cover
Contact Name
Alex Rikki, S.Kom.,M.Kom
Contact Email
alexrikisinaga@gmail.com
Phone
+6282275847123
Journal Mail Official
alexrikisinaga@gmail.com
Editorial Address
Jl. Bilal No. 52 Kelurahan Pulo Brayan Darat I Kecamatan Medan Timur, Medan - Sumatera Utara Telp : (061) 66455670
Location
Kota medan,
Sumatera utara
INDONESIA
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI)
ISSN : 25027786     EISSN : 25977156     DOI : https://doi.org/10.2411/jipiki
Core Subject : Health,
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) (p-ISSN : 2502-7786 ) (e-ISSN : 2597-7156) is a national, peer-reviewed journal. It publishes original papers, reviews and short reports on all aspects of the medical record and health information. 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 12 Documents
Search results for , issue "Vol. 6 No. 1 (2021): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Februari" : 12 Documents clear
Analisis Kelengkapan Formulir A (Evaluasi Awal MPP) Dan Formulir B (Catatan Implementasi) Pasien Rumah Sakit Dicho Zhuhriano Yasli; Devid Leonard; Berly Nisa Srimayarti
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Vol. 6 No. 1 (2021): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Februari
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v6i1.469

Abstract

Completeness of the Inpatient Examination Form is a problem that often causes complaints in several hospitals. The purpose of this study was to conduct a literature review related to the incomplete analysis of filling in form A, MPP Initial Evaluation and Form B Implementation Notes. The collection method is secondary data, the steps are determining keywords, exploration and title selection, reading articles that have not been eliminated. At that stage, the reference list of selected articles is reviewed to determine other related studies. The articles contained in the summary list The results of the literature review, namely, still found incompleteness in filling out medical record forms, the responsibilities and attitudes of officers in filling out medical record files can be said to be still not optimal. The human resources involved are still lacking, for example the assembling officer also serves the file preparation so that the assembly function is not optimal. Based on the literature review of several related articles, further research is needed on other causes of incompleteness in filling out medical record file forms and the obstacles experienced by doctors in filling out medical record files.
Tinjauan Pelaksanaan Kerahasiaan Rekam Medis Di Puskesmas Kuranji Padang Deni Maisa Putra; Rahmadhani
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Vol. 6 No. 1 (2021): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Februari
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v6i1.473

Abstract

The medical record is also a documentation of the patient's condition and the contents of the medical record are medical secrets, especially in the storage of status in the filling room, which must be kept confidential, secure, and the medical record layout, whether it is appropriate or not by every health worker. The purpose of this study was to determine the Knowledge Review and Attitudes of Officers and Patients on the Confidentiality of Medical Record Files Primary Health Center at Kuranji Padang. This type of research is descriptive with a quantitative approach, the research sample is 90 patients and 4 health center officers using accidental sampling technique with data collection using questionnaires for patients and table cklis for officers. The results showed that there are still officers whose knowledge and attitude in maintaining the confidentiality of medical records (50%) or 2 people are still lacking and more than half of the knowledge (51.1%) and attitudes (52.2%) of patients towards maintaining the confidentiality of record files medical who do not understand and know. It can be concluded that Kuranji Primary Health Center, both patients and officers, is still lacking in maintaining the confidentiality of medical records. It is hoped that the head of the Primary Health Center will prepare Standard Operating Procedures (SOP) on medical records so that officers and patients know about medical records and about the confidentiality of medical records. In implementing the confidentiality of medical records, competent and professional medical record officers should know and understand more about medical records, participate in training and provide information to patients so that the confidentiality of medical records is maintained and can create good service.
Tinjauan Pengelolaan Data Berbasis Digital Bagian Registrasi Pendaftaran Di RSUP Haji Adam Malik Medan Puput Melati Hutauruk; Khairani
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Vol. 6 No. 1 (2021): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Februari
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v6i1.474

Abstract

Data management is a data place that will become information which will later become health information. Where patient registration if done manually will be slow automatic management of data will have an impact on the quality of hospital services. Therefore digitization is required. The purpose of this study was to see how the implementation of digital-based data management at RSUP H. Adam Malik Medan. Subjects in this study were registration officers who entered 7 people, with the object being not 5M. This research was conducted with a descriptive method with a qualitative approach. Instrumentation of interview data and observation checklist. With the TOTAL 3 informants. The data analysis used in this research is descriptive qualitative to describe the implementation of data management. Based on the results of the research that there is no one who is not in accordance with the competence, the money is not yet available and adequate, the method is appropriate but has not worked well, the machine is not as expected while the material is in accordance with the competence. Suggestions from researchers are that officers should distribute leaflets (paper leaflets) to the public so that the public can register via cellphones (cellular) and that officers should change the internet speed to MBPS so that the registration process does not occur sluggishly.
Tinjauan Pelaksanaan Review Berkas Rekam Medis Sesuai Standar Manajemen Informasi Dan Rekam Medik (MIRM 13.4) Di Rumah Sakit Imelda Pekerja Indonesia Tahun 2020 Esraida Simanjuntak; Mustamil Alwi Dasopang
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Vol. 6 No. 1 (2021): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Februari
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v6i1.476

