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Analisis Pelaksanaan Pemusnahan Berkas Rekam Medis Rawat Jalan Di RS Khusus Mata SMEC Medan Tahun 2021 Johanna Christy
Cybernetics: Journal Educational Research and Social Studies Volume 2 Nomor 4 Oktober 2021
Publisher : Pusdikra Publishing

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.51178/cjerss.v2i4.452

Inactive medical record files on storage shelves will not always be stored, because the number of medical records in hospitals continues to grow. Destruction of medical records is one of the efforts made by the hospital with the aim of reducing the accumulation of medical record files in the storage room. Special Eye Hospital SMEC Medan has 3 medical record officers. After 10 years, the Medan SMEC Hospital has retained medical record files in July 2021. And will carry out destruction. This study aims to determine how the preparation of human resources in the implementation of the destruction, the facilities used in the implementation of the destruction, and the assessment of inactive medical record files that will be destroyed. The type of research used is descriptive with a qualitative approach. The population in this study were all medical record officers at the Medan SMEC Eye Special Hospital in 2021. The method of data collection was using observation. In the results of the study conducted at the Special Eye Hospital, SMEC Medan, there were 6 medical record officers. One of the reasons for not carrying out the destruction is due to the unavailability of tools for the destruction of medical record files. The SMEC Medan Eye Special Hospital will only hold a retention in July 2021 to be exact on 5 July 2021. It is hoped that the Medan SMEC Eye Special Hospital will add human resources with medical record education, provide facilities in the form of tools to destroy medical record files, and carry out retention of medical record files. on time in accordance with the time set by the Director General of Yanmed.

HUBUNGAN RIWAYAT SAKIT DAN ASUPAN GIZI (ENERGI DAN PROTEIN) DENGAN STATUS GIZI LANSIA DI WILAYAH KERJA PUSKESMAS PADANGMATINGGI KOTA PADANGSIDIMPUAN Johanna Christy
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Vol. 4 No. 2 (2019): 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.v4i2.90

One of the increasing benchmarks of the progress of a nation is seen from the life expectancy of its population. Increasing life expectancy is reflected in the increasing number of elderly (elderly) population. The increasingly elderly population in Indonesia will have a major impact on the management of health problems. This study aims to see aims to know the history of illness, energy intake and protein intake with nutritional status in the elderly in the work area of Padangmatinggi in Padangsidimpuan Health Center.This research type is quantitative with cross sectional research design. This study was conducted by assessing the food method of food recall 24 hours. Nutritional status with IMT / U. The sample in this study amounted to 100 people who are elderly. Data analysis is univariate, and bivariate with Chi Square Test. The result of bivariate test shows that there is correlation between history of illness (p=0,000), energy intake (p=0.000), and protein intake (p=0.000) with nutritional status. Cadres should more often give counseling about balanced nutrition to the community, especially elderly to improve knowledge, attitudes, and behavior of balanced nutrition in elderly and always monitor nutritional status of elderly through posyandu elderly in order to maintain normal BMI. The health office is more often to monitor the nutritional status and health of the elderly in the working area of Padang municipal health center of Padangsidimpuan in order to maintain the normal nutritional status in the elderly and the elderly to avoid degenerative diseases.

TINJAUAN PELAKSANAAN NILAI GUNA REKAM MEDIS BAGI PASIEN DI RUMAH SAKIT UMUM IMELDA PEKERJA INDONESIA (RSU IPI) MEDAN TAHUN 2018 Johanna Christy; Afni Efani Putri S
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Vol. 5 No. 1 (2020): 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.v5i1.335

