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[Hubungan Kepuasan Kerja dengan Kinerja Petugas Rekam Medis di RSUP Dr. Sardjito Yogyakarta ]]>
<![CDATA[Desy Rachmawati]]>;
<![CDATA[Sustin Farlinda]]>;
<![CDATA[Sugeng Sugeng]]>;
<![CDATA[Gamasiano Alfiansyah]]>
<![CDATA[ J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 2 No 2 (2021): March ]]>
Publisher : <![CDATA[Politeknik Negeri Jember ]]>
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DOI: 10.25047/j-remi.v2i2.1984
<![CDATA[Job satisfaction is an important factor that can affect employee performance. If the employee feel satisfiedwith their work, the employee will produce good performance, and vice versa. Based on observations andinterviews with one of the medical recorders, it is known that they never get a reward if they work well inaccordance with applicable procedures. In addition, facilities that support their work such as dumbwaiter andtroli sometimes suffer damage. This condition resulted in work performed by medical recorders at RSUP Dr.Sardjito Yogyakarta is not optimal, so it will affect job satisfaction. The impact of this condition was found alateness providing the patient's medical record to the health services unit or sometimes wrong distribution ofmedical record files that are not in accordance with the patient's destination services unit. This conditioncauses the examination of patients by health professional also hampered. The purpose of this research is toidentify the relationship of job satisfaction with medical recorder at RSUP Dr. Sardjito Yogyakarta. The methodof data collection in this research is a questionnaire. Analysis of the data used is univariate analysis andbivariate analysis using the Spearman rank correlation test. The results showed that the level of jobsatisfaction of medical recorders at RSUP Dr. Sardjito Yogayakarta is classified as moderate (83.3%), whilethe level of performance of the medical records officer at RSUP Dr. Sardjito Yogyakarta is classified as high(50%). Spearman rank correlation test results indicate that there is a relationship with a moderate categorybetween job satisfaction with the performance of medical recorders at RSUP Dr. Sardjito Yogyakarta with asignificance value or p value 0.006 and a correlation coefficient of 0.487.]]>
<![CDATA[STRATEGI KEBIJAKAN UNIT KERJA REKAM MEDIS DENGAN METODE SWOT DI RS PHC SURABAYA ]]>
<![CDATA[Kurnia Arofah]]>;
<![CDATA[Efri Tri Ardianto]]>;
<![CDATA[Dony Setiawan Hendyca Putra]]>
<![CDATA[ J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 2 No 2 (2021): March ]]>
Publisher : <![CDATA[Politeknik Negeri Jember ]]>
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DOI: 10.25047/j-remi.v2i2.2002
<![CDATA[Primasatya Husada Citra (PHC) Hospital Surabaya is one of the private hospitals that is required to providequality services one of which is a medical record. There are several points about medical records services thathave not been implemented optimally such as 43% incomplete filling of medical record files includingincomplete informed consent, and late return of medical record document by exceeded the standard 1x24hours. The purpose of this research is to determine the policy strategy in the medical record unit of the PHCHospital Surabaya using the SWOT method. The research method was the SWOT method that identifiedstrengths, weaknesses, opportunities, and threats. The research instruments used questionnaires andobservations. The subject of this research was 6 medical records officers. The results show that the value ofthe strength factor is 3.69 and the weakness factor is 1.42 while the opportunity factor value is 3.6 and thethreats factor is 1. The position of the medical record unit, PHC Hospital Surabaya, is in quadrant I so thesuitable strategy is SO (Strength-Opportunity), the strategy includes the development of integrated informationsystems, and improve the management of medical records related to recording and documentation formaintaining the quality of medical record documents.]]>
<![CDATA[GAMBARAN TINGKAT PRODUKTIVITAS KERJA BERDASARKAN LINGKUNGAN DAN MOTIVASI KERJA PETUGAS ASSEMBLING RUMAH SAKIT UMUM PUSAT Dr. HASAN SADIKIN TAHUN 2020 ]]>
<![CDATA[Try Ganjar Wati]]>;
<![CDATA[Sustin Farlinda]]>;
<![CDATA[Efri Tri Ardianto]]>
<![CDATA[ J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 2 No 2 (2021): March ]]>
Publisher : <![CDATA[Politeknik Negeri Jember ]]>
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DOI: 10.25047/j-remi.v2i2.2004
