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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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Perancangan Sistem Informasi Pemantauan Kesehatan dan Status Gizi Ibu Hamil Cegah Stunting Faizah Wardhina; Dwidya Poernareksa; Rina Gunarti
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 5 No 2 (2024): March
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v5i2.4388

Abstract

The incidence of stunting in Indonesia according to data from the 2021 Indonesian Nutrition Status Study (SSGI) is 24.4%, still far from the national target of 14% in 2024. One way to prevent stunting is to provide nutritional and health services to pregnant women. When examining pregnant women, recording is one way to monitor the health of pregnant women. All pregnancy examination results are manually recorded in the KIA book and the pregnant mother register book. This manual recording system can cause the search for pregnant women's health history to be slow. Apart from that, there is a possibility that the KIA book was left at home. This research aims to design an information system for monitoring the health and nutritional status of pregnant women. This research used research and development method, and system design using the waterfall method. The results are a system for monitoring the health and nutritional status of pregnant women which can be used to record examination results during pregnancy to prevent stunting. Suggestions to future researchers are to develop this information system so that it can be utilized optimally for stunting prevention.
Perancangan Aplikasi Pembelajaran Kodifikasi Klinis Berbasis Web Angga Eko Pramono; Nuryati Nuryati; Dian Budi Santoso
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 5 No 2 (2024): March
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v5i2.4427

Abstract

One of the main competencies of a Health Information Management (HIM) Practitioner is clinical codification skills. The problem that still occurs is the inaccuracy of clinical codification results. One aspect of the cause is human resource competency, specifically lack of knowledge and skills regarding clinical codification rules and procedures. Therefore, developing a web-based clinical codification learning media application is needed to improve HIM Practitioners' knowledge and skills. This research aims to design a web-based clinical codification learning media. The design was carried out from May to September 2023 using the waterfall method. The research subjects were students and lecturers of health information management and HIM practitioners. The research object was the design of web-based learning media. The data were collected using observation, interview, and documentation study methods. This study resulted in a design system that consists of Unified Modeling Language (UML) of use case diagrams and activity diagrams, a database design that consists of database tables and a database relational diagram, as well as user interface displays which are consists of a login display, home/dashboard, modules, and exercises. The design result should proceed as a blueprint for further system prototyping development process.
Pengembangan Electronic Personal Health Record Anak Sekolah Dasar Di Kota Tasikmalaya Imas Masturoh; Andi Suhenda; Fery Fadly
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 5 No 3 (2024): June
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v5i3.4487

Abstract

The COVID-19 pandemic has caused various impacts in many places, including schools. COVID-19 has led to the closure of many schools to control the spread of the virus, resulting in disruptions to medical services such as regular check-ups for students. The development of E-PHR is effort to monitor the health status of students. This study aimed to design an E-PHR sistem for elementary school students in Tasikmalaya. This research used an RnD type with the SDLC method. The research subjects were selected using purposive sampling, consisting of UKS (School Health Unit) activity managers at the Tasikmalaya City Health Office, all Community Health Centers in Tasikmalaya City, and teachers responsible for UKS. This study used data accumulation techniques through in-depth interviews and focus groups. A needs analysis was conducted to facilitate data collection and retrieval as well as reporting to the health office level. The research results showed that the recording of health issues for students in schools obtained from preventive check-ups, health examinations, and screening results by the UKS team at schools is still not optimal because it is done manually and directly. Therefore, it is recommended that elementary schools, health centers, and the health office prepare the necessary equipment to implement this sistem.
Tingkat Penerimaan Aplikasi SIHA 2.1 pada Petugas Kesehatan di Provinsi Jawa Tengah Diah Kari Artati; Lutfiyah Rizqulloh; Destri Maya Rani
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 5 No 3 (2024): June
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v5i3.4620