Abstract

One of the parameters for determining the quality of health services in the hospital is data or information from good and complete medical records. Medical records are an important part of helping the implementation of service delivery to patients at the hospital. Standards relating to medical records in SNARS Edition 1 are in the group of hospital management standards, namely Medical Record Information Management (MIRM) regarding medical record document processing including provision, filling of medical records and reviewing medical records. This research method is descriptive with the method of observation. When this research was conducted in July 2020 at the Imelda Hospital Worker Indonesia Medan. The population taken was 705 medical record documents while the sample in this study was 87 medical record documents. Based on the results of the study, in the review the accuracy of returning medical record documents was 57.4% and 42.5% were incorrect. Readability review of ER assessment as much as 63.2%, assessment of Inpatient as much as 56.3%, CPPT as much as 60.9%, approval for action as much as 77%, reports of anesthesia as much as 68.9%. 3 forms of completeness review are complete, namely Education Assessment, rejection and education form (100%). Suggestions in this study are that review officers must be more assertive to remind every doctor or other medical personnel to pay attention to the accuracy of the restoration, the legibility of medical record files and the completeness of medical record documents. As well as regularly socializing the elements of the MIRM 13.4 assessment.
Ketidaktepatan Kode Diagnosis Kasus Neoplasma Menggunakan ICD-10 Di RSUP H.Adam Malik Medan Tahun 2019 Johanna Christy; Evi Efriamta Siagian
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Vol. 6 No. 1 (2021): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Februari
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v6i1.477

Abstract

ABSTRAK Informasi peyakit dirumah sakit tidak akan lengkap dan bermanfaat apabila belum diolah, maka untuk itu perlu dilakukan pengkodean. Penelitian ini bertujuan untuk mengetahui ketepatan kode diagnosis pada kasus neoplasma menggunakan ICD-10 di RSUP. H. Adam Malik tahun 2019. Penelitian ini menggunakan metode kuantitatif dengan pendekatan cross sectional, Jumlah sampel yang digunakan sebanyak 93 dokumen dan 4 orang responden. Ketepatan kode morfologi diagnosis neoplasma diperoleh hasil 88 (95%) kode tepat 6 karakter, 0 (0%) kode tepat 5 karakter, 0 (0%) kode tepat 4 karakter, 3 (3%) kode tidak tepat sama sekali dan 2 (2%) tidak dikode. Ketepatan kode topografi diperoleh hasil 79 (85%) kode tepat 4 karakter, 8 (9%) kode tepat 3 karakter, 4 (4%) kode tepat 2 karakter, 0 (0%) kode tepat 1 karakter, 0 (0%) kode tidak tepat sama sekali dan 0 (0%) kode tidak dikerjakan. Faktor yang menjadi penyebab ketidaktepatan dalam pengodean adalah petugas coding sulit untuk membaca tulisan dokter sehingga penulis menyarankan sebaiknya dalam pengkodingan diagnosis tetap mengikuti kaidah dan aturan yang ada pada ICD-10. Kata Kunci: Ketepatan, Diagnosis, Neoplasma, Pengkodean Abstract Information for patients in hospitals will not be complete and useful if it has not been processed, so coding is necessary. This study aims to determine the accuracy of the diagnosis code in cases of neoplasm using ICD-10 in RSUP. H. Adam Malik in 2019. This study used a quantitative method with a cross sectional approach. The number of samples used was 93 documents and 4 respondents. The accuracy of the morphological code for the diagnosis of neoplasm was 88 (95%) the code was exactly 6 characters, 0 (0%) the code was exactly 5 characters, 0 (0%) the code was exactly 4 characters, 3 (3%) the code was not correct at all and 2 ( 2%) is not coded. The accuracy of the topographic code is 79 (85%) the code is exactly 4 characters, 8 (9%) the code is exactly 3 characters, 4 (4%) the code is exactly 2 characters, 0 (0%) the code is exactly 1 character, 0 (0%) code is not correct at all and code 0 (0%) is not working. The factor that caused the inaccuracy in coding was that it was difficult for coding officers to read the doctor's writings, so the authors suggested that the coding of the diagnosis should still follow the rules and regulations in the ICD-10. Keywords: Accuracy, Diagnosis, Neoplasm, Encoding
Dampak Penumpukan Dokumen Rekam Medis Terhadap Waktu Pengambilan Dokumen Rekam Medis Di RSU Sinar Husni Medan Valentina; Selvia Sari Ritonga
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Vol. 6 No. 1 (2021): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Februari
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v6i1.478