<![CDATA[Based on the results of a preliminary study conducted at Hasan Sadikin Hospital, it is known that fromFebruary to March 2020 the achievement of the 20 files per day assembling task target has not been fullyachieved. 7 out of 9 assembling officers work 7 to 15 files and there was an inconsistency of the additionalform's location that assessed by each officer. This resulted in narrow space and files that were stacked toolong causing the medical record file to be damaged and the location of the additional forms to be different.This study aims to describe the level of work productivity based on the environment and the work motivationof assembling officers Dr. Hasan Sadikin 2020. This type of research uses quantitative by observing anddistributing questionnaires to respondents. The results obtained are that the assembling officer at RSUP Dr.Hasan Sadikin who has a higher level of productivity are officers with male sex, age categories 35-49 years,length of work for more than 10 years, last education diploma IV / S1, and with marital status.]]>
<![CDATA[ANALISIS KUANTITATIF KELENGKAPAN PENGISIAN RESUME MEDIS DI RUMKITAL DR. RAMELAN SURABAYA ]]>
<![CDATA[Nofitalia Sawondari]]>;
<![CDATA[Gamasiano Alfiansyah]]>;
<![CDATA[Indah Muflihatin]]>
<![CDATA[ J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 2 No 2 (2021): March ]]>
Publisher : <![CDATA[Politeknik Negeri Jember ]]>
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DOI: 10.25047/j-remi.v2i2.2008
<![CDATA[The medical resume form is a summarize of all the patient's treatment that is conducted by healthcareworkers and signed by a doctor. The filling completeness of the medical resume at RUMKITAL Dr.Ramelan Surabaya only reached 82.5%. The purpose of this research was to analyze e the completenessof medical resumes in RUMKITAL Dr. Ramelan Surabaya. This research was qualitative descriptive. Thedata collection used observation. The sample of this research as many as 20 medical resume forms inFebruary of 2020. The research results indicated the highest percentage of patient identification reviewincompleteness is 45% which is the inpatient’s rank or class item. The highest percentage ofincompleteness on important report's review is 55% which is the inpatient’s duration item. The highestpercentages of incompleteness on authentication are the patient's date item, the filling time, the patient’sor family’s name, also the patient’s or family’s signature. The highest percentage of incompleteness oncorrect documentation review is 20% which is the plain and legible registration. In conclusion, the highestincompleteness is in the identification review and the correct documentation. The research suggestion is tocreate the SOP of medical resume, the SPO socialization, and to sign a commitment about theconsistency of filling medical resumes.]]>
<![CDATA[ANALISIS KUANTITATIF KELENGKAPAN PENGISIAN FORMULIR INFORMED CONSENT RUMKITAL DR. RAMELAN SURABAYA ]]>
<![CDATA[Aditya Dwi Arimbi]]>;
<![CDATA[Indah Muflihatin]]>;
<![CDATA[Niyalatul Muna]]>
<![CDATA[ J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 2 No 2 (2021): March ]]>
Publisher : <![CDATA[Politeknik Negeri Jember ]]>
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DOI: 10.25047/j-remi.v2i2.2009
<![CDATA[Completeness informed consent form of RUMKITAL Dr. Ramelan Surabaya is still less than the MinimumHospital Service Standard of 100%, it is based on a preliminary study of researchers that the incompleteinformed consent form on the identity component is 60%, important reporting is 80%, authentication is40%, and the correct documentation is 0%. The purpose of this study was to conduct a quantitativeanalysis of the completeness of the informed consent form of RUMKITAL Dr. Ramelan Surabaya. Thisstudy uses descriptive research with a cross-sectional approach to identify the completeness of filling outinformed consent. Data collection used is observation and documentation on the informed consent form.The results show the identification component with the highest completeness by 90% and the highestincompleteness by 55%; The important reporting component with the highest completeness is 80% andthe highest incompleteness is 80%; The authentication component with the highest completeness is 90%and the highest incompleteness is 50%; The correct documentation component with the highestcompleteness is 85% and the highest incompleteness is 50. Some suggestion to fix the problem is bymaking the Statement of Commitment, the SOP of evaluating and monitoring the medical recorddocuments completion, improving the Informed Consent SOP and Medical Records Completion SOP byadding completeness standard of informed consent filling which is must be achieved by RUMKITAL Dr.Ramelan Surabaya.]]>
<![CDATA[ANALISIS SISTEM PENGENDALIAN BERKAS REKAM MEDIS DI RUMAH SAKIT UNIVERSITAS AIRLANGGA SURABAYA ]]>
<![CDATA[Septiya Atik Cahyani]]>;
<![CDATA[Andri Permana Wicaksono]]>;
<![CDATA[Novita Nuraini]]>
<![CDATA[ J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 2 No 2 (2021): March ]]>
Publisher : <![CDATA[Politeknik Negeri Jember ]]>
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DOI: 10.25047/j-remi.v2i2.2010