ABSTRAK Rekam medis adalah berkas yang berisi catatan dan dokumen tentang identitas pasien, pemeriksaan, pengobatan, tindakan dan pelayanan lain kepada pasien pada sarana pelayanan kesehatan. Tujuan penelitian ini adalah untuk mengetahui bagaimana pelaksanan nilai guna rekam medis bagi pasien. Jenis penelitian ini adalah deskriptif bertujuan menggambarkan secara sistematis fakta dan karakteristik objek dan subjek secara tepat. Waktu penelitian ini dilakukan pada bulan Juli di Rumah Sakit Umum Pekerja Indonesia Medan (RSU IPI) Tahun 2018. Populasi dalam penelitian adalah 440 berkas rekam medis. Dalam melakukan penelitian, peneliti mengambil sampel sebanyak 81 berkas rekam medis. Berdasarkan hasil penelitian yang dilakukan di RSU IPI pelaksanaan nilai guna rekam medis sudah terlaksana dengan baik, dilihat dari tersedianya ringkasan masuk dan keluar, resume, lembar operasi, identifikasi bayi, lembar persetujuan tindakan, lembar kematian pada setiapberkas pasien pulang meninggal, asuhan keperawatan didalam berkas rekam medis. Tetapi dalam pengisian berkas rekam medis petugas rekam medis belum mengimplementasikan nilai guna rekam medis dengan baik. Kesimpulannya pelaksanaan nilai guna rekam medis sudah baik namun dalam pengisian berkas rekam medis lebih di perhatikan sesuai Permenkes 269 Tahun 2008 Tentang rekam Medis sehingga pelaksaaan nilai guna rekam medis dan pengisisan berkas rekam medis berjalan lebih baik. Kata Kunci: Rekam Medis, Nilai Guna Rekam Medis, Berkas Rekam Medis ABSTRACT Medical record is a document that contains records and documents about patient identity, examination, treatment, care and other services for patients in health care facilities. The purpose of this study was to study how the implementation of the use of medical records for patients. This type of research is descriptive which addresses the systematic problem and the appropriate characteristics of objects and subjects. When this study was conducted in July at the Medan Indonesian Workers General Hospital (RSU IPI) in 2018. The population in this study was 440 medical record documents. In conducting research, researchers took 81 samples of medical records. Based on the results of research conducted at the IPI General Hospital, the implementation of the use value of medical records has been carried out well, seen from the availability of incoming and outgoing assessments, proceeding, surgery sheets, accessing infants, action approval sheets, consent sheets on each patient's return documents, medical care care. However, in applying medical records, medical record officers have not applied the use value of medical records properly. Conclusion the reclamation of the value of the medical record has been better in the reclamation of the medical record is better with the approval in accordance with Minister of Health Regulation 269 of 2008 About the Medical Record requires the implementation of the value of the medical record and the filling of the medical record better.

PENGARUH PENYULUHAN KESEHATAN TERHADAP PENGETAHUAN PENCEMARAN SAMPAH MAKROPLASTIK DAN MIKROPLASTIK PADA MAHASISWA PRODI DIII PEREKAM DAN INFORMASI KESEHATAN STIKes IMELDA Lamtiur Junita Bancin; Johanna Christy
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Vol. 5 No. 2 (2020): 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.v5i2.416

Health education is one of the techniques to increase someone’s knowledge level due to the aim of improving knowledge and well understanding regarding microplastic and microplastic pollution. This research aimed to analyze the effect of health education towards the knowledge regarding macroplastic and microplastic pollution among students at the medical record and health major in the college of health sciences Imelda in terms of health education. This research used a quantitative approach with a Quasi-Experimental Study Design of a non-equivalent control group. The population was all the students with the medical record and health information major. The sampling technique used was purposive sampling, all the first-year students. The group of the sample consisted of two groups- the intervention and the control group. The intervention group consisted of 73 people who have given health education. Control group consisted of 73 people who have not given any health education. The statistic test used was the Wilcoxon test. The statistic result on the knowledge variable among the experiment group who had a good knowledge level refer to the pre-test score only 4.1 %. After given health education, the increasing number of people who had a good knowledge level (76.1%). The good knowledge level among the control group only showed 1.4% (pre-test and post-test). The result showed there was a significant increase after given health education among the experiment group (p=0.00). However, another result showed there was no significant difference among the control group (p=1.00). Health education towards macroplastic and microplastic pollution had a significant influence to the knowledge level for students. It is recommended for further research to examine the role of knowledge towards attitudes and behaviors or actions in the management of macro and microplastic waste pollution. Based on the results of the pre-test where respondents still have less and moderate knowledge while the issue of plastic waste in Indonesia requires full attention and more participation from the community from society, it is necessary to get the attention of educational institutions to further elaborate and educate students in pollution macro-plastic and microplastic waste.

