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All Journal Jurnal Rekam Medis dan Informasi Kesehatan J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan
Meilinda Asrining Hapsari
Poltekkes Kemenkes Semarang
Health Professions Public Health

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Tinjauan Pengelolaan Jobs Description PMIK di Puskesmas Srondol Sri Lestari; Meilinda Asrining Hapsari
Jurnal Rekam Medis dan Informasi Kesehatan Vol 5, No 2 (2022): Oktober 2022
Publisher : Poltekkes Kemenkes Semarang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31983/jrmik.v5i2.9248

Abstract

Puskesmas in carrying out health services, one of its authorities is to carry out medical record management. Referring to Permenkes no. 55 of 2013 article 2 which states that the administration of medical records must be carried out by medical recorders. Medical Recorder is a person who has passed the Medical Record and Health Information education in accordance with the provisions of the legislation. The purpose of this research is to know the management of medical records, and health information as well as the staff for managing medical records at the Srondol Health Center. This type of research is descriptive qualitative with a case study approach. The results showed that the Srondol Health Center provided health services to BPJS patients and general patients. The patient naming system at the Srondol Health Center is adjusted to ID cards, family cards and other identity cards. Medical record management activities experienced several obstacles because they did not have officers with a medical record education background so that the transfer of medical record media from manual to electronic was constrained. The writing of patient names (Mr, Ny, Son, Br) is not standardized. Diagnostic coding is only known and carried out by doctors and midwives. The conclusion obtained is that the management of medical records and health information at the Srondol Health Center still found some things that were not in accordance with the regulations, so it was advisable to make adjustments to the medical record personnel regulations to improve their services.
Analisis Kesiapan Pelaksanaan Rekam Medis Elektronik (RME) Dengan Metode Doctor's Office Quality-Information Technology (DOQ-IT) di Klinik Pratama Polkesmar Meilinda Asrining Hapsari; Kismi Mubarokah
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 4 No 2 (2023): March
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v4i2.3826

Abstract

In order to realize digital transformation, quality data integration is an important element, especially in the field of health services. All Health Service Facilities are expected to have implemented Electronic Medical Records (EMR) following the provisions no later than December 31, 2023. In order to comply with these regulations, health service facilities must prepare all the components needed to implement EMR. The purpose of this study was to analyze the readiness of implementing RME using the Doctor's Office Quality-Information Technology (DOQ-IT) method at the Polkesmar Primary Clinic. The type of research used was descriptive quantitative. Methods of data collection were through filling out questionnaires. Ease of use analysis was done using the EHR Assessment and Readiness Starter Assessment from DOQ-IT. The total readiness score of the Polkesmar Primary Clinic in implementing EMR was 128,45 in category III, which meant that the Polkesmar Primary Clinic was very ready to implement EMR. Readiness for implementing EMR could be ranked as the strongest, namely Human Resources readiness (4,50), Governance and Leadership readiness (4,64), Organizational Work Culture readiness (4,69), and IT Infrastructure readiness (4,54).
Co-Authors Kismi Mubarokah Sri Lestari