Garuda - Garba Rujukan Digital

Muniroh

Universitas Esa Unggul

Author-ID : 4090807

Dentistry Health Professions Medicine & Pharmacology Nursing Public Health Veterinary

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Literature Review: Tinjauan Aspek Keamanan Dan Kerahasiaan Rekam Medis Di Ruang Filing Winda Indri Anggraeni; Deasy Rosmala Dewi; Nanda Aula Rumana; Muniroh
SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat Vol. 1 No. 2 (2022): April 2022
Publisher : Yayasan Literasi Sains Indonesia

To maintain the security and confidentiality of patient medical records, a medical record storage room is required that meets the provisions in maintaining the security and confidentiality of medical records. This study aims to determine the security aspects in terms of physical, chemical and biological as well as the confidentiality aspects of medical records in the filing room. This study uses a literature review method with the PICO framework. Search articles using the Google Scholar database with keywords and Boolean operators in this study are "security" and "medical record confidentiality" and "filing". Research journal published in 2015–2020, in Indonesian, research design: using all research designs. The results of the study found security from the physical aspects that were most often found, namely the maintenance of the cleanliness of the filing room which was not maintained and the humidity temperature was less than optimal, the chemical aspect was that there were still officers eating and drinking in the filing room, the biological aspect of finding insects and pests. Meanwhile, from the aspect of confidentiality, there are officers other than medical records who enter the filing room.

Tinjauan Kelengkapan Pengisian Lembar Informed Consent Pasien Rawat Inap di RSU Adhyaksa Feni Fajriani; Deasy Rosmala Dewi; Nanda Aula Rumana; Muniroh
SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat Vol. 1 No. 2 (2022): April 2022
Publisher : Yayasan Literasi Sains Indonesia

Informed Consent is an agreement given by the patient or his closest family after receiving a complete explanation regarding the medical or dental action to be performed on the patient. Minimum Service Standards for Hospitals which mention filling out Informed Consent must be 100% complete after receiving clear information. This study was conducted with the aim of obtaining the completeness of filling out the consent form for medical treatment for inpatients at Adhyaksa General Hospital. This study uses a quantitative approach with a descriptive method. Based on the research results, the process of filling out the Informed Consent sheet at Adhyaksa RSU is not complete, from the research results of the Information Provider section on the Declaring Identity component by 75%, Completeness of Important Reports by 64%, Author Authentication by 85%, Good Records by 77%. The Informed Consent section on the Identity component is 95%, the Completeness of Important Reports is 91%, Author Authentication is 93%, Good Records is 84%. Adhyaksa General Hospital does not yet have an SOP. Fill out the informed consent form. The existing SOP on Informed Consent. The author's suggestion is that the hospital must re-socialize it to medical personnel so that the filling out of the medical action approval sheet is more complete according to minimum service standards.

Analisis Ketepatan Istilah Terminologi Medis Penyakit Sistem Respirasi Sesuai Klasifikasi Penyakit ICD-10 di Puskesmas Kecamatan Grogol Petamburan Febri Irawan; Deasy Rosmala Dewi; Nanda Rumana; Muniroh
SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat Vol. 1 No. 2 (2022): April 2022
Publisher : Yayasan Literasi Sains Indonesia

Medical terminology is medical language which is a liaison between health workers' facilities. Medical terminology written on the diagnosis should be written by the right health care worker so that it has informative value in order to assist the coding officer in selecting the lead term for determining the diagnosis code. The purpose of this study was to analyze the accuracy of medical terminology in respiratory system diseases according to the ICD-10 disease classification at the Grogol Petamburan District Health Center. Using a quantitative descriptive research method on 90 samples of medical record cases of the respiratory system in August 2020. The sampling technique used was random sampling. The size was determined randomly using the slovin formula. The results showed that the accuracy of using medical terminology in medical records was 74 (82%) and inaccuracy in the use of medical terminology 16 (18%) using abbreviations, Indonesian language, and letter/spelling errors. Factors causing the inaccuracy. The Puskesmas already has a SOP for recording medical records, but the service points have not been explained in detail according to the SOAP, especially the assessment which requires doctors to write diagnoses using medical terminology according to the ICD-10 disease classification. Then the large number of patients can be a factor causing the doctor's inaccuracy in writing a diagnosis. It is recommended to the head of the medical record to evaluate the accuracy of outpatient medical terminology according to the ICD-10 disease classification, so that there are no inaccuracies in medical terminology using Indonesian language, abbreviations, and spelling errors.

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