J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan is a scientific journal that is managed and published by the Program Studi Rekam Medik, Jurusan Kesehatan, Politeknik Negeri Jember. J-REMI contains the publication of research results from students, lecturers and or other practitioners in the field of medical records and health information with coverage and focus on the fields of Health Information Management, Health Information Systems, Health Information Technology, Health Quality Information Management and Classification, Coding of Diseases and Problems. Health and Action.
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<![CDATA[Desain Augmented Reality Unit Rekam Medis di Rumah Sakit Citra Husada Jember ]]>
<![CDATA[Deva Setia Pratama]]>;
<![CDATA[Nugroho Setyo Wibowo]]>
<![CDATA[ J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 4 (2020): September ]]>
Publisher : <![CDATA[Politeknik Negeri Jember ]]>
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DOI: 10.25047/j-remi.v1i4.1992
<![CDATA[Hospital is a health-care institution that provides in-country, alternative health care, and emergency care. Good service must be sustained by sufficient means and infrastructure for each unit including a medical record. Medical records unit are still not up to standard resulting in disruption of employee’s effectiveness. A narrow room and files that stack up on the floor, filling room that's stuffy and narrow and filling that lack nighttime exposure becomes a constrained in the medical record unit. This research was aimed to redesign room of medical records in Hospital of Citra Husada Jember that according to the guidelines. The method is qualitative research with data collection technique observation, interview and brainwriting. The result of this research is redesign room of medical records based of the guidelines to realized ideal facilities and infrastructure for comfort the worked. Also manufactured augmented reality that useful for helped user to simulated room design previously form 2 dimensions pictures to 3 dimensions pictures. The improvement is a design which matches the anthropometrics units to the working facilities and menu programmed on augmented reality application.]]>
<![CDATA[Analisis Kinerja Petugas Dalam Melakukan Pelayanan Rawat Jalan di Puskesmas Kalisat ]]>
<![CDATA[Novia Zahroh]]>;
<![CDATA[Indah Muflihatin]]>
<![CDATA[ J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 4 (2020): September ]]>
Publisher : <![CDATA[Politeknik Negeri Jember ]]>
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DOI: 10.25047/j-remi.v1i4.1995
<![CDATA[Performance is the result of quality and quantity of work accomplished by each employee based on the jobdescription or responsibility. The standard of a good performance are at least precision, intelligence, quickness, and orderliness. Kalisat Public health center has a problem which is underoptimal performance in providing service to patients so that affecting to the pastient’s satisfaction. This research was aimed to analyze employee’s performance within outpatient service in Kalisat Public health center Jember district. The method is analityc observational cross sectional design as the research method. There were 20 employees in outpatient service as the research sample obtained by saturated sampling. It was analyzed by applying the data tabulation software. This result showed that most of the employees were average in their good motivation (60%), they were good at the oppurtunity (50%),they were good at the ability (55%), and the performance of outpatient service belongs to a good category (50%). It shows that there were significant relationship between motivation, oppurtunity, ability, and performance of outpatient employees with significancy value < 0,05 and  X2 value > X2 table. The improvement efforts can be made by developing information system, division of labor improvement, good delegation of competency, and increasing training.]]>