<![CDATA[Medical record controlling is the supervision of medical record borrowing and medical record returning to thestorage rack. Based on observation at Airlangga University Hospital in October 2019 there were 3 out of 5borrowed files were returned by exceeding the deadline. From December 2019 until February 2020 therewere 11 of the 16 medical record files borrowed by other units, but the expedition book did not contain anyinformation regarding the date of returning file. Delay in the medical record returning file results in misplacedor miss file. From March 9th, 2020 to March 13th, 2020 there were 237 of 3053 medical record files thatwere misplaced or miss file. This study aimed to analyze the medical record file control system at AirlanggaUniversity Hospital using the 5M method (man, method, machine, material, and money). This research wasqualitative. Data collection techniques used were observation, interviews, and documentation. The subjectof study was medical record officer. The results show that the factors causing problems in controlling medicalrecord files are high workload of officers, late return of medical record files, officer discipline in usingexpedition books, absence of tracers as a substitute for medical record files, and the number of storageshelves that were under the needs. Suggestions for the problems are to add more officers in the fillingsection, conduct socialization and evaluate officers in using expedition books, make electronic tracerapplications, and adding storage shelves.]]>
<![CDATA[ANALISIS FAKTOR PENYEBAB KETERLAMBATAN PENGEMBALIAN BERKAS REKAM MEDIS RAWAT INAP RUMAH SAKIT PUSAT PERTAMINA ]]>
<![CDATA[Anggia Lutfi Rohmawati]]>;
<![CDATA[Feby Erawantini]]>;
<![CDATA[Mochammad Choirur Roziqin]]>
<![CDATA[ J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 2 No 2 (2021): March ]]>
Publisher : <![CDATA[Politeknik Negeri Jember ]]>
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DOI: 10.25047/j-remi.v2i2.2013
<![CDATA[The process of medical record organizing through a series of activities including registration, processingmedical record data, auditing the contents of medical records, archiving, and presenting the information.One factor that supports the processing of medical record files is returning the medical record of patientswho have finished receiving health services from the inpatient unit. There were 323 (25%) files from 1276which were delayed when they returned. The purpose of this study was to analyze the factors which iscausing the delay in returning the inpatient medical record file at Pertamina Central Hospital with a behavioraltheory consisting of predisposing factors, enabling factors, and reinforcing factors. This type of research wasqualitative with data collection methods, namely interviews and observations. The subjects of this researchwere nurses, distributor officers and file monitoring officers inpatient. The results show that the lack of selfmotivation among officers both doctors and nurses as medical record filler and also distributor officers couldbe the cause of delay in returning the medical records of inpatients unit, the number of distributors who wereless and the distance of the inpatient room to the medical record room could cause a long delay in returningthe inpatient medical record file, the attitude and behavior of the inpatient file monitoring officer who doesnot request the medical record file that has not been returned for immediate return could cause a delay inreturn. The solution obtained from the problem is to increase self-motivation by increasing awareness of theresponsibilities from the doctor, distributor officers, and file monitoring officers when they are performing thetasks, as well as doing recalculation for distributor officers number.]]>
<![CDATA[EVALUASI KETIDAKTEPATAN PEMBERIAN KODE REKAM MEDIS RAWAT JALAN DI RS PHC SURABAYA ]]>
<![CDATA[Mahardika Nugraha]]>;
<![CDATA[Dony Setiawan Hendyca Putra]]>;
<![CDATA[Efri Tri Ardianto]]>
<![CDATA[ J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 2 No 2 (2021): March ]]>
Publisher : <![CDATA[Politeknik Negeri Jember ]]>
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DOI: 10.25047/j-remi.v2i2.2176
<![CDATA[Codification is an activity to transform a diagnosis into a code consisting of letters and numbers.Inaccuracies of coding can slow the process of insurance claims and decrease the quality of medicalrecords. Preliminary study results showed a percentage of inaccuracy in the diagnostic code of 4documents of a total of 10 outpatient medical record documents at PHC Surabaya Hospital. This researchaims to evaluate the correctness of an outpatient medical record file in Surabaya's PHC Hospital. This typeof research used qualitative research. The samples were 44 documents of the outpatient medical record inJanuary 2020. Data collection techniques using observation and documentation. The results of the studyshow that the code inaccuracies in an outpatient medical record document of 13 (29.5%) improper codeand 21 (70.5%) of the right code. The cause of its absence was an error in the code-granting suspect of15.4%, a mistake in giving control code and therapy of 61.5%, and an error in giving the fourth character inthe case of diabetes mellitus by 23.1%. Factors that lead to inaccuracy in the coding of an outpatientmedical record were the less thorough officers in conducting medical record reviews as well as mistakes indetermining the old case and new cases. The suggestions provided by researchers are to conduct routinecoding audits, repair SOP, socialization about the correct encoding procedures, and make a note for thecode which is often to be used.]]>
