Heru Indra Cahya
Poltekkes `Aisyiyah Banten

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TINJAUAN KELENGKAPAN PENGISIAN SURAT KEMATIAN DI RSU BANTEN Heru Indra Cahya; Erwin Muhtaddin
Journal Of Applied Health Research And Development Vol 4 No 1 (2022): Journal Of Applied Health Research And Development
Publisher : Poltekkes 'Aisyiyah Banten

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (814.856 KB) | DOI: 10.58228/jahrd.v4i1.110

Abstract

Background: Filling in the Death Certificate at RSU Banten is the part that gets attention in this study. The Death Certificate form was found to be incomplete in patient identification, completeness of important reports, author authentication and good records. The Medical Certificate of Cause of Death (SMPK) is the main source of mortality data. Death information is usually obtained from health practitioners or in cases of death due to accidents, violence and other diseases. Based on a preliminary study in March 2020 at Banten General Hospital, it was found that out of 20 death certificate forms there were 10 incomplete death certificate forms, including the incomplete identification component of 7.75 (39%) such as in the death serial number section, the main number population and population number. 9 (45%) important report components were incomplete, such as the type of examination, ICD code, method and location of burial. The incomplete authentication component of 10 (50%) is as in the reporting signature and reporting name. An incomplete record component of 6.6 (35%) is like a lot of blanks. The purpose of the study was to find out the Completeness of Filling in Death Certificates at RSU Banten and the results of this study were expected to be useful for hospitals as input and consideration in addressing the issue of completeness of medical certificates causing death. and the approach used in this research is to use a comparative approach, namely through a checklist and interviews at RSU Banten. The research method used is quantitative research. The population in January- February 2020 was 233 death certificate forms at RSU Banten, while the subject population was 12 officers who were responsible for completing death certificates. The sample object taken for this research is a Death Certificate form as many as 77 samples. While the sample of subjects in this study were 2 officers who filled out death certificates. Sampling Technique Subjects in this study used non-random (non-probability sampling) with purposive sampling. The results showed that the SOP (Standard Operating Procedure) already exists and is complete which regulates the Filling of Death Certificates at RSU Banten in the installation section of the funeral procession (IPJ), but it is still not fully implemented because there are still many incomplete forms, from the 5 SOP items it is known that those who are complete with SOP guidelines are (100%) while those that are incomplete with SOP guidelines are (0%). The results of completeness in patient identification with a complete percentage are found in the sub-components of medical record numbers and names, which are 77 (100%), while the incomplete percentages are found in the sub-components of death serial number, population identification number and population identification number, which is 77 (100% , Important reports on death certificates that are filled out completely are found in the time of death sub-component, which is 77 (100%), while the completeness of filling out important reports that are incomplete on the death serial number is 77 (100%).Authentication Author on death certificates which is filled in completely is contained in the sub-components of the doctor's TTD sign and the doctor's name, which is 77 (100%), while the incomplete completeness of author authentication on the reporting blood pressure, the name of the reporter, the identity card number of the reporting person, the address of the reporter is 77 (100%). Both the death certificate that is filled in completely, there are sub-components, there are no scribbles and there is no type - ex, which is 77 (100%). while the completeness of incomplete filling on a good record is found in the sub-components, there are no empty parts, namely 77 (100%). Data collection was carried out by survey, namely the researcher conducted direct interviews with respondents using a questionnaire. The research results obtained the following data; There were 97 toddlers who had pneumonia or 26.5%, almost all of them 94.5% of mothers had good knowledge about pneumonia, 46.7% of mothers had sufficient behavior and 49.5% of mothers had sufficient attitudes and more than half of them 70.2% of mothers had not been exposed to information about pneumonia. The Bivariate results found that attitude and information exposure had a significant relationship with the incidence of pneumonia, while behavior and knowledge had no significant relationship with the incidence of pneumonia among toddlers in the city of Cilegon. From the results of this study, it is hoped that the Cilegon City Health Office can increase socialization and counseling about pneumonia through cooperation with related agencies so that it can improve the degree of public health.
PELEPASAN INFORMASI REKAM MEDIS DALAM MENJAMIN ASPEK HUKUM KERAHASIAAN REKAM MEDIS DI PUSKESMAS TIRTAYASA Heru Indra Cahya; Erwin Muhtaddin
Journal Of Applied Health Research And Development Vol 4 No 1 (2022): Journal Of Applied Health Research And Development
Publisher : Poltekkes 'Aisyiyah Banten

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (815.66 KB) | DOI: 10.58228/jahrd.v4i1.112