<![CDATA[Analisis Faktor Penyebab Keterlambatan Penyediaan Dokumen Rekam Medis Rawat Jalan di RSU Haji Surabaya ]]>
<![CDATA[Mitha Amelia Rahmawati]]>;
<![CDATA[Novita Nuraini]]>;
<![CDATA[Donny Adhasari Hasan]]>
<![CDATA[ J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 4 (2020): September ]]>
Publisher : <![CDATA[Politeknik Negeri Jember ]]>
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DOI: 10.25047/j-remi.v1i4.2000
<![CDATA[Rata-rata akumulasi waktu penyediaan dokumen rekam medis rawat jalan di Rumah Sakit Umum Haji Surabaya berkisar 24,39 menit. Menurut Peraturan Menteri Kesehatan RI tentang Standar Pelayanan Minimal Rumah Sakit bahwa waktu yang teapat untuk penyediaan dokumen rekam medis rawat jalan adalah <10menit. Hal tersebut bahwa terdapat kesenjangan atau masalah terkait keterlambatan waktu dalam proses penyediaan dokumen rekam medis. Keterlambatan dalam proses penyediaan dokumen rekam medis rawat jalan disebabkan oleh beberapa fakor diantaranya adalah faktor dalam unsur manajemen 5M yang meliputi man, machine, matherial, money, methode. Faktor man yang dapat menyebabkan keterlambatan penyediaan dokumen rekam medis rawat jalan yaitu pengetahuan petugas kurang terkait penyediaan rekam medis rawat jalan kerena masih ada petugas dengan kualifikasi pendidikan SMA, kedisiplinan petugas kurang dalam hal waktu peneydiaan dokumen rekam medis, dan kurangnya pelatihan yang perlu dilakukan oleh pihak RS guna menambah pengetahuan petugas. Faktor  machine yaitu kurangnya jumlah rak penyimpanan dokumen rekam medis rawat jalan, komputer sering terjadi lemot, dan kurangnya troly untuk distribusi rekam medis.Faktor method yaitu belum ada Standart Operasional Prosedur (SOP) terkait peneydiaan dokumen rekam medis rawat jalan dan belum pernah dilakukan evaluasi terkait ketepatan waktu penyediaan dokumen rekam medis rawat jalan. Faktor matherial yaitu banyak dokumen rekam medis yang tidak masuk dalam rak penyimpanan. Faktor  money  yaitu anggaran dana disediakan oleh pihak pengadaan, tetapi sampai saat ini belum digunakan untuk pengadaan rak penyimpanan dokumen rekam medis rawat jalan.]]>
<![CDATA[Analisis Pelaksanaan Retensi dan Pemusnahan Berkas Rekam Medis di Rumkital dr Ramelan Surabaya ]]>
<![CDATA[Eltigeka Devi Apriliani]]>;
<![CDATA[Indah Muflihatin]]>;
<![CDATA[Niyalatul Muna]]>
<![CDATA[ J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 4 (2020): September ]]>
Publisher : <![CDATA[Politeknik Negeri Jember ]]>
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DOI: 10.25047/j-remi.v1i4.2012
<![CDATA[The first time retention at RUMKITAL Dr. Ramelan Surabaya were conducted in 2008. Based on data patient visits of Dr. RUMKITAL Ramelan Surabaya from 2015 to 2019 had increased it caused the storage shelf could not accommodate medical record files. SPO (Standard Procedure Operational) about implementation of retention and destruction of medical records in Dr. RUMKITAL Ramelan Surabaya not found provisions of the storage inaktif medical record file. The aim of this research was to analyze the implementation of retention and destruction medical record files in Dr. Ramelan Surabaya with identifying using 5M (Man, Money, Material, Machine, Method) and the USG method (Urgency, Seriousness, Growth) to determine the priority of problem. This research is qualitative research and collecting the data using observations, interview, and documentation. The subject of study is 1 scan officer of medical record and 2 officer of medical record. The results of this research is got 3 priority cause of problem the implementation of retention and destruction of medical record are elements of method, material and machine. The suggestion of this problem are improving the SPO (Standard Procedure Operational) and implementation the system information of retention.]]>
<![CDATA[Tinjauan Keterlambatan Klaim Berkas BPJS Rawat Inap di RSUP dr. Hasan Sadikin ]]>
