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All Journal Journal of Information Technology and Computer Science (JOINTECS) J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Jurnal Rekam Medik & Manajemen Informasi Kesehatan (RAMMIK) International Journal of Health and Information System (IJHIS)
Niyalatul Muna
Politeknik Negeri Jember
Computer Science & IT Control & Systems Engineering Decision Sciences, Operations Research & Management Dentistry Electrical & Electronics Engineering Engineering Health Professions Languange, Linguistic, Communication & Media Library & Information Science Mathematics Medicine & Pharmacology Public Health Veterinary

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Sistem Reminder Peminjaman dan Pengembalian Berkas Rekam Medis Rawat Inap Nur Fadilatul Fitriyah; Niyalatul Muna; Sustin Farlinda; Mudafiq Riyan Pratama
JOINTECS (Journal of Information Technology and Computer Science) Vol 7, No 2 (2022)
Publisher : Universitas Widyagama Malang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31328/jointecs.v7i2.3708

Abstract

Rumah Sakit X telah melaksanakan pengendalian peminjaman dan pengembalian berkas rekam medis rawat inap secara komputerisasi menggunakan microsoft excel. Namun pada proses pengembalian berkas rekam medis, masih belum sesuai dengan SPO (Standar Prosedur Operasional) yang ada. Presentase keterlambatan pengembalian berkas rekam medis rawat inap pada bulan Januari 2021-April 2021 sebesar 74,87%. Tujuan penelitian ini adalah merancang dan membangun sistem peminjaman dan pengembalian berkas rekam medis rawat inap untuk mengatasi permasalahan keterlambatan pengembalian. Penelitian ini menggunakan metode pengembangan prototype. Dalam proses perancangan sistem ini menggunakan flowchart sistem, contex diagram, data flow diagram, entity relationship diagram, serta mengimplementasikan program menggunakan visual studio code versi 1.46.0. Hasil penelitian ini ialah sistem reminder berbasis website yang dapat membantu proses pengendalian peminjaman dan pengembalian berkas rekam medis rawat inap sehingga dapat meminimalisir kejadian keterlambatan pengembalian. Hasil penilaian pengguna terkait sistem yang dihitung menggunakan metode skala likert sebesar 85,09%. Artinya sistem sudah sesuai dengan keinginan dan kebutuhan pengguna. Kelebihan dari sistem ini ialah terdapat notifikasi peminjaman untuk petugas rekam medis sehingga tidak perlu menginput ulang data peminjaman. Dan untuk petugas rawat inap terdapat notifikasi pengingat terkait pengembalian berkas rekam medis rawat inap yang secara otomatis terkirim setiap 2 x 24 jam dan seterusnya hingga status peminjamannya berubah menjadi kembali.
TINJAUAN PELAKSANAAN PENGAMBILAN DOKUMEN REKAM MEDIS BERDASARKAN UNSUR MANAJEMEN 5M DI BAGIAN FILLING RSAL DR.RAMELAN SURABAYA Septin Diah Triwardhani; Niyalatul Muna; Gamasiano Alfiansyah
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 2 No 3 (2021): June
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v2i3.2003

Abstract

AbstrakTersedianya berkas rekam medis secara tepat pada saat pelayanan kesehatan yang diberikan kepada pasien akan menjadikan mutu dalam pelayanan rumah sakit menjadi lebih baik. Sebaliknya jika pelayanan kepada pasien yang terlalu lama akan berdampak buruk pada mutu pelayanan pasien. Berdasarkan hasil observasi yang dilakukan petugas pada bagian filling Rumkital Dr.Ramelan Surabaya tidak menggunakan tracer sesuai dengan prosedur yang ada pada SPO, hal ini berdampak pada kesalahan letak, misfile, dan mempersulit pengembalian berkas rekam medis sesuai dengan urutan nomornya. Penelitian ini bertujuan untuk mengetahui pelaksanaan pengambilan dokumen rekam medis berdasarkan SPO di bagian filling RUMKITAL Dr.Ramelan Surabaya. Penelitian ini menggunakan metode unsur manajemen 5M  antara lain (Man, Money, Material, Method, Machine). Pengumpulan data menggunakan wawancara dan observasi. Berdasarkan unsur man yaitu kurangnya pengetahuan petugas terkait penggunaan tracer. Unsur money yaitu penyusunan dana yang dilakukan tidak secara insidental. Variabel material yaitu terdapat dua jenis tracer yang digunakan di bagian filling RUMKITAL Dr. Ramelan Surabaya, yang pertama berwarna merah dengan bahan plastik tebal terdapat saku untuk menyisipkan kertas tracer  sedangkan yang kedua terbuat dari bahan kertas buffalo yang mudah robek. Variabel method yaitu SPO pengambilan berkas rekam medis tidak bejalan dengan baik. Variabel machine penggunaan tracer dan buku ekspedisi yang belum optimal. Kata Kunci : Filling, pengambilan berkas rekam medis, 5M
ANALISIS KUANTITATIF KELENGKAPAN PENGISIAN FORMULIR INFORMED CONSENT RUMKITAL DR. RAMELAN SURABAYA Aditya Dwi Arimbi; Indah Muflihatin; Niyalatul Muna
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 2 No 2 (2021): March
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v2i2.2009

