Jurnal Rekam Medis dan Informasi Kesehatan
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.
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"Vol 5, No 1 (2022): Maret 2022"
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<![CDATA[Perancangan Prototipe Aplikasi e-Incident Berbasis Android di Rumah Sakit PKU Muhammadiyah Gamping ]]>
<![CDATA[Dian Herawati]]>;
<![CDATA[Nia Fararid Askar]]>;
<![CDATA[Dinar Nugroho Pratomo]]>
<![CDATA[ Jurnal Rekam Medis dan Informasi Kesehatan Vol 5, No 1 (2022): Maret 2022 ]]>
Publisher : <![CDATA[Poltekkes Kemenkes Semarang ]]>
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DOI: 10.31983/jrmik.v5i1.8403
<![CDATA[Recording and reporting of accidents and occupational diseases is a part of health information system that must be owned by the hospital. One of the efforts to achieve zero accidents is to take advantage of information technology such as android in increasing the effectiveness of recording and reporting OHS incident. The purpose of the study was to analyze the needs and create a prototype of an android based application. This research is qualitative with research and development design. The results show that it is necessary to add an incident reporting component related to hazardous and toxic substances. The application can answers the problems such as the delay in manual reporting and the documents are still fragmented. An e-incident application has a menu for reporting incidents, occupational diseases, and hazardous toxic substances. The menus have been made in accordance with OHS incident reporting standards in hospitals. The conclusion is that an android based e-incident application prototype has been made and can be accepted by users because it provides convenience and accuracy of data in OHS reporting in hospitals.]]>
<![CDATA[Pengaruh Pembuatan Tutorial Terhadap Peningkatan Pemahaman Petugas Rekam Medis di Fasilitas Pelayanan Kesehatan tentang Pengisian Data pada Aplikasi SIDeKa-Pro ]]>
<![CDATA[Hikmawan Suryanto]]>;
<![CDATA[Madihah Madihah]]>
<![CDATA[ Jurnal Rekam Medis dan Informasi Kesehatan Vol 5, No 1 (2022): Maret 2022 ]]>
Publisher : <![CDATA[Poltekkes Kemenkes Semarang ]]>
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DOI: 10.31983/jrmik.v5i1.8363
<![CDATA[Medical record officers who are late in filling out data on SIDeKa-Pro application in 2020 are 53% and for January-March 2021 period are 31%. They were late in filling because there was no procedure and did not understand how to fill in the data. The purpose of this study was to determine the effect of making tutorials in the form of manuals and video tutorials on the level of understanding of medical record officers in health care facilities about data entry in the SIDeKa-Pro application. The research design used pure experimental, namely one group pretest and posttest experimental research. The population and sample are medical record officers who are in charge of data entry in SiDeKa-Pro application, as many as 24 people. The sampling technique used was purposive sampling. The results of the Wilcoxon test, the p-value is 0.000 (p-value 0.05). It can be concluded that there is an influence between the provision of tutorials in the form of manuals and videos on the level of understanding of health care facility managers about data entry in the SIDeKa-Pro application. The conclusion is that making tutorials has an effect on increasing the understanding of medical record officers in health care facilities.]]>
<![CDATA[Tinjauan Pelaksanaan Prosedur Pelepasan Informasi Rekam Medis untuk Klaim Asuransi Non-JKN di RSUD dr. R. Soetrasno Rembang ]]>
<![CDATA[Bayu Eko Wahyudi]]>;
<![CDATA[Rizkiyatul Amalia]]>
<![CDATA[ Jurnal Rekam Medis dan Informasi Kesehatan Vol 5, No 1 (2022): Maret 2022 ]]>
Publisher : <![CDATA[Poltekkes Kemenkes Semarang ]]>
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DOI: 10.31983/jrmik.v5i1.8422
<![CDATA[The use of medical records for reimbursement of medical expenses or insurance claims that state the identity of the patient must obtain written consent from the patient or his heirs. Based on preliminary observations at RSUD dr. R. Soetrasno Rembang, it is known that 24 requests for medical record information for non-JKN insurance claims from April to June 2020, 75% of which found requests that did not comply with standard operating procedures, namely the absence of patients’ written consent. The purpose of this study was to describe the implementation of the procedure for releasing medical record information for non-JKN insurance claims at RSUD dr. R. Soetrasno Rembang. This type of research is descriptive qualitative. Data collection methods used are observation and interviews. The subjects of this study were information release officers, medical record unit management, insurance agent and part of the process of releasing medical record information. Data analysis used is non-statistical analysis technique. The results showed the implementation of procedure for releasing medical record information for non-JKN insurance claims at RSUD dr. R. Soetrasno Rembang is not accordance with the SOP, there are procedures that are not followed, namely requests for release of information are still being served even though they do not attach written consent from the patient.]]>