<![CDATA[Lutfiatun Nadibah Herman]]>;
<![CDATA[Sustin Farlinda]]>;
<![CDATA[Efri Tri Ardianto]]>;
<![CDATA[Agus Setiawan Abdurachman]]>
<![CDATA[ J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 4 (2020): September ]]>
Publisher : <![CDATA[Politeknik Negeri Jember ]]>
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DOI: 10.25047/j-remi.v1i4.2030
<![CDATA[The implementation of the National Health Insurance program in hospitals as referral Health Service Provider in collaborate with the Indonesia Health Insurance Implementing Agency to provided public health services by using a prospective payment system. Based on preliminary study, it known the inpatient claim file had delayed as much 11.38%. It’s not according to hospital standards that claimed should be 100%. This research aimed to provided a preview the causing factors of delayed inpatient claims at RSUP Dr. Hasan Sadikin Bandung based on 5M management elements. This research was descriptive qualitative with expose the results of interviews and observations that had been done in comparison of the theories available. The results showed that the officers still found difficulties to read the diagnosis and the patient's actions due to doctor’s handwrinting difficult to read, incorrect diagnosis codes and actions due to differences in perception between the coder and the doctor, incomplete claimed files such as the result of the patient's supporting examination. There was no standard operational procedure as regulation of inpatient BPJS claimed requirements, computers that been used in the process of filing claims often experiencing long loading and often experiencing network disruptions so it could reduce the performance of officers. In response to those factors, it needs to make a standar operational procedure for completing claim files, to conduct training specifically about National Health Insurance coding at least once a year and doing maintenance on the computer at least once a month. ]]>
<![CDATA[Perancangan dan Pembuatan Sistem Informasi Peminjaman dan Pengembalian Dokumen Rekam Medis Rawat Jalan di RSF Mangusada Badung ]]>
<![CDATA[Nur Malika Jamil]]>;
<![CDATA[Sustin Farlinda]]>;
<![CDATA[Atma Deharja]]>
<![CDATA[ J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 4 (2020): September ]]>
Publisher : <![CDATA[Politeknik Negeri Jember ]]>
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DOI: 10.25047/j-remi.v1i4.2045
<![CDATA[Registration of loans and refunds of medical records at RSD Mangusda Badung still there is an obstacle that is the loan and refunds data of medical records in the period of 1x24 hours hours is not complete and, there is no description of loan and return time of medical record documents in the expedition. This research aims to design and create information system for loans and refunds the medical records by using waterfall method at RSD Mangusada Badung. This research was conducted in RSD Mangusada Badung. The method of this research used is a qualitative method with the waterfall system development method. The data collection methods used are interviews, observations and documentation. The result of this research is the design and creation of a loan information system for the return of medical record documents using waterfall method is expected to facilitate the officer filing at Puskesmas Banjarsengon to do their duties.]]>
<![CDATA[Analisis Faktor Penyebab Rendahnya Bed Occupancy Rate (BOR) di Rumah Sakit Mitra Medika Kabupaten Bondowoso ]]>
<![CDATA[Widiyanto Widiyanto]]>;
<![CDATA[Rossalina Adi Wijayanti]]>
<![CDATA[ J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 4 (2020): September ]]>
Publisher : <![CDATA[Politeknik Negeri Jember ]]>
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DOI: 10.25047/j-remi.v1i4.2060
