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[Analisis Risiko Kerja Petugas Filling Rawat Inap Dengan Menggunakan Severity Assessment di RSUP Dr. Hasan Sadikin Bandung ]]>
<![CDATA[Inggil De Crystal]]>;
<![CDATA[Efri Tri Ardianto]]>;
<![CDATA[Sustin Farlinda]]>
<![CDATA[ J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 3 (2020): June ]]>
Publisher : <![CDATA[Politeknik Negeri Jember ]]>
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DOI: 10.25047/j-remi.v1i3.1960
<![CDATA[Risk is the possibilities of an unwanted, or unexpected, adverse loss in an activity. Risk can occur as a form of thepossibility of something bad happening in the future which can not be predicted when it comes. These risks can beresulted as negative impacts for the existing officers in several activities. We have observed the examples of risks thatoccur in the filling room of Dr. Hasan Sadikin General Hospital, Bandung. There are several risks of occupationalaccidents experienced by officers such as fingers affected by stapler attached to the medical record files, officers feelaches and pain in their hands and back when retrieving files, and the possibility of officers being hit by files. Thisresearch was aimed to analyze the risks that occur in filling inpatients. This risk assessment uses severity assessmentand a hierarchy of risk control to overcome the risks that occur. The type of research uses qualitative research with 4respondents. The results of this study produced 7 risks with 4 high injury risks and 3 moderate injury risks. Handling inrisk prevention is needed by making work safety SOPs, mandatory of Personal Protective Equipment (PPE) usage, theuse of tools to lift heavy loads, the use of chairs and stairs with strong materials, giving warning signs, paying attentionto ventilation to regulate proper lighting, and installing thermometers in inpatient filling rooms.]]>
<![CDATA[Evaluasi Kariadi Information System pada Petugas Koding Rawat Jalan di RSUP dr. Kariadi Semarang ]]>
<![CDATA[Nabilah Khoirun Nissa']]>;
<![CDATA[Feby Erawantini]]>;
<![CDATA[Mochammad Choirur Roziqin]]>
<![CDATA[ J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 3 (2020): June ]]>
Publisher : <![CDATA[Politeknik Negeri Jember ]]>
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DOI: 10.25047/j-remi.v1i3.1973
<![CDATA[Based on a preliminary survey that I had done during the Field Work Practice at RSUP Dr. Kariadi Semarang.The output that was there produced the KIS system on the RME menu that was not yet in accordance with thewishes of the outpatient coding officer. In the KIS system, the SIMRS menu entry grouping encoding externalcauses or external causes only have 3 digits of 4 characters. The use of the KIS menu RME systemsometimes occurs errors that are not equipped with guidelines or guidelines if an error occurs. This studyaims to evaluate KIS (Kariadi Information System) users in outpatient coding officers. Use the methoddiscussed, namely the EUCS method to measure the level of satisfaction from using a system. The resultsthat have been obtained from this research in terms of the content (content) of the information obtained isquite helpful for coding officers. The lack of entry grouping coding on the external cause, if complete willbenefit the patient. In terms of accuracy (accuracy) still requires an accuracy process, for example, if the inputerror registers, the data that appears will be different and occasional errors also occur. In terms of format(display) the interface is quite attractive based on user needs. In terms of timeliness, the system is able toprovide up to date information. In terms of ease of use (ease of use) the system is easy to learn only the lackof guidance if there has been an error. This research resulted in several recommendations that IT staff officerscan receive input related to the constraints of the use of the coder officer system, the head of the medicalrecord conducts further evaluation and supervision of the use of the system.]]>
<![CDATA[Analisis Faktor Penyebab Ketidaktepatan Kode Diagnosis Penyakit Diabetes Mellitus di Rumah Sakit Umum Haji Surabaya ]]>
<![CDATA[Errica Rostia Loren]]>;
<![CDATA[Rossalina Adi Wijayanti]]>;
<![CDATA[Nikmatun Nikmatun]]>
<![CDATA[ J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 3 (2020): June ]]>
Publisher : <![CDATA[Politeknik Negeri Jember ]]>
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DOI: 10.25047/j-remi.v1i3.1974
