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Jurnal Rekam Medis dan Informasi Kesehatan

RMIK
Website

Published by Poltekkes Kemenkes Semarang

ISSN : 26221863 EISSN : 26227614 DOI : https://doi.org/10.31983/jrmik.v2i1.4391

Core Subject : Health,

Health Professions

It is aimed at all medical record and health information practitioners and researchers and those who manage and deliver medical record and health information services and systems. It will also be of interest to anyone involved in health information management, health information system, and health information technology.

Arjuna Subject : Profesi Kesehatan - Profesi Kesehatan (Lain-Lain)

Articles 8 Documents

Search results for , issue "Vol 2, No 2 (2019): Oktober 2019" : 8 Documents clear

Keakuratan Kode Diagnosis Penyakit Berdasarkan ICD-10 pada Rekam Medis Rawat Jalan Di Puskesmas Irmawati Irmawati; Nadelia Nazillahtunnisa
Jurnal Rekam Medis dan Informasi Kesehatan Vol 2, No 2 (2019): Oktober 2019
Publisher : Poltekkes Kemenkes Semarang

An accurate diagnostic code is required to achieve the goal of the classification system for disease diagnosis, one of which is the recording of mortality and morbidity data. Based on preliminary study of 7 samples of medical records in health centers Kagok, get results 2 medical records (28.57%) there is an accurate diagnosis and diagnostic code and 4 medical records (57.14%) there is an inaccurate diagnosis and diagnosis code, while 1 medical record (14.29%) no diagnosis. The purpose of this research is to determine the accuracy of the disease diagnosis code based on ICD-10 in the outpatient medical record in health centers Kagok. This study used a quantitative descriptive research with cross sectional research design. The number of samples on this study was 98 medical records of outpatient patients, taken with a proportional stratified sampling method. The results showed that the medical record was diagnosed as much as 57 medical records (58%) while the unwritten diagnosis is as much as 41 medical record (42%). From 57 medical records that have been diagnosed, there are only 18 medical records (32%) with accurate code and 39 medical records (68%) with inaccurate code. The officers of the Diagnosis Code no one has the educational background of the medical record, never participated in special training on coding ICD-10, and did not use the facilities in the health centers in the form of an electronic ICD-10 in giving code diagnosis.

Analisis Penyebab Tidak Digunakannya Sistem Informasi Manajemen Puskesmas (Simpus) dalam Penerimaan Pasien Rawat Jalan di Puskesmas Kalimas Kecamatan Randudongkal Kabupaten Pemalang Linda Ida Tiara; Subinarto Subinarto
Jurnal Rekam Medis dan Informasi Kesehatan Vol 2, No 2 (2019): Oktober 2019
Publisher : Poltekkes Kemenkes Semarang

Simpus is a system to improve the quality of puskesmas management and as a supporter in the smooth management of health information in Puskesmas. Based on the preliminary study of Kalimas Puskesmas in the process of admission an outpatient not use Simpus and still done manually The purpose of this research is to analyze the causal factors of the management Information System Puskesmas (Simpus) seen from the aspects of human resources, supporting materials, infrastructure facilities, implementation and fund source.The type of research used is descriptive research with qualitative approach. Methods of collection observation data and interview. Presentation of the data to be done ie in the form of fish bone diagram that contains about the factors of the cause of the not used SimpusThe results of the qualification study and the number of available medical record officers are not eligible. There has been no obligation from the Department of Health to use Simpus. Simpus from the Department of Health is integrated with Disduccapil and automatic numbering, the medical record number will differ from the number in the Family folder. There is only one computer in the registration. There has been no budget for such infrastructures for computers. Conclusion is not used Simpus seen from the aspect of human resources, the way of implementation, supporting materials, infrastructure and sources of funds have not been in accordance

Tinjauan Kelengkapan Pengisian Sertifikat Penyebab Kematian di Rumah Sakit Umum H. Adam Malik Medan Tahun 2019 Esraida Simanjuntak; Anggraeini Ginting
Jurnal Rekam Medis dan Informasi Kesehatan Vol 2, No 2 (2019): Oktober 2019
Publisher : Poltekkes Kemenkes Semarang