Abstract

Background Medical Record according to Permenkes No.269/Menkes/Per/III/2008, Medical Record is a file that contains notes and documents about the patient's identity, examination results, treatment that has been given to the patient. Health facilities are responsible for protecting health information contained in medical records against possible loss, damage, falsification and unauthorized access. Maintaining information security, accuracy of information and ease of access to information are demands of health service organizations and health practitioners as well as authorized third parties. Meanwhile, parties who need information must always respect patient privacy. Overall, security, privacy, confidentiality and safety are devices that fortify information in medical records [1]. The purpose of this study was to determine the review of the release of medical record information in ensuring the legal aspects of the confidentiality of medical records at Kencana Hospital. Research method The research design used is descriptive research, which is a research method whose purpose is to present a complete picture of the social setting by describing a number of variables that are relevant to the problem and the unit under study among the phenomena being tested. This type of research is used to determine the process of providing medical record information and guaranteeing the legal aspects of medical record confidentiality at Kencana Hospital. The population in this study were all officers involved in the process of providing medical record information at Kencana Hospital which had 8 employees, which were divided into 3 medical record officers (1 head of medical records and 2 people served as distribution and retrieval officers), 2 people who handles related to insurance and 2 officers handles related to BPJS. In this study, the sample used was the party from the medical record unit, namely the medical record officer who has the authority in the process of providing patient medical information to a third party. The instruments used are Checklist Sheets and interview guidelines. In this study, the sampling used was purposive sampling technique because in sampling the authors considered certain things related to the research, The results of the research on Standard Operating Procedures related to providing patient medical information at the Kencana Hospital have an SOP. This SOP contains points for the process of releasing patient medical information, each point with a slightly different procedure depending on who the 3rd party is requesting. What is meant by 3rd parties here are patients, insurance companies, and legal institutions (courts). Each of these 3rd parties has made their respective procedures. The parties involved in the process of releasing patient medical information at Kencana Hospital are all medical record officers totaling 15 people (8 officers in the filing section), (2 people in the distribution of medical record files), and (5 people in the registration section). The information released is in the form of a photocopy of a medical resume sheet. At Kencana Hospital, the only party who can decide on the release of patient medical information is the medical record officer. Kencana Hospital does not yet have special security related to the process of releasing patient medical information, but if a patient is represented in the process of requesting release of information, the representative must have a power of attorney from the patient concerned. If the request for release of information is not represented, the patient will be given a release approval form from the medical record unit. Suggestion It is better to make Standard Operating Procedures related to the Release of Patient Medical Information referring to the Regulation of the Minister of Health of the Republic of Indonesia Number 36 of 2012 concerning Medical Secrets and Guidelines for the Implementation and Procedures of Indonesian Hospital Medical Records issued by the Director General of Yanmed.
TINJAUAN RUANG ASPEK KENYAMANAN RUANG PENYIMPANAN REKAM MEDIS DI PUSKESMAS KRAMATWATU Heru Indra Cahya; Erwin Muhtaddin
Journal Of Applied Health Research And Development Vol 4 No 1 (2022): Journal Of Applied Health Research And Development
Publisher : Poltekkes 'Aisyiyah Banten

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (1043.739 KB) | DOI: 10.58228/jahrd.v4i1.117

Abstract

Background : The security of the medical record file storage room is one of the main parts to support the security of the medical record file, besides that there are still many health care facilities that underestimate the security of the medical record file storage room, look down on the eyes, and consider trivial things for the security of the record file storage room. medical records in addition to the security of the medical record file itself. The purpose of this study was to find out the review of the Security Aspects of the Medical Record File Storage Room at the Kramatwatu Health Center, South Tangerang. This research uses descriptive research method. From the results of observations and interviews, it was found that the SOP regarding the security of the medical record storage room was already available, but in its application it was still not optimal due to space limitations, the available storage space is not 100% in accordance with the criteria. The cleanliness aspect of the medical record file storage room is not fully appropriate, there is no fixed schedule for cleaning the medical record room, and the APAR is not yet available specifically in the medical record storage room. The conclusion of this study is that there is no SOP for work instructions and the safety of the medical record file storage room, the storage space in the Puskesmas has not been able to accommodate the available medical record files. APAR is not yet available specifically in the medical record storage room. The conclusion of this study is that there is no SOP for work instructions and the safety of the medical record file storage room, the storage space in the Puskesmas has not been able to accommodate the available medical record files. APAR is not yet available specifically in the medical record storage room. The conclusion of this study is that there is no SOP for work instructions and the safety of the medical record file storage room, the storage space in the Puskesmas has not been able to accommodate the available medical record files. APAR is not yet available specifically in the medical record storage room