Abstract

The filling system is one of the administrators of medical records which is responsible for orderly administration in an effort to improve health services in hospitals. Accumulation of medical record documents will affect of work of officers in the filling section. The purpose of this study is to determine the impact of the bildup of medical records documents on the time of taking medical record documents at Sinar Husni Hospital. This research is a descriptive study with a qualitative approach. The population is all filling officers at the Sinar Husni Hospital and all patient medical records calculated on average in the third quarter of 2020, counted 719 documents. The samples in this study were 2 filling officers at the Sinar Husni Hospital and part of the medical record documents totaling 86 medical record documents that were taken incidentally. The instrument used was an interview guide. The measurement of time to take medical record documents uses a stopwatch. Data were analyzed descriptively. The results showed that the accumulation of medical record documents had an impact on the time to take medical record documents at the Sinar Husni Hospital, because the officers had difficulty carrying out filling activities because the access between shelves was narrower and the documents piled on the floor were not properly aligned, with an average of 10.05 minute. We recommend to add more storage space and shelves so that medical record documents that are stacked on the floor can be moved to the storage racks.
Tinjauan Alur Prosedur Pelayanan Pasien Rawat Jalan Peserta BPJS di RSU Imelda Pekerja Indonesia Medan Yeyi Gusla Nengsih
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Vol. 6 No. 1 (2021): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Februari
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v6i1.479

Abstract

Rawat jalan merupakan pelayanan yang diberikan kepada pasien untuk berobat atau keperluan lainnya tanpa tinggal diruang rawat inap rumah sakit. RSU Imelda Pekerja Indonesia Medan juga berpotensi menjadi salah satu rumah sakit rujukan di Kota Medan Sumatera Utara. Tempat pendaftaran rawat jalan RSU Imelda Pekerja Indonesia Medan dimulai dari pendaftaran pasien hingga pasien mendapatkan pelayanan. Berdasarkan survey diketahui bahwa jika pasien BPJS tidak melengkapi persyaratan seperti foto copy KTP dan KK, surat rujukan, foto copy SKP dan foto copy kartu BPJS dalam sehari maka pasien tersebut tidak segera mendapatkan pelayanan lebih lanjut. RSU Imelda Pekerja Indonesia Medan belum mempunyai prosedur pendaftaran secara khusus untuk pasien rawat jalan BPJS sehingga masih sulit untuk menelusuri dokumen rekam medis diruang filling dan juga pendistribusian dokumen rekam medis ke poliklinik masih sangat lama. Hal ini menyebabkan pelayanan pasien BPJS tidak segera terpenuhi. Tujuan penelitian untuk mengetahui alur prosedur pelayanan pasien rawat jalan peserta BPJS. Jenis penelitian yaitu deskriptif, subyek yang diteliti yaitu pasien rawat jalan BPJS dengan obyek penelitian yaitu RSU Imelda Pekerja Indonesia Medan. Instrumen yang digunakan dengan wawancara dan observasi langsung ke lapangan.
Tinjauan Pelaksanaan Sistem Penyimpanan Rekam Medis Berdasarkan Standar Akreditasi Di UPTD Puskesmas Kotanopan Mandailing Natal Zulham Andi Ritonga; Hasran Ependi Lubis
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Vol. 6 No. 1 (2021): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Februari
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v6i1.485

Abstract

Storage of medical records is one of the assessments in puskesmas accreditation standards. The medical record file storage system is very important to do in health care institutions, because the storage system can make it easier for medical record files to be stored in storage racks, speed up the recovery or retrieval of medical record files stored on storage racks, easy to return, and protect record files. from theft, physical, chemical and biological damage. The purpose of this study was to determine how the implementation of a medical record storage system based on puskesmas accreditation standards, which was carried out in August 2020. The research method used was descriptive research with a qualitative approach. The number of research informants was 4 people. Storage of medical records had not used tracers and expedition book as a means of replacing medical record files and notes in and out of borrowed medical record files. Meanwhile, tracer and expedition books can assist officers in searching for missing / out of place medical record files. This can hamper the provision of patient medical record files that are needed. It is hoped that the UPTD Puskesmas Kotanopan will provide regular training or debriefing to medical record officers
Literatur Riview Tentang Faktor Penyebab Klaim Tidak Layak Bayar BPJS Kesehatan Di Rumah Sakit Tahun 2020 Oktamianiza; Rahmadhani; Yulfa Yulia; Helmi Mazra Putri
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Vol. 6 No. 1 (2021): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Februari
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v6i1.487

