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Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI)
Published by Universitas Imelda Medan
ISSN : 25027786     EISSN : 25977156     DOI : https://doi.org/10.2411/jipiki
Core Subject : Health,
Health Professions Public 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.
Arjuna Subject : Profesi Kesehatan - Menejmen Informasi Kesehatan
Articles 12 Documents
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Search results for , issue "Vol. 8 No. 2 (2023): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Agustus" : 12 Documents clear
Optimalisasi Tracking Rekam Medis Dengan Barcode di Puskesmas Lendah II Laili Rahmatul Ilmi; Praptana Praptana; Rizky Yuspita Sari; Heri Herawan; Angga Eko Pramono; Meita Indriyani
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Vol. 8 No. 2 (2023): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Agustus
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v8i2.1149

Abstract

In 2014, primary health centres Lendah II was implemented health information system for primary care (Simpus). the use of simpus can help the physician and health practicioners entry data of patient, import dan export data and also improved theirs performance. The implementation of medical records for primary health centres an important role in managing patient data. The use of technology and information systems in the health sector has an impact on optimizing services. One of them is by utilizing a barcode system to support storage at primary health centres Lendah II This study aims to help the storage tracking system in the filing room using barcodes. Data capture with FGD for needs analysis, then application design and trials. This research uses research and develompent. The results of the study by making class diagrams, barcode applications and examples of barcodes applied to poly service names and medical record numbers. Barcodes will be printed and affixed to the patient's medical record to facilitate tracking of the The barcode of the patient's medical record number will also be affixed to the patient's BPJS card, making it easier for officers to check the patient's medical record number on the simpus. There is a scanner reader tool that will make it easier for officers to read barcode codes.
Desain Formulir Rekam Medis Di Bagian Pendaftaran Pada Kegiatan Khitanan Masal Al-Khitan Madinah Banjarmasin Ermas Estiyana; Nirma Yunita
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Vol. 8 No. 2 (2023): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Agustus
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v8i2.1256

Abstract

In all health services it is mandatory to provide recording services medical records, as for the benefits of medical records, one of which is useful as written evidence of acts of service to a patient, too able to protect the legal interests of the patient concerned, hospitals and doctors and other health workers. Medical record is a file that contains notes and documents regarding patient identity, examination, treatment, actions, and services that have been given to patients. Al-Khitan Banjarmasin, which has been established since 2016, in every implementation of mass circumcision does not have a medical record form. The purpose of this study was to make a medical record form in the registration section of the Al-Khitan Medina Banjarmasin mass circumcision. This research method is a qualitative descriptive research. The subjects in this study consisted of the main informants who were registration officers of Al-Khitan Medina Banjarmasin, triangulation informants who were in charge of Al-Khitan Medina Banjarmasin, using observation and interview guide instruments. The data analysis technique is descriptive qualitative. The results of this study are the design of medical record forms that are made by taking into account the anatomical aspects, physical aspects and content aspects. The anatomical aspects of this design include the title of the form, the name of the circumcision house, Al-Khitan, Medina, Banjarmasin, the address of the circumcision house, no. medical record, introduction, basic information explaining the purpose of using the form in question, instructions containing clear instructions for fillers to write down patient data later. Physical aspects are made according to using black ink, white paper color, HVS paper material, A4 paper size, Aspects of the contents of the form are designed consisting of number, date of visit, history of illness, action, therapy/medicine, name and initials of the officer.
Faktor Yang Berpengaruh Dalam Penggunaan Sistem INA CBGs Di Rumah Sakit Islam Jakarta Pondok Kopi Daniel Putra; Niken Kirani; Nanda Aula Rumana; Deasy Rosmala Dewi
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Vol. 8 No. 2 (2023): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Agustus
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v8i2.1284

Abstract

The implementation of the financing system in hospitals using the INA-CBGs system. The INA-CBGs system is a payment made at a package rate covering all components of resources in hospitals used in services, both medical and non-medical services. This research aims to identify the application of the INA-CBGs system and factors influencing the 6M method. The method used in this research is descriptive analysis with a qualitative approach. Descriptive analysis is the process of analyzing, explaining and summarizing events and phenomena from data obtained through interviews and field observations directly regarding the use of the INA-CBGs system. The results showed that the influence factor in the use of the INA-CBGs system can be reviewed from 6M. Man, the influence of humans is the incompatibility of the required crew with officers who do three jobs at once, the incompatibility of the educational background of outpatient coding officers with professional standards and the lack of implementation of special training regarding the INA-CBGs system. Materials, the influence of this factor is the unavailability of ICD-10 and ICD-9-CM books in casemix. Machines, the influence of machine factors, namely sometimes the internet is less stable and the lack of printer machines provided. Methods, the influence of the method factor, namely the unformed SPO from the hospital regarding the use of the INA-CBGs system. Money, the supporting factor is that there is a reward in overtime to encourage officers, while the obstacle is the difference in hospital costs and INA-CBGs packages. Market, supporting influence in the target market, namely inpatient BPJS patients with class 3 selection.
Perancangan Sistem Informasi Pendaftaran Pasien Rawat Jalan Menggunakan Visual Studio 2010 Di RSUD Al-Ihsan Aillin Elizabeth Joel; Yuyun Yunengsih; Falaah Abdussalaam
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Vol. 8 No. 2 (2023): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Agustus
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v8i2.1292

