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Prasko
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prmik@poltekkes-smg.ac.id
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+622476479188
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rmik@poltekkes-smg.ac.id
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Jl. Tirto Agung, Pedalangan, Banyumanik, Semarang, Jawa Tengah 50268
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Kota semarang,
Jawa tengah
INDONESIA
Jurnal Rekam Medis dan Informasi Kesehatan
ISSN : 26221863     EISSN : 26227614     DOI : https://doi.org/10.31983/jrmik.v2i1.4391
Core Subject : Health,
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.
Articles 96 Documents
Analisis Kebutuhan Sumber Daya Manusia Rekam Medis di Unit Filing Rizki Fadila
Jurnal Rekam Medis dan Informasi Kesehatan Vol 2, No 1 (2019): MARET 2019
Publisher : Poltekkes Kemenkes Semarang

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (567.902 KB) | DOI: 10.31983/jrmik.v2i1.4049

Abstract

Peningkatan jumlah kunjungan pasien di RS Permata Bunda Malang menyebabkan penambahan beban kerja pegawai terutama petugas Rekam Medis di Unit Filing. Jumlah SDM di Unit Filing RS Permata Bunda Malang saat ini adalah 4 orang dengan kondisi ruangan Filing yang kurang memadai atau sempit serta kurangnya fasilitas rak penyimpanan dokumen rekam medis, sehingga pada saat pengambilan DRM, beberapa kali didapati petugas harus bekerja melebihi jam kerja. Penelitian ini bertujuan untuk mengetahui besarnya beban kerja perekam medis yang ada di unit Filing Rumah Sakit Permata Bunda, selanjutnya beban kerja digunakan untuk menganalisis kebutuhan jumlah tenaga perekam medis di Unit Filing Rumah Sakit Permata Bunda. Penelitian ini menggunakan pendekatan kualitatif dengan melakukan observasi, wawancara mendalam dan menggunakan teknik work sampling. Hasil penelitian didapatkan bahwa penggunaan waktu kerja staf untuk aktivitas produktif rata-rata 82,13%, aktivitas non produktif rata-rata 5,13% dan aktivitas pribadi 12,57%. Hasil perhitungan tenaga kerja dengan metode WISN didapatkan jumlah kebutuhan tenaga Perekam Medis di Unit Filing seharusnya adalah 6 orang dengan ratio 0,67. Dengan demikian sesuai dengan beban kerja yang ada, perlu adanya penambahan tenaga Perekam Medis di Unit Filing Rumah Sakit Permata Bunda Malang sebanyak 2 orang. 
Efektifitas Penempatan Penanggung Jawab Rekam Medis Pada Setiap Bangsal Terhadap Pengelolaan Rekam Medis Subinarto Subinarto; Monalisa Monalisa; Anton Kristijono
Jurnal Rekam Medis dan Informasi Kesehatan Vol 2, No 1 (2019): MARET 2019
Publisher : Poltekkes Kemenkes Semarang

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (253.698 KB) | DOI: 10.31983/jrmik.v2i1.4638

Abstract

Rekam Medis merupakan bagian yang sangat penting dalam suatu sarana pelayanan jesehatan karena rekam medis memuat segala informasi selama pasien diberikan perawatan di sarana pelayanan kesehatan. Penanggung Jawab Rekam Medis (PJRM) adalah perekam medis yang ditempatkan di bangsal untuk mengerjakan kegiatan rekam medis ketika pasien masih dirawat. Dampak jika tidak adanya perekam medis di bangsal adalah menumpukknya rekam medis di unit kerja rekam medis, kejadian overcost yang tinggi, pelayanan yang tidak terkontrol, ketidak lengkapan rekam medis tinggi. Penelitian ini adalah analisis kuantitatif, dengan rancangan cross sectional yaitu, untuk mengetahui efektifitas dari penanggung jawab rekam medis yang berada di setiap bangsal terhadap pengelolaan rekam medis artinya setiap subyek penelitian diobservasi, faktor risiko serta dampak diukur menurut keadaan atau status pada saat observasi dan seberapa besar potensi kerugian atau keuntungan yang akan diterima oleh rumah sakit.
Sistem Informasi Pencatatan dan Pelaporan Pelayanan Kesehatan Berbasis Android di Kawasan Terpencil dan Sangat Terpencil Syefira Salsabila
Jurnal Rekam Medis dan Informasi Kesehatan Vol 2, No 1 (2019): MARET 2019
Publisher : Poltekkes Kemenkes Semarang

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (341.146 KB) | DOI: 10.31983/jrmik.v2i1.3962