MUTU PELAYANAN PETUGAS REKAM MEDIS TERHADAP TINGKAT KEPUASAN PASIEN BPJS RAWAT JALAN DI RUMAH SAKIT UMUM IPI MEDAN TAHUN 2019 Johanna Christy
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Vol. 5 No. 2 (2020): 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.v5i2.419

Quality of service is the overall characteristics of the service that shows its ability to satisfy the needs of consumers, and the Health BPJS is a legal entity formed to carry out a health insurance program, and patient satisfaction is the level of patient feelings that arise as a result of the performance of health services obtained after the patient compares it with what he hoped for. The purpose of this study was to determine the quality of medical record officer services to the level of satisfaction of outpatient BPJS patients in General Hospital. IPI Medan 2018. This research uses Analytical research design. The independent variable is BPJS Health service quality and the dependent variable is patient satisfaction. Samples taken using the Slovin Formula found 33 patients in the Outpatient Installation at the General Hospital. IPI. Medan in 2018. The research instrument used a questionnaire. The results showed that 28 respondents (84.8%) stated that the quality of BPJS Health services was good, and 32% of respondents (97.0%) expressed satisfaction with BPJS Health services. Chi Square statistical test results state there is a relationship between the quality of BPJS Health services with patient satisfaction Outpatient Installation at the General Hospital. IPI. Medan Year 2018 (pValue = 0,000). The implication of the results of the study shows that the quality of BPJS Health services has an important role in influencing patient satisfaction.

Ketidaktepatan Kode Diagnosis Kasus Neoplasma Menggunakan ICD-10 Di RSUP H.Adam Malik Medan Tahun 2019 Johanna Christy; Evi Efriamta Siagian
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.v6i1.477

ABSTRAK Informasi peyakit dirumah sakit tidak akan lengkap dan bermanfaat apabila belum diolah, maka untuk itu perlu dilakukan pengkodean. Penelitian ini bertujuan untuk mengetahui ketepatan kode diagnosis pada kasus neoplasma menggunakan ICD-10 di RSUP. H. Adam Malik tahun 2019. Penelitian ini menggunakan metode kuantitatif dengan pendekatan cross sectional, Jumlah sampel yang digunakan sebanyak 93 dokumen dan 4 orang responden. Ketepatan kode morfologi diagnosis neoplasma diperoleh hasil 88 (95%) kode tepat 6 karakter, 0 (0%) kode tepat 5 karakter, 0 (0%) kode tepat 4 karakter, 3 (3%) kode tidak tepat sama sekali dan 2 (2%) tidak dikode. Ketepatan kode topografi diperoleh hasil 79 (85%) kode tepat 4 karakter, 8 (9%) kode tepat 3 karakter, 4 (4%) kode tepat 2 karakter, 0 (0%) kode tepat 1 karakter, 0 (0%) kode tidak tepat sama sekali dan 0 (0%) kode tidak dikerjakan. Faktor yang menjadi penyebab ketidaktepatan dalam pengodean adalah petugas coding sulit untuk membaca tulisan dokter sehingga penulis menyarankan sebaiknya dalam pengkodingan diagnosis tetap mengikuti kaidah dan aturan yang ada pada ICD-10. Kata Kunci: Ketepatan, Diagnosis, Neoplasma, Pengkodean Abstract Information for patients in hospitals will not be complete and useful if it has not been processed, so coding is necessary. This study aims to determine the accuracy of the diagnosis code in cases of neoplasm using ICD-10 in RSUP. H. Adam Malik in 2019. This study used a quantitative method with a cross sectional approach. The number of samples used was 93 documents and 4 respondents. The accuracy of the morphological code for the diagnosis of neoplasm was 88 (95%) the code was exactly 6 characters, 0 (0%) the code was exactly 5 characters, 0 (0%) the code was exactly 4 characters, 3 (3%) the code was not correct at all and 2 ( 2%) is not coded. The accuracy of the topographic code is 79 (85%) the code is exactly 4 characters, 8 (9%) the code is exactly 3 characters, 4 (4%) the code is exactly 2 characters, 0 (0%) the code is exactly 1 character, 0 (0%) code is not correct at all and code 0 (0%) is not working. The factor that caused the inaccuracy in coding was that it was difficult for coding officers to read the doctor's writings, so the authors suggested that the coding of the diagnosis should still follow the rules and regulations in the ICD-10. Keywords: Accuracy, Diagnosis, Neoplasm, Encoding