Abstract

Registration is the initial process of the entire medical recording process that will be carried out on patients in the implementation of health services to patients. Registration is one of the very important initial processes. This study aims to determine the design of the outpatient patient registration information system using Microsoft Visual Studio 2010 at RSUD Al-Ihsan so that the outpatient patient registration process can be well-integrated and efficient in terms of patient service time and also make it easier for officers to register patients. The research method used in this study is a qualitative method with a descriptive approach. The technique used to collect data was through direct observation, interviews with medical record officers, and also a literature review of previous studies. The problem that occurred in the hospital was when patients registered for outpatient services, the patient's name did not appear in the system. To overcome this problem, this design was made using the System Development Life Cycle (SDLC) development method through the stages of needs analysis, design, implementation, and testing assisted by the creation of flowmap designs, Context Diagrams, Data Flow Diagrams, and Entity Relationship Diagrams, which were then implemented using Microsoft Visual Studio 2010 as a programming language using the Microsoft Access database so that the data that has been inputted can be saved so that the names of patients who have registered for outpatient services can appear. The results of the system design that have been made and tested using Black Box testing show that the system functions as intended. In conclusion, the information system design can help and facilitate registration officers in serving patients at the outpatient patient acceptance site effectively and efficiently.
Tinjauan Pelaksanaan Audit Koding Berkas Pengklaiman Pasien Peserta BPJS Kesehatan di Rumah Sakit Umum Imelda Pekerja Indonesia Tahun 2021 Mei Sryendang Sitorus; Esraida Simanjuntak; Yeyi Gusla; Cicha Olviya
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Vol. 8 No. 2 (2023): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Agustus
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v8i2.1296

Abstract

The coding audit is a review to ensure that the results of the diagnosis and treatment coding produced by the clinical coder are accurate, consistent and timely when compared to the information contained in the patient's medical record. The purpose of this study was to determine the implementation of the coding audit and to find out the efforts made to minimize the non-compliance of claims to the BPJS Health at Imelda Pekerja Indonesia Hospital in 2021. The type of research used was qualitative research with the number of informants as many as three coders who took Total Sampling. The research instrument used was an interview guide with qualitative descriptive data analysis techniques. Based on the results of the study, it was found that the level of knowledge of coding audit officers about coding audits is quite good but coding audits are still carried out post-claims and there are no instruments in implementing coding audits while the person in charge of coding audits at Imelda General Hospital is the Medical Committee, Verifier Internal, Quality Control and Cost Control Teamand Koder. Suggestions from researchers should Imelda Pekerja Indonesia Hospital socialize the coding audit SPO, then the coding audit is carried out pre-claim and in its implementation a coding audit instrument is made.
Implementasi Clinical Pathway Kasus Tuberkulosis Paru Berdasarkan Rekam Medis Pasien di RSUD dr. Soekardjo Kota Tasikmalya Namira Fatimah Azahra; Ida sugiarti
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Vol. 8 No. 2 (2023): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Agustus
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v8i2.1313

Abstract

Hospitals should have tools to control the quality of services provided to patients so that health services provided by health workers can be integrated and can reduce risks in the process of clinical services. One tool to control the quality of service is a clinical pathway. Preparation of clinical pathways at Dr. Soekardjo, Tasikmalaya City, based on five criteria in filling out the clinical pathways for pulmonary tuberculosis cases in this study included initial examination, follow-up examination, management, evaluation, and validation. Implementation of a clinical pathway for pulmonary tuberculosis cases based on patient medical records in the third quarter of 2022 at Dr.Soekardjo Hospital Tasikmalaya City. This type of research is a quantitative method, the implementation of clinical pathways at Dr. Soekardjo Hospital has been carried out well with the results obtained for the initial review examination carried out as many as 63 files (76%), the average follow-up review examination was carried out as many as 77 files (93 %), the average management review is 74 files (89%), the average evaluation review is 79 files (95%), the average authentication review is 83 files (100%).
Analisis Penerapan Sistem Informasi Kesehatan Daerah (SIKDA) Generik Dalam Meningkatkan Pelayanan Rawat Jalan Di Puskesmas Rawat Inap Ciranjang Muhammad Naufal Fernanda; Ade Irma Suryani
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Vol. 8 No. 2 (2023): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Agustus
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v8i2.1322