The cause of death is all diseases, conditions of illness, or injuries that cause or facilitate death, and accidents or violence that cause such injuries. The cause of death data in the cause of death certificate is used as the main source of hospital mortality data. Quantitative analysis is a review or review of certain parts of the contents of the medical record with the intention of finding specific deficiencies related to recording medical records. Quantitative analysis consists of four components, namely the identification review, important report review, authentication review and record review. The purpose of this research was to determine the percentage of completeness in completing certificates of cause of death. This type of research is a description of the check-list sheet method and observation. The research site was conducted at H. Adam Malik General Hospital in Medan. When the research was conducted in April-May 2019. The population and sample used were data on patient deaths and certificates of cause of death in March. Based on the results of the research, obtained the calculation of the percentage of completeness of the certificate of the cause of death based on an identification review of 40.5%, the completeness based on the important report review of 28.9%, the completeness based on the 98.5% authentication review and the review recording can be read and clear at 85, 5%. The conclusion of this research is that a low percentage of completeness in the identification review and review of the report is important because of the large number of components that must be filled so that it requires more time. The suggestion from this research is that officers should be able to complete the certificate of causes of death completely and clearly.

Tinjauan Aspek Keamanan dan Kerahasiaan Rekam Medis di Rumah Sakit Setia Mitra Jakarta Selatan Siswati Siswati; Dea Ayu Dindasari
Jurnal Rekam Medis dan Informasi Kesehatan Vol 2, No 2 (2019): Oktober 2019
Publisher : Poltekkes Kemenkes Semarang

Maintaining the confidentiality of the patient's medical record, required storage of medical records that meet the requirements in maintaining security and confidentiality. Medical record storage can be said to be good if the room guarantees security and avoid the threat of loss, neglect, disaster and anything that can jeopardize the medical record. The medical record storage room at Setia Mitra Hospital is not yet secure, because the door is unlocked. Besides nurses, radiology and nutrition can enter the medical record storage room and some medical records were found damaged. The general purpose of this study was to determine the security and confidentiality aspects in the medical record storage room. This research method is qualitative with a case study approach to illustrate how the security and confidentiality aspects in the Setia Mitra Hospital medical record storage room. Data collection techniques by observation and interview. The results found that the security and confidentiality policies have been made but have not been implemented well. The conclusion from the results of this study was only found about security policies while standard operating procedures related to the security and confidentiality of medical records have not been made. The physical medical record does not guarantee the safety and confidentiality of the contents of the medical record. Medical record storage room does not guarantee the security of medical record storage. The Setia Mitra Hospital leadership should be able to reaffirm the established policies related to the security and confidentiality of medical records, in addition to that the SPO was made related to the security and confidentiality of medical records.

Tinjauan Ketepatan Koding Penyakit Gastroenteritis Pada Pasien BPJS Rawat Inap di UPTD RSUD Kota Salatiga Elise Garmelia; Maulida Sholihah
Jurnal Rekam Medis dan Informasi Kesehatan Vol 2, No 2 (2019): Oktober 2019
Publisher : Poltekkes Kemenkes Semarang

One of the factors causing the inaccuracy of writing diagnosis code is sometimes doctors do not write the diagnosis in the complete form so that medical record errors occur in determining the diagnosis code. Based on preliminary studies that researchers have done in UPTD RSUD Salatiga, the researchers found the results of encoding gastroenteritis disease is inappropriate. Researchers took a random sample, from 8 medical records of patients with BPJS gastroenteritis inpatient there were 6 medical records showing the inaccuracy of encoding diagnosis with 75% percentage of incorrect code and there was different writing of gastroenteritis diagnosis on admission discharge form and discharge summary form.The purpose of this study to determine the accuracy of coding disease gastroenteritis. The type of the research is descriptive quantitative research using cross sectional approach. The population in this research is medical record of inpatients of BPJS gastroenteritis case in january 2017 until october 2017, with the sample of 82 medical record by using simple random sampling method.The results showed the percentage of appropriateness of writing diagnosis on the outline forms form outgoing and returning home is 93.9%, the percentage of accuracy of gastroenteritis disease code is 91.5% and the percentage of appropriateness of diagnosis with the result of laboratory examination is 89%. Factors affecting the inaccuracy of coding results are that medical personnel (physicians) write incomplete and incompatible patients' diagnostic diagnosis of the form sheet, the coder does not check the results of the laboratory to determine the correct code, the lack of update activity of the ICD-10 coding latest version.Of these factors can affect the quality of medical records with the results of coding, claims results and analysis of hospital reporting data.