Abstract

The amount of payment made by BPJS Kesehatan to health facilities is determined based on an agreement between BPJS Kesehatan and the relationship of health facilities in the area where the health facilities are located and refers to the INA-CBG's tariff standard. During the leveraging process by the BPJS verifier, several claims were found, one of which was an unfeasible claim. Therefore, the researchers are interested in further examining the factors that cause the BPJS health unfit claims at the hospital. The purpose of this review literature is to describe the factors that cause claims for not worth paying BPJS health at the hospital in 2020. The literature review research uses descriptive analysis which is carried out by describing the facts. The library sources used are 4 libraries from journals. Analyze the data by looking for several groups (comparing), inequality (contrasting), views (criticizing), comparing (synthesizing) and summarizing (summarizing) the research. Based on a review of 4 journals on the appropriateness of the Participation Administration an average of 66%, the suitability of service administration as much as 25%, the accuracy of disease diagnosis as much as 75%, the accuracy of the main diagnosis and the accuracy of the secondary diagnosis as much as 88%, the accuracy of the diagnosis code was 55% correct and the effect of the administrative completeness of the claim requirements on average is still <75%, which means that the administrative completeness of the BPJS Health requirements is still incomplete because it does not meet the BPJS Health standards and regulations in the submitted requirements file. Based on the results of the study, it can be ignored that the administrative completeness of the BPJS Health claim requirements in the hospital is still incomplete, due to the perception of perceptions between internal verifiers and external verifiers, the knowledge and responsibilities of health service workers on the importance of filling in complete, accurate and trustworthy medical record files. . So the researchers suggest that there is periodic socialization to equalize perceptions about policies and standards in the process of submitting BPJS Health claims between internal verifiers and external verifiers and health service workers who participate in filling out medical record files so that problems related to claims not worth paying can be minimized so that services health can run well and smoothly.
Perancangan Ulang Formulir Rawat Jalan Untuk Mendukung Praktik Di Laboratorium RMIK Unjaya Kori Puspita Ningsih; Kuswanto Hardjo
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Vol. 6 No. 1 (2021): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Februari
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v6i1.488

Abstract

Laboratorium Prodi RMIK (D-3) Fakultas Kesehatan Universitas Jenderal Achmad Yani Yogyakarta (Unjaya) memiliki formulir rawat jalan. Saat ini format formulir masih minimal, belum menggambarkan format dokumentasi rekam medis yang terintegrasi. Penelitian ini menggunakan metode deskriptif, dengan pendekatan studi kasus. Subjek penelitian ini adalah Ketua Prodi RMIK (D-3), Kepala Laboratorium, dosen dan staf laboratorium Prodi RMIK (D-3) Fakultas Kesehatan Universitas Jenderal Achmad Yani Yogyakarta. Informan triangulasi pada penelitian ini adalah praktisi senior rekam medis di RSUD Tipe B Kota Yogyakarta. Peneliti melakukan studi pendahuluan dan studi pustaka untuk mengidentifikasi masalah. Selanjutnya analisis data dilakukan identifikasi kebutuhan perancangan ulang desain formulir berdasarkan aspek fisik, anatomi dan isi. Hasil analisis tersebut digunakan sebagai dasar untuk perancangan ulang formulir rawat jalan. Terdapat 2 usulan perancangan ulang formulir rekam medis rawat jalan. Pemilihan desain dan bahan formulir dilakukan dengan diskusi bersama informan triangulasi, perbaikan desain sesuai masukan dari informan triangulasi untuk mendapatkan desain akhir dari perancangan formulir rawat jalan. Hasil analisis pada aspek fisik, anatomi dan isi menunjukkan perlu dilakukan perancangan ulang formulir pada aspek anatomi dan isi dengan menghilangkan item nomor registrasi, kelas/ruangan, pekerjaan, menambahkan riwayar alergi, riwayat penyakit, assasmen nyeri dan kode ICD, serta merestrukturisasi dokumentasi rekam medis terintegrasi dengan format SOAP.

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