Abstract

Completeness informed consent form of RUMKITAL Dr. Ramelan Surabaya is still less than the MinimumHospital Service Standard of 100%, it is based on a preliminary study of researchers that the incompleteinformed consent form on the identity component is 60%, important reporting is 80%, authentication is40%, and the correct documentation is 0%. The purpose of this study was to conduct a quantitativeanalysis of the completeness of the informed consent form of RUMKITAL Dr. Ramelan Surabaya. Thisstudy uses descriptive research with a cross-sectional approach to identify the completeness of filling outinformed consent. Data collection used is observation and documentation on the informed consent form.The results show the identification component with the highest completeness by 90% and the highestincompleteness by 55%; The important reporting component with the highest completeness is 80% andthe highest incompleteness is 80%; The authentication component with the highest completeness is 90%and the highest incompleteness is 50%; The correct documentation component with the highestcompleteness is 85% and the highest incompleteness is 50. Some suggestion to fix the problem is bymaking the Statement of Commitment, the SOP of evaluating and monitoring the medical recorddocuments completion, improving the Informed Consent SOP and Medical Records Completion SOP byadding completeness standard of informed consent filling which is must be achieved by RUMKITAL Dr.Ramelan Surabaya.
Analisis Pelaksanaan Retensi dan Pemusnahan Berkas Rekam Medis di Rumkital dr Ramelan Surabaya Eltigeka Devi Apriliani; Indah Muflihatin; Niyalatul Muna
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.v1i4.2012

Abstract

The first time retention at RUMKITAL Dr. Ramelan Surabaya were conducted in 2008. Based on data patient visits of Dr. RUMKITAL Ramelan Surabaya from 2015 to 2019 had increased it caused the storage shelf could not accommodate medical record files. SPO (Standard Procedure Operational) about implementation of retention and destruction of medical records in Dr. RUMKITAL Ramelan Surabaya not found provisions of the storage inaktif medical record file. The aim of this research was to analyze the implementation of retention and destruction medical record files in Dr. Ramelan Surabaya with identifying using 5M (Man, Money, Material, Machine, Method) and the USG method (Urgency, Seriousness, Growth) to determine the priority of problem. This research is qualitative research and collecting the data using observations, interview, and documentation. The subject of study is 1 scan officer of medical record and 2 officer of medical record. The results of this research is got 3 priority cause of problem the implementation of retention and destruction of medical record are elements of method, material and machine. The suggestion of this problem are improving the SPO (Standard Procedure Operational) and implementation the system information of retention.
Analisis Pelaksanaan Layanan Perawatan Dukungan dan Pengobatan (PDP) HIV–AIDS di Rumah Sakit Daerah Balung Rintan Illahi Wahyu; Faiqatul Hikmah; Rossalina Adi Wijayanti; Niyalatul Muna
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.v1i4.2070

