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Muhammad Yunus
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Program Studi Rekam Medik Politeknik Negeri Jember Jl. Mastrip PO Box 164, Jember, Jawa Timur
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J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan
Published by Politeknik Negeri Jember
ISSN : -     EISSN : 2721866X     DOI : https://doi.org/10.25047/jremi
Core Subject : Health,
Health Professions Public Health
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.
Arjuna Subject : Profesi Kesehatan - Menejmen Informasi Kesehatan
Articles 8 Documents
 1 
Search results for , issue "Vol 4 No 2 (2023): March" : 8 Documents clear
GAMBARAN UMUM PELAYANAN PENDAFTARAN RAWAT JALAN DI RS SANTA ELISABETH BATAM KOTA Masriani Situmorang; Rahmawati Rahmawati; Fani Farhansyah
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 4 No 2 (2023): March
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v4i2.3709

Abstract

Registration services are the first type of service that interacts directly with patients. The outpatient registration procedure of each hospital has a different service system that depends on the policies of each hospital. Hospitals have an outpatient registration process that is still not optimal and there are still many patients who do not understand the outpatient registration process. This study aims to find out an overview of outpatient registration services at Santa Elisabeth Hospital Batam City. This research used qualitative methods with interviews and direct observation / observation at Santa Elisabeth Hospital Batam City. From the results of the study, the outpatient registration system at Santa Elisabeth Hospital Batam City was obtained directly, and indirectly (by telephone). During the service process, there were several problems that occurred, including patients not knowing that the queue number to see a certain doctor was separated, resulting in patients who had taken the queue number on the queue machine returning to the security guard table to retrieve the new queue number, as well as an error Information System Server. The flow of outpatient services at Santa Elisabeth Hospital Batam City is in accordance with the SOP although there are still some problems at the Outpatient Registration Site (TPPRJ).
Analisis Kelengkapan Pengisian Berkas Rekam Medis Fahrunisa Fahrunisa; Musparlin Halid; Ikhwan Ikhwan
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 4 No 2 (2023): March
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v4i2.3373

Abstract

Minimum Service Standards (MSS) indicators in the form of completing the filling of medical record documents for 24 hours. There are medical record files and informed consent that are incomplete and not in accordance with MSS. The purpose of the study was to identify and analyze the completeness of the medical record file. The study was conducted at the Hospital of NTB Province. The purpose of the study was to determine the level of completeness of the contents of the medical record document. This research uses quantitative type. The sample is 87 medical record files. Services in the medical record section are not in accordance with the MSS. With details of the completeness of the contents of the medical record document for 24 hours after the service, it has not been completely filled out, such as the initials of the doctor/nurse (62%). Indicators of filling out informed consent from completeness after the patient is given incomplete information, such as providing information (76%), type of information (76%), doctor's signature (76%), and signatures of witnesses 1 and 2 (76%). The medical record document has not been filled in completely by the medical record officer.
ANALISIS IMPLEMENTASI KESELAMATAN PASIEN DI PUSKESMAS KOTA SURABAYA DITINJAU DARI ENAM SASARAN KESELAMATAN PASIEN Bernadeta Lintang Hardy; Sutopo Patria Jati; Yuliani Setyaningsih
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 4 No 2 (2023): March
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v4i2.3776

Abstract

Patient safety is one of the important elements of a health service system that is effective and efficient in improving the quality of health services. Public health center as a first-level health facility must be able to improve the quality of health services to the maximum, especially on patient safety indicators, so that accreditation status can increase. However, the development of patient safety issues in Indonesia, especially at the public health center level, is not as dynamic as hospitals and the reporting of patient safety incidents at public health center is still not transparent, especially in Indonesia. This research method uses qualitative research with a case study approach. Data collection was carried out using in-depth interview techniques and secondary data collection. The implementation of the patient safety program has been running well in accordance with the Policy / SOP contained in Permenkes 11 Th.2017 by adjusting the needs of the public health center. In addition, in the implementation of patient safety, several obstacles were found, such as insufficient human resource needs, the absence of special budgeted funds, minimal facilities and infrastructure, ineffective communication between officers so that miscommunication occurred, and human error. So, it is necessary to evaluate DKK Surabaya in relation to human resources, funds, facilities, and infrastructure, as well as the need to update the standards / guidelines in Permenkes related to patient safety standards. Finally, there is a need for an IKP data transparency policy, especially in public health center.
Precede Proceed Faktor Ketidaklengkapan Pengisian Mechanism Of Injury Pada Ringkasan Keluar Pasien Ni Putu Linda Yunawati; Irma Ultimaningsih; Dara Hastarin; Chistina Ayu Dewi Anggraeni; Vina Shabrina; Dinar Neynda Maharani; Kristin Desi Rahayu; Ni Komang Muryati; Ayu Prastikiswara; Ni Made Indira Sari
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 4 No 2 (2023): March
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v4i2.3777

Abstract

The content of medical records is a reflection the quality hospital services so that the incompleteness of medical records can have a bad impact on the health care process to patients. The discrepancy in the writing of the MOI by the PPA with the information on the police report regarding the chronology of the trauma incident resulted in difficulties for coding officers in determining into ICD-10 code for the 4th and 5th characters. This study aims to determine the precede proceed factor affected the incompleteness MOI. This research is a qualitative descriptive with a cross-sectional research design using PRECEDE PROCEED model. The results were obtained based on predisposing factors that the level of DPJP discipline is still lacking so that monitoring and evaluation need to be carried out. Enabling factors caused by interface need to be revised it is necessary to compile an input and output interface design. Reinforcing factors are caused by the absence of a policy governing the filling of MOI, so it is necessary to draft a policy for filling in MOI on medical record files. Optimization efforts for the completeness the MOI is designing a draft policy for filling in the MOI and optimizing monitoring evaluation.
Faktor Kesuksesan SIM-RS Berdasarkan Teori DeLone and McLean di Rumah Sakit Umum Daerah Kota Mataram Yan Reiza Permana; Musparlin Halid; Uswatun Hasanah; Rizal Pratama Adi Putra; Ikhwan Ikhwan
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 4 No 2 (2023): March
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v4i2.3783

