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

Integrasi Sistem Internasional Classification Primary Care Pada Rekam Medis Elektronik Berbasis Software As A Service Bagi Dokter Keluarga Nuryati Nuryati; Dian Budi Santoso; Nur Rokhman
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 4 No 4 (2023): September
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v4i4.3838

Abstract

Referring to Law Number 29 of 2004 it is stated that every doctor or dentist in carrying out medical practice is obliged to make medical records. The results of the research on the readiness of ICPC implementation carried out in 2020 and the design of the interface for family doctor services equipped with the International Classification Primary Care (ICPC) carried out in 2021, the design was implemented and integrated in the Electronic Medical Record application with the concept of Software as a Services (SaaS) owned by the Department of Health Information and Services at the UGM Vocational School. This type of research is research and development by following the stages of developing an information system using the prototyping method. The steps taken in this research are conducting needs analysis through in-depth interviews with family doctors and medical record officers, in addition to conducting documentation studies and medical record observations conducted at family doctor clinics. The results of the analysis are ICPC codes in electronic medical records and interoperable with p-Care BPJS, so that family doctors only need to do data entry once, diagnosis code reports can be presented in the form of ICD-10 or ICPC code
Perancangan Aplikasi Pembelajaran Kodifikasi Klinis Berbasis Web Angga Eko Pramono; Nuryati Nuryati; Dian Budi Santoso
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 5 No 2 (2024): March
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v5i2.4427

Abstract

One of the main competencies of a Health Information Management (HIM) Practitioner is clinical codification skills. The problem that still occurs is the inaccuracy of clinical codification results. One aspect of the cause is human resource competency, specifically lack of knowledge and skills regarding clinical codification rules and procedures. Therefore, developing a web-based clinical codification learning media application is needed to improve HIM Practitioners' knowledge and skills. This research aims to design a web-based clinical codification learning media. The design was carried out from May to September 2023 using the waterfall method. The research subjects were students and lecturers of health information management and HIM practitioners. The research object was the design of web-based learning media. The data were collected using observation, interview, and documentation study methods. This study resulted in a design system that consists of Unified Modeling Language (UML) of use case diagrams and activity diagrams, a database design that consists of database tables and a database relational diagram, as well as user interface displays which are consists of a login display, home/dashboard, modules, and exercises. The design result should proceed as a blueprint for further system prototyping development process.