<![CDATA[The accuracy of determining the disease diagnosis code is one of the important things that must beconsidered in carrying out the coding process of the patient's disease diagnosis made by the coder. Theaccuracy and inaccuracy of providing disease diagnosis codes will affect data and information in the healthservice process and reduce the quality of services in hospitals. Besides, in the era of National HealthInsurance (JKN), the accuracy of the diagnosis code was also very influential in financing at hospitals. Thisresearch was aimed to analyze the factors which cause the diagnosis code inaccuracy in Diabetes Mellitus inSurabaya Hajj General Hospital in 2019. This research used qualitative methods with data collectiontechniques such as interviews, observation, and literature studies. The number of samples used in the studywas 21 medical records of Diabetes Mellitus patients and 2 informants. The results of research on the medicalrecord documents of patients with Diabetes Mellitus found that the documents have an incorrect code of 13medical record documents (62%) and documents that have an exact code of 8 medical record documents(38%). The results of the analysis found were several factors that influence the inaccuracy of the code such ascoder's competency, coder's knowledge, as well as the experience of coder and medical record document,both the completeness of the filling and the documentation. The solution that can be proposed by theresearcher is to included the coder and medical personnel in training and outreach related to thedetermination of diagnosis code, especially Diabetes Mellitus.]]>
<![CDATA[Faktor Keterlambatan Berkas Rekam Medis Rawat Inap di RSUP Kariadi Semarang ]]>
<![CDATA[Riza Umami Agustin]]>;
<![CDATA[Feby Erawantini]]>;
<![CDATA[Mochammad Choirur Roziqin]]>
<![CDATA[ J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 3 (2020): June ]]>
Publisher : <![CDATA[Politeknik Negeri Jember ]]>
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DOI: 10.25047/j-remi.v1i3.1985
<![CDATA[That delay file medical record in-patient could impede the service event assembling, medical record filling,koding, cause to be lost or damaged and probably file. medical recordThat file medical record in-patient rsup.drAre still experiencing keterlabatan. kariadi semarangBased on the observations and the interviewsconducted by researchers implementation has been delayed at pjrm. assembling orThe purpose of thisresearch is conducting apasaja analyzing the factors that cause the repayment record. in-patient medicalfileThe kind of research used the qualitative.This study using theory lawreens green variable, predisposingfactors enabling, factors reinforcing factors and the repayment of file medical record by, throughinterviews. The research results show delays in the repayment of file medical record in-patient caused byindividual competence the attitude the repayment of knowledge and the officer to file medical record , thesecond caused by of facilities and infrastructure who are supporting yet there still implementation has beendelayed return and the lack of a motivation that granted to officers .In reaction to this, should be created aroutine meeting that special committee to discuss about delays in the repayment of medical record file so thatthey do not file medical record delays there was a problem .]]>
<![CDATA[Analisis Manajemen Risiko Kesehatan dan Keselamatan Kerja di Bagian Filing RSUP dr. Soeradji Tirtonegoro Klaten ]]>
<![CDATA[Novia Zahroh]]>;
<![CDATA[Andri Permana Wicaksono]]>;
<![CDATA[Atma Deharja]]>
<![CDATA[ J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 3 (2020): June ]]>
Publisher : <![CDATA[Politeknik Negeri Jember ]]>
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DOI: 10.25047/j-remi.v1i3.1989
<![CDATA[Medical records storage is an activity to protect the medical records from the physical damage and the contentof the medical records. Medical records storage process has risks that can threatening the occupational safetyand health of medical records staff. One of the efforts in occupational safety and health is by giving protectionfor the medical records staff by using personal protective equipment. At filing RSUP dr. Soeradji TirtonegoroKlaten found a problem that employees do not use personal protective equipment such as masks andhandscoon, the roll o’pack high is not ergonomic and it does not have Standart Prosedure Operational. Thenurse has risk to experience musculosveletal disorders, hands are itchy, sneeze, scraped paper or sharpmedical record map, and has strangulated the roll o’pack when they do the job. The purpose of this researchwas to analyzed the Health Management risk and Occupational Safety in ifiling RSUP dr. Soeradji TirtonegoroKlaten. Type of qualitative research. Some employees in filing used as Respondents. The results of thisresearch were 16,6% low risk, 50 % moderat risk, and 33,4% in high risk. Based on this results the controlefforts was redesign the map folders material, regulated the high of roll o pack, provided the vacuum cleaner,had encouraged the officers to always washed their hands after touched the medical records, made theStandart Prosedure Operational for occupational safety and health in filing, and gave a punishment ifemployees did not used personal protective equipment.]]>