Abstract

Health care is the right of every community to get service without exception, even though it is in an area that is difficult to reach due to geographical access. Mobile Health Services (PKB) is one of the innovations in equitable health services in remote and very remote areas. The process of recording and processing data is generally held also on PKB is still done manually. Recording that is still running in handwriting causes many obstacles in the process of processing, searching, and making reports on health service activities. The purpose of this study is to identify and develop information systems for recording and reporting on maternal and child health service activities at PKB. This research method uses Action Research. This design was chosen because it would delve deeply into the process and management of the development of Android-based applications for PKB. The results of this study present that the use of android-based mobile phones as a tool in data collection for the implementation of recording and reporting of mother and child activities can be carried out offline. This prototype information system made the process more efficient in term of time, especially when the data is uploaded to a properly administered server, makes the data much more secure, more effective to use for mobile health clinic team or health provider for data reporting.
Tinjauan Pelaksanaan Pemberian Kode Diagnosa dan Tindakan pada Pasien Rawat Inap Irmawati Irmawati; Sugiharto Sugiharto; Rozalia Mayasari
Jurnal Rekam Medis dan Informasi Kesehatan Vol 2, No 1 (2019): MARET 2019
Publisher : Poltekkes Kemenkes Semarang

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (203.29 KB) | DOI: 10.31983/jrmik.v2i1.4397

Abstract

Penelitian ini menggunakan penelitian deskriptif dengan pendekatan cross sectional melalui kuesioner yang diberikan kepada semua petugas koding rawat inap dan checklist yang untuk prosedur dan sarana prasarana koding. Penelitian dilakukan di Bagian Koding Rawat Inap RSUD Kota Salatiga pada bulan Mei - Juni. Analisis data menggunakan analisis univariate yaitu berupa distribusi frekuensi.Berdasarkan hasil penelitian, semua petugas koding rawat inap di RSUD Kota Salatiga berlatar belakang pendidikan DIII Rekam Medis dan sudah pernah mengikuti pelatihan tentang koding. Semua petugas koding rawat inap RSUD Kota Salatiga memiliki pengetahuan dan sikap yang baik dalam pelaksanaan pemberian kode diagnosa dan tindakan. Namun kelengkapan sarana prasarana koding bagi setiap petugas koding belum lengkap serta kepatuhan melaksanakan prosedur koding belum sesuai dan belum semua dilaksanakan.AbstractThis research uses descriptive research with cross sectional approach through a questionnaire given to all officers inpatient coding and checklist for procedures and infrastructure coding. Research conducted at the Hospital Inpatient Coding Part of Salatiga in May-June. Data analysis using univariate analysis in the form of a frequency distribution.Based on the results of the study, all officers in the hospital inpatient coding Salatiga educational background DIII Medical Records and have completed training on coding. All inpatient hospital coding clerk in RSUD Kota Salatiga have knowledge and a good attitude in the implementation of the diagnose and the procedure code. However, the completeness of the infrastructure coding for each officer incomplete coding and compliance implement coding procedure is not appropriate and not all implemented.
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

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (285.53 KB) | DOI: 10.31983/jrmik.v2i2.5359

Abstract

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 Peramalan Jumlah Penderita Hipertensi pada Lansia di Kabupaten Malang Menggunakan Metode Arima Box-Jenkins Nanta Sigit; Arief Setiyoargo
Jurnal Rekam Medis dan Informasi Kesehatan Vol 3, No 1 (2020): Maret 2020
Publisher : Poltekkes Kemenkes Semarang

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (22.76 KB) | DOI: 10.31983/jrmik.v3i1.5578

