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All Journal Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Jurnal Ilmiah Pengabdian Kepada Masyarakat
Zulham Andi Ritonga
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Computer Science & IT Economics, Econometrics & Finance Health Professions Medicine & Pharmacology Nursing Public Health

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Tinjauan Pelaksanaan Sistem Penyimpanan Rekam Medis Berdasarkan Standar Akreditasi Di UPTD Puskesmas Kotanopan Mandailing Natal Zulham Andi Ritonga; Hasran Ependi Lubis
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Vol. 6 No. 1 (2021): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Februari
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v6i1.485

Abstract

Storage of medical records is one of the assessments in puskesmas accreditation standards. The medical record file storage system is very important to do in health care institutions, because the storage system can make it easier for medical record files to be stored in storage racks, speed up the recovery or retrieval of medical record files stored on storage racks, easy to return, and protect record files. from theft, physical, chemical and biological damage. The purpose of this study was to determine how the implementation of a medical record storage system based on puskesmas accreditation standards, which was carried out in August 2020. The research method used was descriptive research with a qualitative approach. The number of research informants was 4 people. Storage of medical records had not used tracers and expedition book as a means of replacing medical record files and notes in and out of borrowed medical record files. Meanwhile, tracer and expedition books can assist officers in searching for missing / out of place medical record files. This can hamper the provision of patient medical record files that are needed. It is hoped that the UPTD Puskesmas Kotanopan will provide regular training or debriefing to medical record officers
SOSIALISASI SISTEM PENYIMPANAN REKAM MEDIS DI UPT PUSKESMAS PADANG BULAN SELAYANG II TAHUN 2022 Esraida Simanjuntak; Mei Sryendang; Siti Permata Sari Lubis; Zulham Andi Ritonga; Ani Soraya
Jurnal Ilmiah Pengabdian Kepada Masyarakat (Ji-SOMBA) Vol. 2 No. 1 (2022): Jurnal Ilmiah Pengabdian Kepada Masyarakat (Ji-SOMBA)
Publisher : Universitas Imelda Medan

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (505.948 KB) | DOI: 10.52943/ji-somba.v2i1.1161

Abstract

Puskesmas merupakan salah satu sarana pelayanan kesehatan masyarakat, dimana dalam pelayanan tersebut terdapat pelayanan rekam medis. Pelyanan rekam medis merupakan adalah kegiatan menjaga, memelihara dan melayani rekam medis baik secara manual maupun elektronik sampai menyajikan informasi kesehatan di Puskesmas. Puskesmas PB Selayang II belum melaksanakan sistem penyimpanan rekam medis dikarenakan puskesmas tersebut hanya melayani pasien rawat jalan. Tujuan dari kegiatan ini adalah untuk membuat SOP sistem penyimpanan rekam medis, menerapkan sistem penyimpanan rekam medis dan tracer di puskesmas. Metode yang digunakan adalah project based learning. Hasil dari pengabdian ini adalah bertambahnya pengetahuan petugas rekam medis mengenai sistem penyimpanan rekam medis dan tracer. Pembuatan SOP dan tracer di UPT puskesmas PB Selayanng II. Pengabdian ini berhasil dilaksanakan berkat kerjasama yang baik antara tim pelaksana, mahasiswa, petugas puskesmas dan kepala UPT Puskesmas PB Selayang II serta Dinas Kesehatan Kota Medan.
Tinjauan Kelengkapan Pengisian Formulir Persetujuan Tindakan Kedokteran Pasien Bedah Rawat Inap Di Rumah Sakit Tere Margareth Tahun 2022 Ali Sabela Hasibuan; Zulham Andi Ritonga; Marta Simanjuntak; Edward Ramos Nababan
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Vol. 8 No. 2 (2023): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Agustus
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v8i2.1357

Abstract

Completeness of filling in the informed consent form is very important because it can affect the quality of medical records and the legal aspects contained in the medical records themselves. This type of research is descriptive with an observational approach, namely research that describes the current situation. The study population was the medical record document of the informed consent form of inpatients with the sample in this study being a portion of the total population. An overview of the completeness of filling out informed consent sheets in surgical cases at Tere Margareth General Hospital can be seen from the sample count with a total population of (235) divided by 1+235 (precision level/10%=0.1) which results in a sample of 70. Completeness of filling in the identification of providing information is 97% filled and 3% not filled. Completeness of filling in important report items is 92% filled and 8% not filled. Completeness of filling in medical action items is 98% filled and 2% not filled. Completeness of filling in authentication items is 87% filled and 3% not filled. The medical record unit is trying to be able to ask the nurse in charge to fill out the informed consent form so that it can fill it out completely.
Co-Authors Alan Juli Wannara Ali Sabela Hasibuan Ani Soraya Edward Ramos Nababan Esraida Simanjuntak Faradila Maya Sari Hasran Ependi Lubis Insan Mansuri Marta Simanjuntak Mei Sryendang Nur Aisah Ritonga Rahel Oktavia Manurung Siti Permata Sari Lubis Sri Rusanti