<![CDATA[Analisis Kebutuhan Tenaga Kerja Menggunakan Metode WISN di Rumah Sakit PHC Surabaya ]]>
<![CDATA[Septianingtyas Risti Anggraeni]]>;
<![CDATA[Efri Tri Ardianto]]>;
<![CDATA[Dony Setiawan Hendyca Putra]]>
<![CDATA[ J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 3 (2020): June ]]>
Publisher : <![CDATA[Politeknik Negeri Jember ]]>
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DOI: 10.25047/j-remi.v1i3.1996
<![CDATA[Medical record personnel is one part of the profession in the hospital. Medical record personnel also have animportant role in a patient service. Because it is responsible for the procurement of files beginning from patientregistration, assembling, coding, indexing, filling, internal or external reporting and INACBG’s. There is aproblem concerning the workload of medical records personnel at Surabaya PHC Hospital. A number ofofficers are have been resigning for the last few years, causing a reduction of a number of officers. Theworkload indirectly becomes higher and double jobs occurred. In addition, there are also found several officerswho have 2 jobs such as an outpatient coding officer become a filling officer, an inpatient coding officerbecome an information release officer and an assembling officer become a hemodialysis coding officer. Thepurpose of this study was to analyzed the needs of medical record personnel based on workload in SurabayaPHC Hospital using the WISN (Workload Indicator Staffing Need) method. A quantitative research approachwith a descriptive study design used as this research type. Respondents that used were 1 person reporting, 1person assembling, 1 person coding outpatient and 1 person filling. The results of this research were 12 ofofficers with an educational background in Medical Records. It took the addition of 1 person for the assemblingunit, 6 people for the outpatient coding unit, 2 people for the inpatient coding unit, 3 people for the filling unitand 1 person for the information release unit.]]>
<![CDATA[Analisis Faktor Penyebab Terjadinya Duplikasi Nomor Rekam Medis Rawat Jalan di Puskesmas Kencong Kabupaten Jember ]]>
<![CDATA[Esa Amanda Setiawan]]>;
<![CDATA[Rossalina Adi Wijayanti]]>;
<![CDATA[Atma Deharja]]>;
<![CDATA[Selvia Juwita Swari]]>
<![CDATA[ J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 3 (2020): June ]]>
Publisher : <![CDATA[Politeknik Negeri Jember ]]>
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DOI: 10.25047/j-remi.v1i3.2005
<![CDATA[Duplication that occurred in the Kencong Public Health Center was 46 files on February 2019, this could beextremely powerful on legality aspect of medical record file interrupted if it happens the legal case. The aimof this research was to analyze and decide the priority causes of the happening duplication by using USG.The variety of this research is qualitative one by using the collection of interviewing data, observation,documentation and brainstorming. The result of this research stated that the case causing priority is by usingUSG method namely, the education of officer whose education qualification is Diploma D3 degree of MedicalRecord had been appropriated. The trial solving that trouble is recruiting the officers whose educationDiploma D3 degree of Medical Record and they need to have the recommendation about more educationespecially for the officers who still have the minimal education or knowledge about medical record side.]]>
<![CDATA[Evaluasi Kesuksesan Sistem Informasi Manajemen Rumah Sakit dengan Metode Delone and Mclean ]]>
<![CDATA[Mochammad Arief Darmawan]]>;
<![CDATA[Dony Setiawan Hendyca Putra]]>
<![CDATA[ J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 3 (2020): June ]]>
Publisher : <![CDATA[Politeknik Negeri Jember ]]>
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DOI: 10.25047/j-remi.v1i3.2020