Abstract

Changes in the elderly in developed countries, namely changes in the cardiovascular system which is a major disease that takes its toll because it will affect other diseases such as hypertension, coronary heart disease, pulmonic heart, cardiomyopathy, stroke, kidney failure.Hypertension or high blood pressure is a medical condition where people whose blood pressure rises above normal is 140/90 mmHg and can run the risk of morbidity and even death. Risk factors for hypertension are divided into 2 groups, namely hypertension that cannot be changed and hypertension that can be changed. Modifiable hypertension includes smoking, obesity, a monotonous lifestyle and stress. Hypertension that can not be changed include age, gender, ethnicity, heredity. So this time the researchers tried to predict hypertension sufferers in Malang using the Jenkins ARIMA Box model. Researchers hope that forecasting methods and forecasting results can be used as additional information for the health department in Malang district in determining policies to be taken in the prevention of hypertension patients according to the needs of patients in Malang district.AbstrakHipertensi merupakan sebuah kondisi medis dimana orang yang tekanan darah meningkat diatas normal yaitu 140/90 mmHg dan hipertensi dapat mengalami resiko kesakitan (morbiditas) bahkan kematian (mortalitas). Dalam rangka membuat perencanaan menurunkan jumlah penderita hipertensi di daerah dengan prinsip efektif dan bertanggung jawab diperlukan perkiraan peramalan yang valid. Adanya selisih yang relatif cukup besar antara target dan capaian dalam menanggulangi penderita hiperteni Kabupaten Malang selama tahun 2014 - 2019, dan mengingat pentingnya peramalan sebagai indikator menurunkan penderita hipertensi, maka dipandang perlu melakukan penelitian mengenai penerapan model Box-Jenkins dalam peramalan penderita hipertensi. Penelitian ini bertujuan untuk membuat model estimasi penderita hipertensi kabupaten malang dengan mengunakan data dinkes dari tahun 2014 sampai dengan tahun 2019.Teknik analisis yang diterapkan adalah model Box-Jenkins atau Autoregresive Integreted Moving Average (ARIMA). Hasil penelitian menunjukkan bahwa dengan menggunakan data dinas kesehatan kabupaten malang tahun 2014 sampai dengan tahun 2019, disimpulkan bahwa model peramalan yang terbaik adalah dengan ARIMA(1,0,1). Peneliti berharap metode peramalan dan hasil peramalan tersebut dapat digunakan sebagai tambahan informasi bagi pihak dinas kesehatan di kabupaten malang dalam menentukan kebijakan yang harus diambil dalam pencegahan penderita hipertensi sesuai kebutuhan pasien di kabupaten Malang.
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

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (317.629 KB) | DOI: 10.31983/jrmik.v2i2.5348

Abstract

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

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (342 KB) | DOI: 10.31983/jrmik.v2i2.5355

Abstract

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.
Studi Deskriptif Kelengkapan Dokumen Rekam Medis Ika Setya Purwanti; Diah Prihatiningsih; Ni Luh Putu Devhy
Jurnal Rekam Medis dan Informasi Kesehatan Vol 3, No 1 (2020): Maret 2020
Publisher : Poltekkes Kemenkes Semarang

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (370.516 KB) | DOI: 10.31983/jrmik.v3i1.5194

Abstract

Medical records are files that contain records and patient identify documents, the results of examination treatments, action, and services that have been provided. The completeness of filling in the medical record file can make it easier for other health workers to provide patient action or treatment, and can be used as a useful source of information for hospital management in determining the evaluation and development of health services. The purpose of this research was to study the complete picture of medical record documents at Sanjiwani General Hospital, Gianyar. This research is a quantitative study using the checklist in accordance with Permenkes RI No. 269/Menkes/Per/III/2008. The method used in this study was observation using cross sectional and restrospective data collection. The results of this study indicate that the completeness of the medical record from the patients identity, the identity of the doctor, the identity of the nurse shows a completeness of 100% and the completeness of the information was 64,1%. Analysis of data from this research used descriptive methods. So that it is expcted from the results of this study to maintain the awareness and discipline of the officers responsible for filling out medical record in accordance with predetermined procedures.AbstrakRekam medis adalah berkas yang berisi catatan dan dokumen identitas pasien, hasil pemeriksaan, pengobatan, tindakan dan pelayanan yang telah diberikan. Kelengkapan pengisian berkas rekam medis dapat memudahkan tenaga kesehatan lain dalam memberikan tindakan atau pengobatan pasien, dan dapat dijadikan sebagai sumber informasi yang berguna bagi manajemen rumah sakit dalam menentukan evaluasi dan pengembangan pelayanan kesehatan. Tujuan penelitian ini adalah untuk mengetahui gambaran kelengkapan  rekam medis di RSUD Sanjiwani, Gianyar. Penelitian ini merupakan penelitian kuantitatif dengan menggunakan Check list sesuai dengan Permenkes RI No. 269/Menkes/Per/III/2008. Metode yang digunakan dalam penelitian ini adalah observasi dengan pendekatan cross sectional dan pengambilan datanya secara retrospektif. Hasil dari penelitian ini menunjukkan bahwa kelengkapan rekam medis dari kelengkapan identitas pasien, kelengkapan identitas dokter, kelengkapan identitas perawat menunjukkan kelengkapan rekam medis sebesar 100% sedangkan kelengkapan inform concern sebanyak 64,1%. Analisis data dalam penelitian ini menggunakan metode deskriptif. Dari hasil penelitian ini diharapkan agar rumah sakit dapat mempertahankan kesadaran dan kedisiplinan petugas yang bertanggung jawab dalam pengisian rekam medis sehingga sesuai dengan prosedur yang telah ditetapkan.
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

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (161.573 KB) | DOI: 10.31983/jrmik.v2i2.5349

Abstract

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.

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