Gambaran Waktu Penyediaan Dokumen Rekam Medis di Puskesmas Karang Pule Kota Mataram Maria Yovita; Uswatun Hasanah; Reni Chairunnisah
Jurnal Rekam Medis dan Informasi Kesehatan Vol 2, No 2 (2019): Oktober 2019
Publisher : Poltekkes Kemenkes Semarang

The time for the provision of medical record documents from when the patient registers until the medical record documents are provided or found by officers with a minimum standard of service is 10 minutes. The purpose of this study was to determine the time description of the supply of medical record documents at the Karang Pule Health Center in Mataram City. The research design used is descriptive. The population in this study was 200 medical record documents with a total sample of 67 documents. The sampling technique used is accidental sampling. The results showed that the frequency distribution of old patient medical record documents 65 and new patient medical record documents 2. The average time needed to provide medical records for old patients is 1 minute 29 seconds and new patients 2 minutes 29 seconds. The average length of time for providing medical records in TPP is 51.65 seconds, Filling 17.64 seconds, 32 seconds distribution. Based on these results it can be concluded that when providing medical record documents at the Karang Pule Puskesmas it has met the minimum service standards, it is recommended to the Karang Pule Puskesmas to maintain and improve service quality.

Analisis Kelengkapan Rekam Medis Rawat Inap Rumah Sakit Ganesha Di Kota Gianyar Tahun 2019 Ni Luh Putu Devhy; Anak Agung Gede Oka Widana
Jurnal Rekam Medis dan Informasi Kesehatan Vol 2, No 2 (2019): Oktober 2019
Publisher : Poltekkes Kemenkes Semarang

Hospital is an organization engaged in services, therefore it is obliged to hold a medical record for the achievement of good administration. Registration, data filling, processing and analysis as well as documentation, this is the process of organizing medical records. Filling in the medical record is said to be good if each item on the medical record sheet is filled with complete data. A complete medical record is a quality image of a hospital.Based on the above background, the researcher wants to find out the percentage of completeness of medical record filling in the inpatients of Ganesa hospital in the city of Gianyar. This type of research is a descriptive study with a cross-sectional design. The sample in this study was 95 inpatient medical record files. Percentage of completeness for RM Patient identity is 100%, doctor's identity is 96.8%, nurse's identity is 85.3%, informed consent is 95.8%, anesthesia is 43.2%, resume is 100%, diagnosis is 100%, abbreviations of 66.3%, readability of 76.8%, rectification of 23.2% and structuring of 100%. The incompleteness in filling the inpatient medical record at the Ganesha Gianyar Hospital was highest in the correction item.

Identifikasi Penerapan Family Numbering System di Puskesmas Wilayah Dinas Kesehatan Kota Surakarta Harjanti Harjanti; Astri Sri Wariyanti
Jurnal Rekam Medis dan Informasi Kesehatan Vol 2, No 2 (2019): Oktober 2019
Publisher : Poltekkes Kemenkes Semarang

Implementation of numbering in the Health District of Dinas Kesehatan Kota Surakarta 1 applies Personal Numbering and 16 health centers implement Family Numbering. The number classification used is 8 digits consisting of 2 initial digits as a regional code, 4 digits as the serial number of the head of the family, 2 digits of the final digit status in the family. However, in the implementation of area code numbering, it has not yet been utilized for the index, but it has not been used for mapping the spread of disease, even if it is used, it helps in making decisions in reducing morbidity. The qualitative analysis research method is a case study approach. Samples of 16 puskesmas with purposive sampling technique. Data collection is done by observation, interview, documentation study and Focus Group Discussion (FGD). The results of the numbering research in the Surakarta City Health Department Area Health Center consists of 8 and 10 digits. Classification of 2 digits area / village / kelurahan code, 4-6 digits sequence number of head of family, final 2 digits of family status code / sequence of visits in one family. The difference in the middle number is due to the different number of patient visits. Utilization of number classification is used to facilitate storage, the percentage of visits, mapping the spread of disease. Policy should be made regarding the implementation of numbering in accordance with the agreement, namely numbering the Unit Numbering Sytem or Family Numbering with personal indexes and the use of 2 digit front numbers and 2 digit final numbers as needed. A tracer is needed to reduce misfolders with data on medical record numbers, patient names, loan dates and borrowing units.

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Home Page

OAI Link

Editorial Team

Contact

Reviewer

Google Scholar

Contact Name Prasko

Contact Email prmik@poltekkes-smg.ac.id

Phone +622476479188

Journal Mail Official rmik@poltekkes-smg.ac.id

Editorial Address Jl. Tirto Agung, Pedalangan, Banyumanik, Semarang, Jawa Tengah 50268

Location Kota semarang, Jawa tengah INDONESIA

Abstract

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Abstract

Contact Name
Prasko

Contact Email
prmik@poltekkes-smg.ac.id

Phone
+622476479188

Journal Mail Official
rmik@poltekkes-smg.ac.id

Editorial Address
Jl. Tirto Agung, Pedalangan, Banyumanik, Semarang, Jawa Tengah 50268

Location
Kota semarang,

Jawa tengah

INDONESIA