Abstract

The SIHA application is the official platform for recording and reporting HIV/AIDS and IMS at the national, district, and provincial administrative levels. Since 2012, SIHA has been used by the health office but in its application, there are still frequent problems, especially when inputting patient data and sending reports that often experience errors. In addition, this application can only be accessed using Mozilla Firefox. At the beginning of the emergence of SIHA until 2023, there has never been an evaluation. The purpose of the study was to identify the level of acceptance of the SIHA 2.1 application among health workers in 3 (three) districts/cities in Central Java Province, namely Semarang, Jepara, and Grobokan. A cross-sectional design was used in this study and the sample selection technique used a non-probability sampling technique with an accidental sampling method. So that the number of samples that fit the researcher's criteria was 56 people. The results showed that there is a significant relationship between Performance Expectancy, Effort Expectancy, and Price Value related to health workers' interest in implementing the SIHA 2.1 application. As for Hedonic Motivation, there is no significant relationship. It is expected that the development of the SIHA 2.1 application to further improve services to minimize the occurrence of errors in the use of information systems for recording and reporting HIV/AIDS data and to simplify the filling of the SIHA 2.1 application.
Hubungan Karakteristik Individu dengan Kinerja Petugas Rekam Medis di Puskesmas Wilayah Kota Mataram Rizal Pratama Adi Putra; Sismulyanto Sismulyanto; Agus Supinganto; Menap Menap; Sastrawan Sastrawan; Suardi Suardi; Uswatun Hasanah; Musparlin Halid
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 5 No 3 (2024): June
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v5i3.4627

Abstract

Efforts to improve the performance of healthcare workers at Community Health Centers are crucial due to various aspects related to improving healthcare services. This study aimed to determine the relationship between individual characteristics and the performance of medical recorders at Community Health Centers in the Mataram City area. The research used a cross-sectional design with a sample size of 43 people. Bivariate analysis was used with a confidence level of 95% and a p-value <0.05. The study showed that there was no significant relationship between gender (p=0.737) and the performance of medical record officers. On the other hand, there were a relationship between educational background and performance with p=0.036, length of service and performance with p=0.036, age and performance with p=0.006. Additionally, employment status and performance with p=0.001, and training and performance with p=0.019. Therefore, individual characteristics such as educational qualifications, length of service, age, employment status, and training play an important role in improving the performance of medical record officers at Community Health Centers in the Mataram area. Healthcare service organizations need to optimize workforce management strategies and improve the quality of medical record management.
Studi Meta-Analisis Kesediaan Penggunaan Electronic Medical Record pada Tenaga Kesehatan Muhammad Dudayev Caesar Putra; Sarah Ayu Safitri Ekamas
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 5 No 3 (2024): June
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v5i3.4656

Abstract

A survey conducted by the Indonesian Hospital Association found that 50% of hospitals had implemented an electronic medical record system and only 16% had implemented electronic medical records properly. There needs to be preparation such as training, computer access, the attitude of health workers and the presence of technicians in implementing electronic medical records. This study aims to determine the relationship between training, presence of technicians, attitudes and computer access on the willingness to use electronic medical records among health workers. This research uses a systematic review and meta-analysis with dependent variables in the form of training, presence of technicians, attitudes and computer access and an independent variable in the form of willingness to use electronic medical records, which later these variables are transformed into PICO. Articles were selected using prism flow with inclusion criteria and data analysis using the Review Manager 5.3 application. A total of 12 articles met the inclusion criteria with a total sample of 5,171 health workers. The results of the meta-analysis research show that the forest plot shows that there is a relationship between training, the presence of technicians, attitudes and computer access and the willingness to use electronic medical records among health workers. Meanwhile, the funnel plot results for the presence of officers and computer access are symmetrical, while those for training and attitudes have the potential for publication bias.
Pelaksanaan Penganalisisan Data Rekam Medis Elektronik (Studi Perancangan Sistem Informasi Analisis Kuantitatif) Suyoko Suyoko; Faik Agiwahyuanto; Dyah Ernawati; Jaka Prasetya; Maulana Tomy Abiyasa
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 5 No 3 (2024): June
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v5i3.4666