Abstract

The use of good information system technology can help the implementation of the work program of the puskesmas effectively, reports on the performance of the puskesmas can be reported periodically and systematically so that the puskesmas management can make the right decisions. SIKDA at the Medical Record Unit at the Ciranjang Inpatient Health Center just started in April 2019. This study aims to analyze the implementation of the Regional Health Information System (SIKDA) in improving outpatient services at the Ciranjang Inpatient Health Center and to analyze the inhibiting factors for the implementation of generic SIKDA at the Ciranjang Inpatient Health Center. The research method used is qualitative analysis with a descriptive approach. The time of the research was conducted in March-May 2023 at the Ciranjang Inpatient Health Center. The results of the study when viewed from the perspective of human factors found that SIKDA at the Ciranjang Inpatient Health Center could not be carried out by every officer in the service unit, there were no special technical staff who managed the information system and there was no further training or outreach. While from the technological factor there are several damaged devices and information systems that are not updated. It can be concluded that generic SIKDA human resources are still lacking in operating generic SIKDA in all outpatient service units due to limited human resources. The technological factor for the application of SIKDA is already very good. However, support from the leadership for the implementation of generic SIKDA is considered to be lacking due to limited facilities and infrastructure, and the availability of human resources. And the benefits generated by the regional health information system (SIKDA) at the Ciranjang Inpatient Health Center are still not being felt due to not being integrated in all outpatient services and software applications that have never been updated again.
Analisis Ketepatan Pendistribusian Rekam Medis Rawat Jalan Terhadap Efektivitas Pelayanan Di RSUD Kota Bandung Tia Qurota Aeni Firjatullah; Ade Irma Suryani
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Vol. 8 No. 2 (2023): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Agustus
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v8i2.1341

Abstract

The distribution of medical record document is very important for the ongoing effective health service activities, the faster the medical record document reach the service unit, the faster the patient will get the health services provided by the doctor. The distribution of medical records is required to meet minimum service standards of ≤ 10 minutes from the provision of medical record document, the purpose of this study was to analyze the distribution of medical record document at Bandung City Hospital, this type of research uses a qualitative approach, data collection through interviews and observation with a sample size 100 medical records document and 20 distribution officers and polyclinic nurses at Bandung City Hospital were taken. The percentage of timeliness according to the minimum service standard is 79 document (79%) with an average distribution time of 3,6 minutes and those that do not meet the standard are 21 document (21%) with an average distribution time of 12 minutes. It is also known that there are 88 record document medical record document (88%) were correct at the polyclinic, while medical record document were incorrect at the intended polyclinic as many as 12 medical record document (12%), and according to the survey results determined the effectiveness of the distribution of medical record document at Bandung City Hospital, namely 72%. The conclusion of this study is that there are still delays in the distribution time and inaccuracy of medical record document to the intended polyclinic at Bandung City Hospital, by increasing the evaluation of medical record officers, especially distribution, also adding distribution officers can increase the number of medical record document that meet minimum service standard ≤ 10 minutes.
Analisis Kesiapan Implementasi Rekam Medis Elektronik Menggunakan Instrumen CAFP (California Academy of Family Physicians) di Puskesmas Kartasura Dyah Ayu Hapsari; Rika Andriani; Prita Devy Igiany
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Vol. 8 No. 2 (2023): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Agustus
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v8i2.1342

Abstract

Indonesian Ministry of Health Regulation No. 24 of 2022 on Medical Records requires all healthcare facilities must implement Electronic Medical Records (EMR) no later than December 31, 2023. Kartasura Primary Healthcare is one of the healthcare in Sukoharjo Regency that has not implemented EMR yet. A readiness analysis of EMRS is required to to improve service quality and workflow efficiency. CAFP instrument can be used for evaluating primary healthcare in transitioning to EMR. The purpose of this study is to determine the readiness of implementing EMR on management capacity, finance & budgeting, operations, technology, and organizational alignment. This was a descriptive-quantitative- research. Sample was 9 people who selected by stratified random sampling. Data collection used interviews and documentation studies. Results showed that management capacity was in range II with average score 9.3; financial capacity and budget were in range III with average score 5.2; operational capacity was in range III with average score 3.5; technology capacity was in range III with average score 9.4; and organizational alignment capacity was in range II with average score 17.3. Overall readiness for EMR implementation at Kartasura Primary Healthcare was in range II. To increase financial & budgetary, operational, and technological capacity, it is suggested to recruit IT team, EMR training, and EMR socialization to all potential users.
Tinjauan Kelengkapan Pengisian Formulir Persetujuan Tindakan Kedokteran Pasien Bedah Rawat Inap Di Rumah Sakit Tere Margareth Tahun 2022 Ali Sabela Hasibuan; Zulham Andi Ritonga; Marta Simanjuntak; Edward Ramos Nababan
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Vol. 8 No. 2 (2023): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Agustus
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v8i2.1357

Abstract

Completeness of filling in the informed consent form is very important because it can affect the quality of medical records and the legal aspects contained in the medical records themselves. This type of research is descriptive with an observational approach, namely research that describes the current situation. The study population was the medical record document of the informed consent form of inpatients with the sample in this study being a portion of the total population. An overview of the completeness of filling out informed consent sheets in surgical cases at Tere Margareth General Hospital can be seen from the sample count with a total population of (235) divided by 1+235 (precision level/10%=0.1) which results in a sample of 70. Completeness of filling in the identification of providing information is 97% filled and 3% not filled. Completeness of filling in important report items is 92% filled and 8% not filled. Completeness of filling in medical action items is 98% filled and 2% not filled. Completeness of filling in authentication items is 87% filled and 3% not filled. The medical record unit is trying to be able to ask the nurse in charge to fill out the informed consent form so that it can fill it out completely.

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