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Muhammad Yunus
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j-remi@polije.ac.id
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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 220 Documents
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Analisis Kuantitatif Kelengkapan Pengisian Formulir Assesmen Rawat Inap Obsgyn di RS X Jember Irfiah Irfiah
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 4 No 3 (2023): June
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v4i3.3908

Abstract

The process of providing hospital plenary services has the role of many parties, one of which is the role of medical record management. The results of the assessment of the completeness of filling out the obsgyn inpatient assessment form at Hospital X still contained deficiencies (incomplete) which in this case had not reached the minimum standard of hospital services, which had to be 100%. The aim of this study was to analyze the completeness of the completeness of the filling out of the inpatient obsgyn assessment form at X Jember Hospital. This type of research uses descriptive research with a retrospective approach. The object of research is the obsgyn inpatient assessment form at X Jember Hospital for the 2022 period, totaling 1035 medical record files. The method of collecting data in this study is observing the components of identification, important reporting, authentication, and correct documentation and the analysis used is using quantitative descriptive analysis. The results of the identification component analysis with the highest completeness of 97.34%, and the highest incompleteness of 82.15%; important reporting components with the highest completeness of 93.91% and the highest incompleteness of 35.17%. The results of the authentication component analysis with the highest completeness were 75.17% and the highest incompleteness was 58.26%; the correct documentation component with the highest score of 92.46% and incorrect documentation with the highest score of 8.99%.
Faktor Penyebab Terjadinya Duplikasi Nomor Rekam Medis Pasien Riska Rosita; Rini Apriyani
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 4 No 3 (2023): June
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v4i3.3920

Abstract

The medical record numbering system is a procedure for writing the number given to patients when they come for treatment at a health service. Based on observations at the Toboali Health Center, there were 13 patients who had more than one medical record number, there were also 14 cases where one medical record number was used for more than one patient. The purpose of this study was to determine the factors that cause duplication of patient medical record numbers. The research method is descriptive using a cross sectional survey design approach. The results showed that the causes of duplication of patient medical record numbers consisted of regulations/policies, facilities and infrastructure, human resources, patient compliance with MNH and changes in patient data that were not confirmed. The conclusion of this study is that all of these causal factors must be suppressed so that the history of patient data becomes continuous and prevents the risk of medical errors or malpractice.
Penerapan Particle Swarm Optimization Untuk Meningkatkan Kinerja Algoritma K-Nearest Neighbor Dalam Klasifikasi Penyakit Diabetes Dyah Susilowati; Sutrisno Sutrisno; Muhammad Yunus
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 4 No 3 (2023): June
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v4i3.3980

Abstract

The study aims to apply the KNN algorithm to classify diabetes by combining the PSO algorithm as a selection so as to obtain the best accuracy from the KNN algorithm in classifying, so that it can be applied to diagnose diabetes. This research consists of several stages of research including dataset collection, data pre-processing, data sharing, finding the optimal k-value to the classification process and performance or accuracy testing. From this research, the accuracy of the KNN algorithm before feature selection using PSO is 75% at k-optimal 19 and after feature selection using PSO is obtained an increase in accuracy to 77.213% at the same k value with features that affect the pima dataset, namely Glucose, Blood Pressure, Skin Thickness, Insulin, BMI, Diabetes Pedigree Function, and Age. Thus the use of KNN with PSO feature selection can be used to identify diabetes because it has a much better level of accuracy.
Analisis Faktor Penyebab Rendahnya Bed Occupancy Rate (BOR) di Balai Besar Kesehatan Paru Masyarakat Makassar Agus Salim; Ervina Rachmawati; Maya Weka Santi; Indah Muflihatin
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 4 No 4 (2023): September
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v4i4.3322

Abstract

The Bed Occupancy Rate (BOR) at the Makassar Community Lung Health Center in the last 3 years has decreased in 2018 by 64%, in 2019 by 62% and in 2020 by 52%. BOR is an indicator of health services that can be used to determine the level of quality, level of utilization of facilities and efficiency of health services. The impact of the decrease in BOR causes a decrease in economic income for the Hospital. The purpose of this study was to analyze the factors causing the low BOR at the Makassar Community Lung Health Center with (human resources), (facilities and infrastructure), (discipline of health care providers) and (problem improvement efforts. This study used qualitative research methods, with the intention of digging deeper into the factors causing the low BOR by using interview, observation, documentation and brainstorming techniques involving 3 informants including HRD, head of facilities and infrastructure and head of nursing.The results of this study indicate that the factor causing low BOR is the lack of resources. human nurses, facilities and infrastructure are not adequate, the discipline of health service providers is not consistent. The solution is that human resources need to be added to facilities and infrastructure that are immediately improved and complete the facilities and infrastructure that are not yet available.
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.
Hubungan Kelengkapan Informasi Klinis dengan Ketepatan Kode Diagnosis Berdasarkan ICD-10 pada Kasus Fracture Wulandari Dewi Susilawati; Uswatun Hasanah; Rizal Pratama Adi Putra; Musparlin Halid; Ikhwan; Beny Binarto Budi Susilo; Yan Reiza Permana; Aditiyani Nugraha Pertiwi; Rian Wahyul Ikhtiar
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 4 No 4 (2023): September
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v4i4.3784

Abstract

Kodefikasi kasus fracture wajib menerapkan karakter ke-5 dan kelengkapan external cause apabila tidak dilakukan penerapan karakter ke-5 dan external cause maka kode yang diberikan salah sehingga menyebabkan kerugian bagi pasien maupun rumah sakit. Tujuan penelitian untuk mengetahui hubungan antara kelengkapan informasi dengan ketepatan kode diagnosis kasus fracture pasien. Metode penelitian menggunakan observasional analitik dengan pendekatan crsoss sectional. Populasi penelitian adalah dokumen rekam medis pasien rawat inap dengan kasus fracture periode Januari-Oktober 2021. Sampel berjumlah 92 dokumen rekam medis. Uji statistik menggunakan uji Lambda dengan menggunakan SPSS 20.0. Hasil penelitian menununjukkan bahwa terdapat hubungan antara kelengkapan informasi dengan ketepatan kode diagnosis (p = 0.29). Mayoritas ketidaklengkapan informasi medis (62.0%) dan ketidaktepatan kode diagnosis (76.1%) lebih banyak daripada jumlah kelengkapan informasi (38.0%) dan ketepatan kode diagnosis (23.9%)  kasus fracture. Kesimpulan untuk menekan pentingnya kelengkapan informasi terhadap ketepatan kode diagnosis harus ditetapkan oleh petugas kodefikasi.
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).

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