<![CDATA[Tinjauan Penyelesaian Dispute Klaim Rawat Inap Pasien Coronavirus Disease 2019 (COVID-19) di RSUD Ajibarang Tahun 2020 ]]>
<![CDATA[Eliyah Eliyah]]>;
<![CDATA[Aulia Ughti Ratriana]]>
<![CDATA[ Jurnal Rekam Medis dan Informasi Kesehatan Vol 5, No 1 (2022): Maret 2022 ]]>
Publisher : <![CDATA[Poltekkes Kemenkes Semarang ]]>
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DOI: 10.31983/jrmik.v5i1.8394
<![CDATA[Dispute claim are disagreement between BPJS Kesehatan and health facilities over claims caused by coding or medical. The dispute becomes a workload for the claim submission officers and affects the hospital revenue. We found that there 66 files in dispute category at RSUD Ajibarang in April-July 2020 with a percentage of 50,8%. The purpose of this study is to analyze the causes of disputed claims for inpatient treatment based on inputs and processes, to find the solution overview. This research uses a qualitative descriptive method with case study approach and the research subjects are 4 people. The research on human resources and facilities showed relatively good conditions. Regarding the technological factor, SIMRS development is needed, the planning factor requires the creation of a special SOP to handle the COVID-19 claim dispute issue and the claim process implementation factor is seen from the flow that is in accordance with existing regulations, an introduction to the procedure for inputting COVID-19 claims is needed on INA-CBG's application. So, it can be concluded that it is necessary to prepare SOP related to disaster cases in collecting claims in the INA-CBG's application and providing human resources who have special competencies for medical recorders.]]>
<![CDATA[Tinjauan Ketepatan Kode dengan Pending Klaim Pasien Rawat Inap BPJS Kesehatan di RSUD dr. Adnaan Wd Payakumbuh Tahun 2021 ]]>
<![CDATA[Oktamianiza Oktamianiza]]>;
<![CDATA[Isya Apda Reza]]>;
<![CDATA[Dian Novita]]>
<![CDATA[ Jurnal Rekam Medis dan Informasi Kesehatan Vol 5, No 1 (2022): Maret 2022 ]]>
Publisher : <![CDATA[Poltekkes Kemenkes Semarang ]]>
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DOI: 10.31983/jrmik.v5i1.8397
<![CDATA[The accuracy of the coding of a diagnosis is influenced by the clarity of writing and the completeness of the diagnosis. The right diagnosis will produce the right code data as well. If there is an error in coding, this will have an impact on claims for health care costs. This research was conducted at the Regional General Hospital dr. Adnaan WD Payakumbuh. This type of research is descriptive qualitative with in-depth interviews with the head of the medical record installation, inpatient coder, and case mix officers. The results showed that there were 3 human resources related to coding with educational qualifications of D3 Medical Record, coding SOPs and case mix SOPs already existed and had been implemented, the implementation of coding training was carried out, the implementation of the disease diagnosis code was still constrained because the resume did not match the status. , insufficient supporting data, and incorrect placement of primary and secondary diagnoses, it takes several days for the revision of pending claims to be carried out to the doctor in charge of the patient (DPJP). In addition, the coder still has difficulty in reading the doctor's diagnosis, thus affecting the quality of the code and having an impact on pending claims.]]>
<![CDATA[Literature Review Faktor Penyebab Keterlambatan Penyediaan Rekam Medis Rawat Jalan ]]>
<![CDATA[Arief Tarmansyah Iman]]>;
<![CDATA[Nursanie Puspita]]>
<![CDATA[ Jurnal Rekam Medis dan Informasi Kesehatan Vol 5, No 1 (2022): Maret 2022 ]]>
Publisher : <![CDATA[Poltekkes Kemenkes Semarang ]]>
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DOI: 10.31983/jrmik.v5i1.7962
<![CDATA[The provision of outpatient Medical Records (MR) affects the length of waiting time for patient services. The time of providing outpatient MR in several hospitals was more than the standard average time of ≤10 minutes. This study aims to analyse the factors causing the delay in providing outpatient medical records. Method: The research design was systematic review uses Google Scholar and Garuda Databases with topics related to factors causing delays in the provision of outpatient MR. Two reviewers were screening and found articles which match the criteria and have 13 full-length articles included to final review. The average time for providing outpatient MR was in range of 11-20 minutes. The causes of delays in providing outpatient MR were grouped based on 5M factors including lack of MR educated officers, indiscipline, lack of knowledge, train and motivation (Man), unavailability of funds (Money), unavailability of MR, storage and folder, easily damaged material, infrastructure unavailability and technical problems (Machine), as well as unavailability and not maximized SOP use, no evaluation and outpatient registration flow (Method). The time delay in providing outpatient MR was still high, the main cause was the unavailability of infrastructure and the lack of MR educated officers. ]]>
