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All Journal Jurnal Kesehatan J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan
Ferly Ferly
Politeknik Negeri Jember
Computer Science & IT Health Professions Public Health

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Analisis Pelaksanaan Sensus Harian Rawat Inap di RSUD Dr. Saiful Anwar Malang Ferly Ferly; Rossalina Adi Wijayanti; Novita Nuraini
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.v1i4.2163

Abstract

Abstract Information obtained from the daily inpatient census in the form of data that will be processed into information needed by the hospital, so that the daily inpatient census activities must be carried out correctly in accordance with procedures so that the data generated is accurate and can be used as a basis for decision making for management. This study aims to analyze the factors causing the inactivity of inpatient daily census activities correctly using a fishbone diagram. This research is a qualitative descriptive study conducted at Dr. Saiful Anwar Malang in February - March 2020. The subjects of this study were the daily census officer of the inpatient room, and the daily census officer of the medical record section. Data was taken by interview and observation methods. Data were analyzed using fishbone diagrams. The results of this study indicate that the factors that cause the inability of the inpatient daily census to be conducted correctly are Man (misperception of the inpatient census daily officer between the understanding day of care with the length of stay, educational background of the officer not from the medical record, and the officer has never attended training on the census), Money (there is no funding budget for training implementation, Materials (census information system on billing system is not implemented, census recapitulation is still manual using paper forms and Microsoft excel), Method (Daily SOP for inpatient census has not been revised), Machine (census application on billing system is not implemented) Fishbone diagrams where the in-patient census daily activities are carried out correctly are mostly caused by Man factors and Materials factors.
Design Formulir Informed Consent Unit Layanan Kesehatan Jiwa Puskesmas Candipuro Ferly Ferly; Ida Nurmawati
Jurnal Kesehatan Vol 8 No 3 (2020): Desember
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-kes.v8i3.172

Abstract

Pencatatan data tentang tindakan yang dilakukan tenaga medis terhadap pasien sangat penting untuk didokumentasikan dalam formulir rekam medis. Sehingga formulir perlu didesain sedemikian rupa guna memenuhi kebutuhan pengguna. Berdasarkan survei pendahuluan di Puskesmas Candipuro formulir persetujuan tindakan kedokteran pasien gangguan jiwa masih menggunakan formulir rawat jalan biasa, tidak mencerminkan formulir informed consent pasien gangguan jiwa. Tujuan penelitian ini adalah untuk mendesain formulir informed consent pasien gangguan jiwa pada Unit Layanan Kesehatan Jiwa Puskesmas Candipuro. Metode yang digunakan kualitatif dengan teknik pengumpulan data observasi, wawancara, dan brainstorming, subjek penelitian yaitu 1 petugas rekam medis, 2 perawat pasien jiwa, dokter yang menangani pasien gangguan jiwa, dan kepala puskesmas. Analisis data dalam penelitian ini menggunakan analisis data reduction, data display, dan conclusions. Hasil penelitian ini adalah rancangan desain formulir informed consent pasien gangguan jiwa yang sesuai kebutuhan pengguna berdasarkan aspek fisik menggunakan kertas HVS F4 dengan berat 70 gram, aspek anatomi menyesuaikan standar desain formulir, dan aspek isi formulir menyesuaikan kebutuhan pengguna dengan mencantumkan data administratif dan data klinis yang terdiri dari diagnosa dan dasar penegakannya, tindakan medis yang terdiri dari indikasi, tata cara, tujuan, dan risikonya, serta informasi lain yang dibutuhkan dalam informed consent. Desain formulir informed consent pasien gangguan jiwa yang baru dapat diterapkan di Unit Layanan Kesehatan Jiwa Puskesmas Candipuro untuk menunjang kelengkapan informasi rekam medis pasien gangguan jiwa dan untuk menghindari malpraktik.
Co-Authors Novita Nuraini nurmawati, ida Rossalina Adi Wijayanti