<![CDATA[BOR (Bed Occupancy Rate) di Rumah Sakit Mitra Medika Bondowoso masih rendah dimana pada bulan Oktober sebesar 59%, November sebesar 55% dan Desember sebesar 57%. Kondisi tersebut kemungkinan disebabkan oleh jumlah sumber daya manusia yang kurang, fasilitas atau prasarana yang masih belum lengkap, faktor lingkungan baik itu lingkungan internal dan eksternal maupun sikap petugas dalam memberikan pelayanan kepada pasien. Tujuan dri penelitian ini adalah untuk menganalisis faktor penyebab rendahnya persentase BOR di Rumah Sakit Mitra Medika Bondowoso. Jenis penelitian ini adalah penelitian kualitiatif dengan menggunakan teknik pengumpulan data wawancara, observasi dan dokumentasi yang melibatkan 5 responden meliputi kepala rekam medik, HRD, perawat, petugas rekam medik dan petugas administrasi atau pendaftaran. Penentuan prioritas utama penyebab masalah menggunakan metode USG (Urgency, Seriousnes, Growth) yang dilaksanakan dengan melakukan skoring. Selanjutnya menentukan alternatif solusi melalui diskusi bersama dengan responden. Hasil penelitian menunjukan bahwa penyebab utama rendahnya persentase BOR di Rumah Sakit Mitra Medika Bondowoso adalah fasilitas atau sarana dan pasarana yang masih belum lengkap. Alternatif solusi yang disarankan untuk mengatasi masalah tersebut dengan cara penyediaan fasilitas atau sarana dan prasarana yang masih belum lengkap. Sebagai saran, Rumah Sakit Mitra Medika Bondowoso harus segera berbenah dan melengkapi fasilitas atau sarana dan prasarana yang masih belum tersedia.]]>
<![CDATA[Analisis Pelaksanaan Layanan Perawatan Dukungan dan Pengobatan (PDP) HIV–AIDS di Rumah Sakit Daerah Balung ]]>
<![CDATA[Rintan Illahi Wahyu]]>;
<![CDATA[Faiqatul Hikmah]]>;
<![CDATA[Rossalina Adi Wijayanti]]>;
<![CDATA[Niyalatul Muna]]>
<![CDATA[ J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 4 (2020): September ]]>
Publisher : <![CDATA[Politeknik Negeri Jember ]]>
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DOI: 10.25047/j-remi.v1i4.2070
<![CDATA[The implementation of HIV - AIDS Support and Treatment (PDP) Care Services at Balung Regional General Hospital is not yet in line with the target. This is evidenced by the number of PLHIV fulfilling the requirements to start treatment, not all of them are taking ARV treatment, so an analysis of these services is needed. The purpose of this study was to analyze the implementation of HIV - AIDS support and treatment (PDP) care services at Balung Regional Hospital. This type of research is qualitative, using interview, observation and documentation data collection methods. Informants in this study were 1 doctor, 1 counselor and 1 nurse and 8 ODHA This type of research is qualitative, the result of this study is an analysis of the implementation of HIV-AIDS support and treatment care services using 4M indicators (man, method, material and mechine). The results of the study were obtained that the analysis of PDP services based on the aspects of man, namely the availability of resources in the service is lacking and knowledge of HIV – AIDS related to HIV - AIDS is still low, aspects of the method that there are SOP but there is no clear jobdesc, material aspects there is a medical record used for know the development of ODHA, but the officers in filling it are still incomplete, aspects of the mechine are available tools that are used to assist the process of conducting maintenance services such as general inspection tools and SIHA. Efforts to resolve the problem above so that the Balung Regional General Hospital for submitting letters to the Health Office regarding job analysis, the role of the medical recorder for checking the filing of ODHA medical record files and for problems of low knowledge of HIV – AIDS can be done by counseling in privacy.]]>
<![CDATA[Analisis Ketidaksesuaian Kode Diagnosis pada SIMRS dengan Berkas Klaim BPJS Klinik Obgyn ]]>
<![CDATA[Ika Rahmadhani]]>;
<![CDATA[Rossalina Adi Wijayanti]]>;
<![CDATA[Novita Nuraini]]>
<![CDATA[ J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 4 (2020): September ]]>
Publisher : <![CDATA[Politeknik Negeri Jember ]]>