Ketepatan Waktu Pengembalian Berkas Rekam Medis Berdasarkan Unsur-Unsur Manajemen Di RSU Bina Kasih Medan Tahun 2021 Johanna Christy; Siti Suarni Waruwu
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Vol. 8 No. 1 (2023): 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.v8i1.987

Management is a process consisting of regulatory, planning, organizing, directing and controlling activities carried out to determine and achieve goals through the use of human resources and other resources to achieve organizational goals effectively and efficiently. Elements of management include 5M including (Man, Method, Material, Machine, Money). The purpose of this research is to determine the 5 element of The Timely Return of Inpatient Medical Record Files at Bina Kasih Hospital in 2021. This type of research is qualitative with a case study approach. The research was conducted in August-September 2021 which coincided with Bina Kasih Hospital in Medan with 7 subjects and head of medical record informants, the sampling technique used was purposive sampling. The timeliness of returning inpatient medical record files in August 2021 totaled 270 files and the number of inaccuracies in inpatient medical record files was 60.74% machine and money elements.

The Relationship Between the Nutritional Status of Pregnant Women, Infant Birth Weight and Stunting Incidence in Toddlers Johanna Christy; Esraida Simanjuntak
Contagion: Scientific Periodical Journal of Public Health and Coastal Health Vol 5, No 1 (2023): CONTAGION
Publisher : Universitas Islam Negeri Sumatera Utara, Medan

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.30829/contagion.v5i1.14952

Stunting is still a major nutritional problem faced by Indonesia. The prevalence of stunting in North Sumatra ranks nineteenth at 21.1%. Mandailing Natal District has the highest prevalence in North Sumatra Province at 47.7%. This study aimed to determine the relationship between the nutritional status of pregnant women (LILA) and the birth weight of infants aged 6-36 months with the stunting process in the Working Area of the Kotanopan Health Center, Mandailing Natal. This type of research is observational with a cross-sectional study design with a sample of all infants aged 6-36 months at the Kotanopan Health Center, Mandailing Natal. This research was conducted in the Working Area of the Kotanopan Health Center, Mandailing Natal, in December-February 2023. The population in this study was all toddlers aged 6-36 months, totaling 1457 toddlers. The sample in the study was 97 toddlers. They collected data in this study using a questionnaire. The sampling technique uses simple random sampling—data analysis in this study with the Chi-Square test. The results of the study explained that there were 97 respondents for the category of nutritional status of pregnant women (LILA), and 34.0% of pregnant women experienced chronic energy deficiency. There were 25.7% of babies born with low birth weight (LBW) and 47.4% of babies experiencing stunting for the category of infant nutritional status based on height/age. The results of statistical tests showed that there was a significant relationship between the Nutritional Status of Pregnant Women (LILA) and stunting in infants (p=0.01) and birth weight in infants with stunting (p=0.02). Suggestions for health workers need to increase the provision of PMT to pregnant women to prevent an increase in the number of pregnant women suffering from CED in the working area of the Kotanopan Health Center, Mandailing Natal. Keywords: Infant Birth Weight, Stunting, Upper Arm Circumference (LILA)