Abstract

Information systems with technology support are one of the systems that have a big role in the success of the organization. The purpose of this study is to describe the success factors of the Hospital Management Information System (SIM-RS) in the medical record installation based on the theory of DeLone and McLean which consists of six variables. namely system quality, information quality, service quality, use, user satisfaction and benefits. This research was conducted at the Mataram City Hospital (MCH) with a sample of 48 medical record officers who use a SIM-RS. The results obtained from this study according to the system quality variable that as many as 48% of medical record officers stated that the SIM-RS had quality. The information quality variable, as much as 54% of respondents stated that the SIM-RS was of high quality. Service quality variable as much as 79% of respondents said they were satisfied with the SIM-RS. The use variable as many as 43% of respondents stated that the SIM-RS was often used. The user satisfaction variable as much as 94% of respondents stated that the SIM-RS was of good quality. The benefit variable, as many as 56% of respondents stated that the SIM-RS was useful.
Analisis Kesiapan Pelaksanaan Rekam Medis Elektronik (RME) Dengan Metode Doctor's Office Quality-Information Technology (DOQ-IT) di Klinik Pratama Polkesmar Meilinda Asrining Hapsari; Kismi Mubarokah
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 4 No 2 (2023): March
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v4i2.3826

Abstract

In order to realize digital transformation, quality data integration is an important element, especially in the field of health services. All Health Service Facilities are expected to have implemented Electronic Medical Records (EMR) following the provisions no later than December 31, 2023. In order to comply with these regulations, health service facilities must prepare all the components needed to implement EMR. The purpose of this study was to analyze the readiness of implementing RME using the Doctor's Office Quality-Information Technology (DOQ-IT) method at the Polkesmar Primary Clinic. The type of research used was descriptive quantitative. Methods of data collection were through filling out questionnaires. Ease of use analysis was done using the EHR Assessment and Readiness Starter Assessment from DOQ-IT. The total readiness score of the Polkesmar Primary Clinic in implementing EMR was 128,45 in category III, which meant that the Polkesmar Primary Clinic was very ready to implement EMR. Readiness for implementing EMR could be ranked as the strongest, namely Human Resources readiness (4,50), Governance and Leadership readiness (4,64), Organizational Work Culture readiness (4,69), and IT Infrastructure readiness (4,54).
Bahasa Inggris Aghasi Hana Faradila; Rossalina Adi Wijayanti; Novita Nuraini; Riskha Dora Candra Dewi
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 4 No 2 (2023): March
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v4i2.3831

Abstract

The incomplete filling of medical records affects the quality of medical record services and has an impact on the discontinuity of health services provided to patient. Based on the result of observations at the Puskesmas Babadan , it is known that there was an incompleteness of outpatient medical records with a percentage of 27,3% with the number of medical records that are not completely filled as many as 44 from 161 outpatient medical records. This study aims to analyze the factors causing the incompleteness of outpatient medical records at the Puskesmas Babadan by priorotizing problems using the Urgency, Seriousness, Growth (USG) method and improvement efforts through brainstorming. The results found in this study are based on motivation variables namely the absence of rewards and punishments given to officers,  based on the opportunity variables namely that there is no Standard Operating Procedures (SOP) that regulates the completeness of filling out medical records and officers involved in filling out outpatient medical records have never received training on the completeness of filling out medical records, based on the ability variables, namely the ability of education, experience and medical staff to assist in filling out outpatient medical records. The absence of Standard Operating Procedures (SOP) which is the cause of incomplete filling of outpatient medical records. The effort to fix the problem is by making clear Standard Operating Procedures (SOP) regarding the completeness of filling out medical records in accordance with applicable medical record service standars.
PEMBUATAN APLIKASI PADA PRAKTIK MANDIRI BIDAN MENGGUNAKAN METODE WATERFALL Andri Permana Wicaksono; Dara Ayu Sadiyanti Rukmana; Mudafiq Riyan Pratama
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 4 No 2 (2023): March
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v4i2.3863

Abstract

Patient medical record in Midwife Independent Practice (MIP) must save and keep the secret for give quality of health care, quantity, and quick response to patients. MIP of Erliyanti Sukirno, S.ST,. Tanah Bumbu build at 2012. Since 11 years old, patients must queue in waiting room in quite a while. This is because of the service process and medical record using manual. The purpose of this research is to make a design for MIP application. Researchers use the research and development method to facilitate the research process and the waterfall method as a reference for the MIP application development process. The product is MIP application can give ease to the midwife officer in providing service to the patient and reduce the length of the patient queue in waiting room. Data collection used interview to 2 respondents are the owner of MIP and midwife. The result is functional system needs and non-functional to MIP application. Then, needed to transmit in system design by flowchart system, use case diagram, class diagram, activity diagram, entity relationship diagram, and data flow diagram. The design is then translated to a programming language using PHP program and MySQL database. From the results of this study, it has several features are login features, patient visit report features, patient referral letter features, patient and midwife detail identity data features, notification features, patient registration features independently, and feature records of patient examination results. Features that unavailable in the MIP application are the automatic payment features and the distance between the MIP and the referred hospital.

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