<![CDATA[SIMRS at RSIA Srikandi IBI Jember has been running since 2011. However, based on the preliminary studyfound several problems including, there are some data that is not stored properly, information generated bySIMRS is still incomplete or incomplete, and the discovery of several system users who are not satisfied withthe SIMRS. Therefore, it is necessary to further study how to evaluate the success of the implementation ofthe SIMRS by using the Update D&M IS Success Model evaluation method (Delone and Mclean 2003). Thepurpose of this study is to evaluate the performance of SIMRS in supporting service activities based onvariables of system quality, information quality, service quality, intensity of use, usage, user satisfaction andnet benefits. The analysis used is the analysis of the relationship with the Spearman rank test using the SPSS24.0 program. The results of this study indicate the significance value of all variables <0.05 and positive value,so that the quality of the system, the quality of information, the quality of service is related to the direction ofthe intensity of use and user satisfaction. Usage intensity and user satisfaction are also related to the directionof net benefits. A very strong influence occurs on service quality on the intensity of use with a significancevalue of 0,000 and a coefficient correlation value of 0.826. The influence that is going on on the quality ofinformation on user satisfaction with a significance value of 0,000 and a coefficient correlation value of 0.425.]]>
<![CDATA[Desain Tata Ruang Filing Poliklinik JKN Berdasarkan Lingkungan Fisik yang Ergonomis ]]>
<![CDATA[Mochammad Arief Darmawan]]>;
<![CDATA[Mochammad Choirur Roziqin]]>;
<![CDATA[Feby Erawantini]]>
<![CDATA[ J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 3 (2020): June ]]>
Publisher : <![CDATA[Politeknik Negeri Jember ]]>
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DOI: 10.25047/j-remi.v1i3.2021
<![CDATA[The physical environment is all that exists around the workplace that can affect employees both directly andindirectly. Several problems exist in the JKN Polyclinic filing room at Pertamina Central Hospital, amongothers, the room is not large, some documents RM are not stored in the available shelves, there is one light sothe filing room is not bright enough. The purpose of this study is to design a JKN polyclinic filing layout basedon an ergonomic physical environment at Pertamina Central Hospital. This research is qualitative, with datacollection techniques carried out by observation, interviews, and documentation. The results of this study areto produce a new JKN Polyclinic spatial filing design at Pertamina Jakarta Central Hospital following anergonomic physical environment. Spacious room for new filing room measuring 35 m² with the addition ofsupporting facilities such as 57 medical record shelves for the needs of the next 5 years, 1 piece of AC (AirConditioning) measuring 1PK, 3 lamps measuring 20 watts, and additional ventilation of 5.25 m². It isrecommended to Pertamina Central Hospital to add facilities such as medical record shelves, repairs ofrefrigeration equipment such as AC (Air Conditioning), lights, and indoor air ventilation. These facilities arevery important because they affect the comfort and health of officers working in the filing room.]]>
<![CDATA[Analisis Faktor Penyebab Lost To Follow Up Pengobatan ARV (Antiretroviral) di Puskesmas Kencong ]]>
<![CDATA[Septianingtyas Risti Anggraeni]]>;
<![CDATA[Faiqatul Hikmah]]>
<![CDATA[ J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 3 (2020): June ]]>
Publisher : <![CDATA[Politeknik Negeri Jember ]]>
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DOI: 10.25047/j-remi.v1i3.2035
<![CDATA[The key to the success of HIV / AIDS treatment is ARV therapy. Continuous therapy can inhibit the spread ofHIV infection in the body and improve the quality of life of patients. Lost to follow-up is the absence of thepatient to return to the VCT clinic according to the date of the drug agreement and consultation. The KencongCommunity Health Center found a problem regarding lost to follow up. The cause of lost to follow upsuspected due to factors that can be related to Lawrence Green's theory such as presdiposing factors(knowledge, attitudes), enabling factors (patient books and help cards), and reinforcing factors (motivation,SOP). The purpose of this research was to analyze the factors that can cause lost to follow up antiretroviral(ARV) treatment in HIV patients in Kencong Health Center. The type of this research was qualitative and thisresearch used 6 patients, 1 counselor and 1 doctor as respondent. The results of this research shows that theknowledge of patients is still lacking, especially way of virus transmission and the side effects caused and thelocation of the HIV virus in the body, meanwhile scheduling knowledge of patient is good. Respondents have apositive attitude towards ARV treatment. The book which use to record the patient’s visit data has beendeemed capable to control the arrival of patient. There are still many patients who don't carry a patient cardwhen they want to take medicine. Counselors and doctors have provided the best motivation during thecounseling process. Kencong Puskesmas still does not have SOP about lost to follow up]]>