Abstract

The implementation of HIV - AIDS Support and Treatment (PDP) Care Services at Balung Regional General Hospital is not yet in line with the target. This is evidenced by the number of PLHIV fulfilling the requirements to start treatment, not all of them are taking ARV treatment, so an analysis of these services is needed. The purpose of this study was to analyze the implementation of HIV - AIDS support and treatment (PDP) care services at Balung Regional Hospital. This type of research is qualitative, using interview, observation and documentation data collection methods. Informants in this study were 1 doctor, 1 counselor and 1 nurse and 8 ODHA This type of research is qualitative, the result of this study is an analysis of the implementation of HIV-AIDS support and treatment care services using 4M indicators (man, method, material and mechine). The results of the study were obtained that the analysis of PDP services based on the aspects of man, namely the availability of resources in the service is lacking and knowledge of HIV – AIDS  related to HIV - AIDS is still low, aspects of the method that there are SOP but there is no clear jobdesc, material aspects there is a medical record used for know the development of ODHA, but the officers in filling it are still incomplete, aspects of the mechine are available tools that are used to assist the process of conducting maintenance services such as general inspection tools and SIHA. Efforts to resolve the problem above so that the Balung Regional General Hospital for submitting letters to the Health Office regarding job analysis, the role of the medical recorder for checking the filing of ODHA medical record files and for problems of low knowledge of HIV – AIDS can be done by counseling in privacy.
Evaluasi Kinerja Petugas Distribusi Berkas Rekam Medis Rawat Jalan di RSUD dr. Saiful Anwar Malang Najla Kamil; Dony Setiawan Hendyca Putra; Feby Erawantini; Niyalatul Muna
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.v2i1.2077

Abstract

Patrang Health Center has implemented medical records management, but there are problems in the implementation of medical record management. when duplicating medical record numbers at Patrang Health Center. Duplication in the Patrang Community Health Center results in a decrease in the quality of medical records. The purpose of this study was to analyze the causal factors and determine the priority causes of duplicate medical record numbers at Patrang Health Center. This type of research is qualitative. The technique of collecting data in this study is observation of data duplication of medical records and interviews with respondents based on 7M indicators. Data processing with CARL criteria. The results of this study were found in studies that found the main priority of less useful duplication of the medical record number on the medical record data map with a score of 144. Further problems were officers, filing space was less extensive, filing shelves were inadequate and patients did not carry KIB with a score 108. With the discovery of priorities leading to duplication, the study provides the main solution that discusses the medical record number written on the front and sides of the file as well as other solutions to overcome the problem and made a draft policy to reduce the incidence of duplicate medical record numbers that have been approved.
Perancangan dan Pembuatan Website Puskesmas Kaliwates Jember sebagai Media Informasi Pelayanan Kesehatan dan Promosi Kesehatan Resti Aprilia Tri Hendaryanti; Feby Erawantini; Sustin Farlinda; Niyalatul Muna
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 2 No 3 (2021): June
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v2i3.2232

Abstract

Kaliwates Jember Health Center is one of the health centers that does not have a website as a medium of information and promotion to the public, so that the public lacks information related to the health center. The purpose of this research was to design and to create a website of Kaliwates Jember Health Center. Researchers used qualitative research and used the waterfall model system design method. The stages in this method included Requirement Analysis and Definition,System and Software Design, Implementation and testing, Integration and system testing and Operation and maintenance. In the process of designing this system the researchers used a Flowchart system, Contex Diagram, Data Flow Diagram, Entity Relationship Diagram and in implementing programs they used notepad ++ and xampp. The strengths of the website that have been made are the doctor's questioning service for patients to be able to communicate with doctors in the Kaliwates Puskesmas without having to come to the puskesmas, patients can register online for treatment, there are statistical data about the number of patient visits through the website.It is expected that the development of existing websites such as distinguishing questions asked by doctors coming from new patients and old patients and hopefully, the future researchers will get more complete data related to puskesmas.
SISTEM INFORMASI PEMINJAMAN DAN PENGEMBALIAN DOKUMEN REKAM MEDIS MENGGUNAKAN METODE WATERFALL (STUDI KASUS PUSKESMAS BANJARSENGON) Nur Malika Jamil; Niyalatul Muna; Rossalina Adi Wijayanti; Andri Permana Wicaksono
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.v1i2.2241