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DOI: 10.25047/j-remi.v1i4.2075
<![CDATA[Ketidaksesuaian kode Diagnosis utama pada SIMRS dan pada berkas Kalaim BPJS sangat penting karena jika tingkat ketidakakuratan tinggi maka berdampak pada ketidakakuratan data morbiditas penyakit yang akan mempengaruhi data pelaporan 10 besar penyakit. Berdasarkan data hasil observasi di RSUD DR Saifur Anwar Malang terhadap ketidaksesuain kode diagnosis utama pada SIMRS dengan kode berkas Klaim BPJS menunjukkan bahwa sebesar 25.8% kode diagnosis utama pada SIMRS tidak diisi atau tidak lengkap, dan sebesar 48.3% kode diagnosis utama yang tertera pada SIMRS tidak sesuai atau tidak sama dengan kode yang tertera pada berkas klaim (casemix), serta sebesar 25.8% kode yang tertera pada SIMRS sesuai dengan kode yang tertera pada berkas klaim (casemix). Tujuan Penelitian ini yaitu Menganalisis Ketidaksesuaian Kode Diagnosis Utama Pada SIMRS Dengan Berkas Klaim BPJS Klinik Obgyn Di RSUD Dr. Saiful Anwar Malang berdasarkan metode Motivation, Opputunity dan Ability. Jenis penelitian yang digunakan yaitu penelitian kualitatif dengan metode pengumpulan data wawancara dan observasi. Hasil yang didapatkan pada saat observasi sebanyak 146 berkas klaim BPJS klinik Obgyn pada tanggal 26-28 Februari dan 3 Maret 2020 angka ketidaksesuain kode diagnosis sebesar 72.6%. Dari hasil analisis didapatkan bahwa ketidaksesuain tersebut terjadi karena kurangnya kedisiplinan petugas Koding di poliklinik dalam menginputkan kode di SIMRS, tidak adanya pelatihan terkait tata cara kodefikasi diagnosis yang benar, petugas entri data di poliklinik bukan lulusan rekam medik serta tidak adanyan job description spesifik yang mengatur tentang pelaksanaan kodefikasi diagnosis untuk kasus rawat jalan.]]>
<![CDATA[Analisis Faktor Penyebab Keterlambatan Pengembalian Berkas Rekam Medis Rawat Jalan di RSUPN Dr. Cipto Mangunkusumo ]]>
<![CDATA[Rizky Farah Dilla]]>;
<![CDATA[Demiawan Rachmatta Putro Mudiono]]>;
<![CDATA[Gamasiano Alfiansyah]]>
<![CDATA[ J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 4 (2020): September ]]>
Publisher : <![CDATA[Politeknik Negeri Jember ]]>
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DOI: 10.25047/j-remi.v1i4.2085
<![CDATA[Keterlambatan pengembalian berkas rekam medis dapat mempengaruhi pelayanan rekam medis dan akan menghambat kegiatan selanjutnya, seperti kegiatan assembling, koding, analisis, indeks. Pengembalian berkas rekam medis rawat jalan di RSUPN Dr. Cipto Mangunkusumo masih mengalami keterlambatan. Pada bulan januari sampai dengan februari total berkas rekam medis rawat jalan yang terlambat sebanyak 282 berkas (0,016%) dari 17.616 berkas. Tujuan dari penelitian adalah menganalisis faktor penyebab keterlambatan pengembalian berkas rekam medis rawat jalan di RSUPN Dr. Cipto Mangunkusumo. Jenis penelitian yang digunakan adalah kualitatif. Teknik pengumpulan data berupa wawancara dan observasi. Subjek penelitian ini adalah Kepala Rekam Medis, Petugas Penanggung Jawab Operasional Unit Rekam Medis, Petugas Filling, Petugas Pengembalian Berkas. Penelitian  dilakukan pada bulan februari sampai bulan maret 2020. Hasil dari penelitian yang didapatkan yaitu pengetahuan dan sikap beberapa petugas masih belum paham dengan SOP pengembalian berkas rekam medis dan kepatuhan sikap petugas pengembalian masih kurang baik. Sarana dan prasarana sudah mendukung, hanya kurangnya ketelitian pada sumber daya petugas pengembalian. Sudah diberikan motivasi oleh koordinator pelayanan Unit Rekam Medis, dan sudah terdapat (SOP) pengembalian berkas rekam medis. Upaya yang dilakukan adalah memberi tahu perawat tentang batas waktu pengembalian berkas rekam medis rawat jalan, kepala rekam medis memberi teguran kepada perawat yang terlambat mengembalikan berkas rekam medis, memberikan motivasi kerja dan sering melakukan sosialisasi SOP terkait pengembalian berkas rekam medis rawat jalan.]]>
