jember will be announced at the end of 2019SIMPUS will be fully operated in 50 puskesmas throughout the Jember district. This study is aimed to describethe level of acceptance and use of the Puskesmas management information system using the Theory ofAcceptance and Use of Technology (UTAUT) method. This study discusses the variables of performanceexpectancy, effort expectancy, sosial influence, facilitating conditions, behavioral intention, and the usebehavioral of SIMPUS users that are spread across 16 public health platforms in the District Health Office ofJember. This type of research is observational descriptive. The data analysis technique used is descriptive.The results of this study were that the officers were quite confident that they would get ease while workingusing SIMPUS (55.9%), the work became easy when the officers used SIMPUS (69.5%), the head of thepuskesmas and health offices supported the use of SIMPUS (73,7%), the facilities and infrastructure providedcan support the use of SIMPUS (58.5%), officers wish to use SIMPUS in the near future (70.3%), and officersuse SIMPUS when working (65.3%). The district health office of Jember needs to operate SIMPUS again andincrease server capacity so that the acceptance and use of SIMPUS increases.