Penyuluhan Tentang Pencegahan Stunting Dan Gizi Buruk Di Desa Tombang Bustak, Kabupaten Mandailing Natal Johanna Christy; Nila Sari; Khairani Khairani
Educativo: Jurnal Pendidikan Vol 2 No 1 (2023): Zadama: Jurnal Pengabdian Masyarakat
Publisher : PT. Marosk Zada Cemerlang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.56248/zadama.v2i1.46

Stunting merupakan suatu kondisi dimana kurang gizi kronis yang disebabkan oleh asupan gizi yang kurang dalam jangka waktu yang cukup lama akibat pemberian makanan yang tidak sesuai dengan kebutuhan gizi. Stunting masih menjadi masalah gizi utama yang dihadapi Indonesia. Prevalensi stunting di Sumatera Utara menempati urutan kesembilan belas sebesar 21,1%, Provinsi Sumatera Utara masih menghadapi permasalahan tingginya angka prevalensi stunting pada balita diatas standard WHO yakni sebesar 21,1%, dan salah satu wilayah dengan prevalensi stunting tertinggi adalah kabupaten Mandailing Natal berada di posisi paling atas yakni dengan 47.7 persen setelah Padang lawas, Pakpak Barat, Nias Selatan dan Nias Utara (SSGI, 2022). Metode yang dipakai pada pengabdian masyarakat ini yaitu dengan memberikan sosialisasi/penyuluhan secara langsung tentang pencegahan stunting dan gizi buruk di Desa Tombang Bustak. Hasil kegiatan pengabdian kepada masyarakat ini yaitu bertambahnya pengetahuan masyarakat terkait stunting dan gizi buruk. Kegiatan ini berhasil dilaksanakan dengan baik berkat kerjasama yang baik serta dukungan dari semua pihak baik tim pelaksana, mahasiswa, petugas dan Kepala Puskesmas Kotanopan serta masyarakat setempat.

PENYULUHAN TENTANG FAKTOR YANG MENYEBABKAN KERUSAKAN FISIK DOKUMEN REKAM MEDIS DI UPT PUSKESMAS PULO BRAYAN, MEDAN Johanna Christy; Erlindai; Mei Sryendang Sitorus
Jurnal Ilmiah Pengabdian Kepada Masyarakat (Ji-SOMBA) Vol. 2 No. 1 (2022): Jurnal Ilmiah Pengabdian Kepada Masyarakat (Ji-SOMBA)
Publisher : Universitas Imelda Medan

Rekam medis adalah catatan atau dokumen yang berisikan identitas, anamnesa, penentuan fisik, laboratorium, diagnosa dan tindakan medis yang diberikan kepada pasien dan pengobatan baik rawat jalan, rawat inap mauapun pelayanan gawat darurat. Dokumen rekam medis harus didukung dengan keamanan dan kerahasiaan di ruangan peyimpanan berkas rekam medis itu sendiri. Metode yang digunakan dalam pengabdian masyarakat ini adalah dengan memberikan sosialisasi/penyuluhan secara langsung tentang faktor penyebab kerusakan fisik dokumen rekam medis di Puskesmas Pulo Brayan dan demonstrasi serta pendampingan tentang kerusakan fisik dokumen rekam medis di ruang penyimpanan. Hasil dari kegiatan pengabdian kepada masyarakat ini adalah bertambahnya pengetahuan dan keterampilan petugas penyimpanan dalam mengelola dokumen rekam medis untuk meminimalisir terjadinya kerusakan fisik dokumen rekam medis. Kegiatan ini berhasil dilaksanakan dengan baik berkat kerjasama yang baik serta dukungan dari semua pihak baik tim pelaksana, mahasiswa, petugas dan Kepala Puskesmas Pulo Brayan serta Dinas Kesehatan Kota Medan.

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