Abstract

The information system is made based on problems in recording the implementation of loans, returningmedical records. This computerized information system where in the borrowing and returning of medicalrecords is no longer manual. The purpose of this information system is to facilitate officers in recording,borrowing, returning, controlling and controlling medical records. The borrowing and return of medical recordsmust be controlled properly to reduce duplication of medical record numbers and delays in medical recorddocuments. Qualitative research using documentation data collection methods and interviews at theBanjarsengon Health Center in Jember. The method used in this research is the 2011 somerviel waterfallmethod. The steps taken are requirements analysis, system design, program code writing, and programtesting. The design of this information system uses flowchart design, context diagrams, Data Flow Diagrams(DFD), and Entity Relationship Diagrams (ERD) then the design results are implemented into a visual basicprogramming language using Miscrosoft Visual Studio 2010. The results of this study are lending informationsystems. and return of medical record documents. This information system is equipped with a warning alert asa notification that medical record documents borrowed by POLI to be returned immediately, can help ease theworkload of filing officers by minimizing the number of delays in medical record documents and duplication ofmedical record documents.
PERANCANGAN DAN PEMBUATAN REKAM MEDIS ELEKTRONIK POLI GIGI MENGGUNAKAN VISUAL BASIC.NET DI PUSKESMAS BANJARSENGON Nur Hasanah Ayu Purnamawati; Niyalatul Muna
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 3 No 1 (2021): Desember
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v3i1.2353

Abstract

Pelayanan rekam medis poli gigi di Puskesmas Banjarsengon masih dilakukan secara manual. Hal tersebut menyebabkan petugas merasa kesulitan dalam pengisian odontogram, tulisan tidak terbaca, terjadi missfile, kesulitan untuk menemukan riwayat medis maupun hasil pemeriksaan penunjang dan keterlambatan proses pelaporan. Penelitian ini bertujuan untuk merancang dan membuat rekam medis elektronik poli gigi menggunakan Visual Basic.Net di Puskesmas Banjarsengon. Pengumpulan data menggunakan observasi, wawancara dan dokumentasi. Metode pengembangan sistem yang digunakan yaitu metode waterfall. Rekam medis elektronik poli gigi dibuat berbasis dekstop menggunakan visual basic.net. Hasil pengujian black box testing yang diujikan kepada dokter gigi, petugas rekam medis dan kepala rekam medis menunjukan sistem data berjalan dengan baik sesuai dengan perancangan. Kelebihan dari rekam medis elektronik poli gigi yaitu dapat membantu petugas untuk meningkatkan efisiensi sistem pencatatan secara cepat dan akurat, mempermudah proses pencarian data. Sistem ini secara otomatis menyediakan 3 laporan yaitu laporan bulanan data kesakitan terbanyak gigi dan mulut, laporan bulanan UKP pelayanan puskesmas, dan yang terakhir terdapat laporan bulanan UKP 4 kesakitan terbanyak.  
Analisis Aspek Keamanan Informasi Data Pasien Pada Penerapan RME di Fasilitas Kesehatan Siti Sofia; Efri Tri Ardianto; Niyalatul Muna; Sabran Sabran
Jurnal Rekam Medik & Manajemen Informasi Kesehatan Vol. 1 No. 2 (2022): Oktober
Publisher : Indonesian Journal Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (182.832 KB) | DOI: 10.47134/rmik.v1i2.29

Abstract

Data security issues are becoming increasingly serious as the trend of data theft is increasing. This causes not only material losses but also psychological victims. The purpose of this study was to determine how the information security of patient data in the application of RME in terms of information security aspects. The method used is a literature review by analyzing 20 articles from various sources. The results of the study show that from the articles reviewed in terms of 6 security aspects, namely username and password, changes or deletions of data by administrators, electronic signatures and the use of PINs, aspects of using data backup processes to anticipate patient data hacking, restrictions on access rights by using user id & password for each user, as well as log file usage. Overall, health facilities basically have carried out data security on the information systems they use, but in practice there are still health facilities that do not fully meet the data security aspect or are not optimal in using the techniques used. System managers need to develop techniques or ways to secure data more optimally that can fulfill 6 aspects of information security in electronic medical records.
Co-Authors Aditya Dwi Arimbi Andri Permana Wicaksono Demiawan Rahmatta Putro Mudiono dony setiawan hendyca putra Efri Tri Ardianto Eltigeka Devi Apriliani Faiqatul Hikmah Feby Erawantini Gamasiano Alfiansyah Indah Muflihatin Mudafiq Riyan Pratama Najla Kamil Nur Fadilatul Fitriyah Nur Hasanah Ayu Purnamawati Nur Malika Jamil nurmawati, ida Puspito Arum Resti Aprilia Tri Hendaryanti Rintan Illahi Wahyu Rossalina Adi Wijayanti Sabran Sabran Septin Diah Triwardhani Siti Sofia Sustin Farlinda