<![CDATA[ANALISIS FAKTOR RISIKO PADA PENYAKIT KARSINOMA PARU (C34) PASIEN RAWAT INAP DI RUMAH SAKIT BALADHIKA HUSADA JEMBER ]]>
<![CDATA[Salma Firyal Nabila]]>;
<![CDATA[Dony Setiawan Hendyca Putra]]>;
<![CDATA[Sustin Farlinda]]>;
<![CDATA[Efri Tri Ardianto]]>
<![CDATA[ J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 2 No 2 (2021): March ]]>
Publisher : <![CDATA[Politeknik Negeri Jember ]]>
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DOI: 10.25047/j-remi.v2i2.2197
<![CDATA[Lung carcinoma or commonly known as lung cancer is one of the main causes of death from disease in theworld that reach 7.6 million deaths or about 13% of all cancer diagnoses. Baladhika Husada Jember Hospitalis a third-level hospital in Jember Regency that has oncology and chemotherapy services including a cancerdiagnosis. Based on existing data of the morbidity and mortality rates of pulmonary carcinoma are alwaysincreasing from 2016 until 2018. This study aims to analyze the risk factors for lung carcinoma such as age,gender, smoking history, genetic history, and predisposition of other lung disease based on medical records ofinpatients with the pulmonary disorder at Baladhika Husada Hospital in Jember. The research method usedquantitative analysis with a cross-sectional research design. The number of samples was 98 respondents.Data analysis used the chi-square test for bivariate and the logistic regression test for multivariate. Thebivariate analysis result shows that each independent variable had an influence on lung carcinoma cases.Multivariate analysis shows that the variable had a simultaneous influence (p value=0,000). Partially, eachvariable has an influence, age (p value=0,003), smoking history (p value=0,003), genetic history (pvalue=0,002), predisposition of other lung disease (p value=0,000), except on genders (p value=0,857). Theconclusion is the risk factors can explain the effect on the incidence of pulmonary carcinoma by 84.8%. Thisresearch is expected to be used as information to cope with the increased morbidity and mortality rates ofpulmonary carcinoma.]]>
<![CDATA[Gambaran Stres Kerja Petugas Pendaftaran Rawat Jalan di RSUP Dr. Sardjito Yogyakarta ]]>
<![CDATA[Risma Dwi Ambarwati]]>;
<![CDATA[Gamasiano Alfiansyah]]>;
<![CDATA[Sustin Farlinda]]>;
<![CDATA[Sugeng Sugeng]]>
<![CDATA[ J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 2 No 2 (2021): March ]]>
Publisher : <![CDATA[Politeknik Negeri Jember ]]>
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DOI: 10.25047/j-remi.v2i2.1998
<![CDATA[Occupational stress is recognized as a global health issue that affects all professions, no other profession inthe health field i.e. medical record registration section. RSUP Dr. Sardjito Yogyakarta has a total data visitannually on an outpatient registration, which is in 2018 as much as 469813 and in 2019 as many as 518806.The number of visits explained at least the registration staff should serve 200-300 patients every day. Knownerrors that occur in SIMETRISS also harm the officer because inevitably officers should double job. TheStress of work felt by the officers of the list is often felt muscle tension, feel tension, fast anger, feel anxiety,and difficulty concentrating in the work. Stressful work if not resolved will have an impact on activities in thescope or out of work. The research aimed to figure out the work stress overview of the registration officers inRSUP Dr. Sardjito Yogyakarta. The collection methods used are interviews. The analysis of the data used inthis study was qualitative. The results of the study showed work stress experienced by outpatient registrationofficers, that is caused by a physical work environment that was less comfortable so later would cause a lackof concentration by the officers and the declining of officers performance; the conflict between family demandsand the institution demands such as the lack of break time and the presence of a sustained shift; performancedemands to work quickly and precisely however the support facilities, Simetriss, which was still error alsoraised the pressure for the worker. RSUP Dr. Sardjito Yogyakarta has reduced some problems by conductingeffective consultation on outpatient registration officers.]]>