<![CDATA[Analisis Pelaksanaan SIMRS pada Unit Kerja Rekam Medis dengan Metode Technology Acceptance Model (TAM) ]]>
<![CDATA[Deni Maisa Putra]]>;
<![CDATA[Chairunnisa Mufli Hunna]]>;
<![CDATA[Washi Fadhila]]>
<![CDATA[ Jurnal Rekam Medis dan Informasi Kesehatan Vol 5, No 1 (2022): Maret 2022 ]]>
Publisher : <![CDATA[Poltekkes Kemenkes Semarang ]]>
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DOI: 10.31983/jrmik.v5i1.8401
<![CDATA[Hospital Management Information System (SIMRS) is an application system used in the management of hospital services aimed at improving health services. The success of an information system depends on how users are willing to accept and use it to achieve organizational goals. The purpose of this study was to find out how the SIMRS was implemented in the medical record work unit with the TAM method. The method used in this study is a literature study to examine journals regarding the implementation of SIMRS in the medical record work unit with the tam method, the data collection used is using secondary data and analyzed descriptively by describing the existing facts, data analysis was carried out by looking for similarities, dissimilarities, views, summaries of several studies. The results of the 12 literature study journals show that in terms of the SIMRS components, they are not adequate and sufficient in providing services. The acceptance of the system by the user from the aspect of usefulness and the aspect of ease of knowing that the information system is already useful for users and easy to operate. The acceptance of the system from the attitude of the user is quite satisfied with the existence of the information system. Acceptance of information systems from the user's behavioral intentions assume good and have a desire to motivate other users. In addition, the acceptance of information systems depends on the real conditions of users where the information system increases their productivity which is reflected in the real conditions of use. To maintain user acceptance of the information system, it is hoped that the hospital will conduct regular training to improve user skills in order to avoid errors that can arise in the future and the hospital must meet the information system components to support the implementation of SIMRS]]>
<![CDATA[Evaluasi Implementasi Sistem Informasi Manajemen Rumah Sakit (SIMRS) di Pelayanan Rawat Jalan RSUD dr. Gondo Suwarno Ungaran Menggunakan Metode Unified Theory of Acceptance and Use of Technology (UTAUT) ]]>
<![CDATA[Setya - Wijayanta]]>
<![CDATA[ Jurnal Rekam Medis dan Informasi Kesehatan Vol 5, No 1 (2022): Maret 2022 ]]>
Publisher : <![CDATA[Poltekkes Kemenkes Semarang ]]>
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DOI: 10.31983/jrmik.v5i1.8277
<![CDATA[RSUD dr Gondo Suwarno Ungaran has used the SIMRS application in every unit, including the medical record section, but there are problems that arise in the application of the system, namely the use of the system is still low on sustainable information systems and there are still staff who do not know and understand in utilizing the Hospital Management Information System. In outpatient services there is often duplication of data and inaccuracies in patient data. The research method used is quantitative research using a survey approach and analyzed using SmartPLS software. This evaluation uses the UTAUT method. The results of this study are: The effect of the PE variable on BI has a parameter coefficient value of 0.260 and a tstatistic value of 1.169*. The effect of the EE variable on BI has a parameter coefficient value of 0.038 and a tstatistic value of 2.027 *. The effect of the SI variable on BI has a parameter coefficient value of 0.089 and a statistical value of 1.795*. The effect of the FC variable on BI has a parameter coefficient value of 0.260 and a tstatistic value of 2.217*. The conclusion of this study is that the independent variables (EE, SI and FC) have a positive and significant effect on the dependent variable (BI), while the variable (PE) has a positive but not significant effect. It can be seen that business expectations, social influences, and facilitating conditions are factors that must be improved because these factors affect officers in using SIMRS. Recommendations for improvement that have been proposed are: To develop (upgrade) the SIMRS application. Perform interoperability/integration of SIMRS with several service units/sections and other applications. Conduct socialization and provide training to officers in the use of SIMRS.]]>