Abstract

Telogorejo Hospital has implemented an electronic medical record (EMR) system. However, the documentation of EMRs remains incomplete, and completeness analysis is still conducted manually. This necessitates a quality improvement program within the digital transformation process to ensure complete EMR documentation. This study aims to investigate the implementation of EMR data analysis based on PMK 24 of 2022, as well as the design and evaluation of an information system for quantitative analysis of medical records. The research methodology employs a mixed-methods approach, combining Research and Development and descriptive research. The study was conducted in the medical record department from July to December 2023. Data collection methods include interviews, observations, and questionnaires. The system development utilizes the waterfall model, while testing employs the black box method and the TAM method for user acceptance evaluation. The findings indicate that the quality improvement program adheres to PMK 24 of 2022. However, doctors continue to use uncertified signatures for authentication, and mandatory settings for EMRs are absent. Application testing demonstrates successful operation, and TAM evaluation reveals that users strongly agree with the quantitative analysis application (90.5%). Recommendations include implementing certified electronic signatures and mandatory settings for EMR forms to optimize EMR completeness.
Analisis Diagnosis Tuberkulosis Paru Pasien Rawat Inap Bulan November 2023 di RSUD Banyumas Najwa Azkia Rahma; Zahrasita Nur Indira; Harry Fauzi; Utami Budi Lestari
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 5 No 3 (2024): June
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v5i3.4718

Abstract

According to the World Health Organization (WHO) in the Global Tuberculosis Report 2021, TB is one of the 10 causes of death in the world. The Ministry of Health of the Republic of Indonesia recorded a total of 658,543 TB cases in 2023 as of November 3, 2023. At Banyumas Hospital, TB cases are still relatively high, the factors that affect this pulmonary TB are clinical factors. The research was made to determine the clinical factors of Pulmonary TB disease and supporting examination factors in determining the success of claims at Banyumas Hospital. This type of research method uses quantitative, with analytical descriptive research design, and cross sectional research design. The type of data used is secondary data, namely medical record data for inpatients with pulmonary TB, Data analysis using Univariate which describes the percentage of Pulmonary TB. The total number of TB patients had 43 medical records in November 2023 at Banyumas Hospital, the result of the percentage of male sex factors (62.79%) Female (37.21%), the most OAT-giving factor RHZE (76.74%), the most age factor for the elderly (30.23%). Supporting Factors for positive TCM reading (48.83%) and RO factor Thorax pulmonary TB reading (93.02%). The advice from this study is to monitor TB patients to regularly take OAT so that they never break up for 6 months.
Analisis Penerimaan SIMRS Rumah Sakit TK IV DKT Kediri dengan Technology Acceptance Model Eva Firdayanti Bisono; Krisnita Dwi Jayanti; Putri Indra Suryandari; Nurhadi Nurhadi; Agustinus Nugroho Pudji Lestarjo; Sonia Ghaniy Anassya
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 5 No 3 (2024): June
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v5i3.4920

Abstract

The Hospital Information System (SIMRS) integrates the entire process of hospital services through information technology. The transition from the old system to the new one developed by a vendor requires a transition process due to SIMRS still requiring manual data input. This study aims to analyze the acceptance of SIMRS in the medical record unit using the TAM method. The research method employed is quantitative descriptive with purposive sampling technique involving 4 medical record staff. Data was collected through questionnaires. The research results indicate that the percentage calculation of perceived ease of use (84.16%), perceived usefulness (80%), Attitude toward using (73%), behavioral intention (87.50%), and actual usage (80%) falls under the category of strongly agree. It is hoped that the TK IV DKT Kediri Hospital will provide periodic training on SIMRS usage, especially for staff members using SIMRS, and enhance the completeness of SIMRS features in the future.
The Hubungan Kelengkapan Rekam Medis Terhadap Akurasi Pengkodean ICD-10 dan ICD-9 Annisa Wahyuni; Nurul Fitri Khumaira; Siska Siska
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 5 No 3 (2024): June
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v5i3.4947

Abstract

The completeness of medical records is an important factor that affects the quality of data and coding accuracy. Based on the initial survey at the 'Aisyiyah General Hospital, found from 20 medical records still 75% completeness of filling in the incoming and outgoing summary sheets, the absence of anamnesis and diagnosis results, and 60% completeness of the doctor's item recording component. The purpose of this study was to find out the relationship between the completeness of medical record documents with the accuracy of the ICD-10 and ICD-9 coding. This study used descriptive and inferential quantitative methods with a population of 638 documents, and the number of samples of 84 files uses simple random techniques. The frequency of filling in the medical record document is incomplete 89.3%, the duration of the ICD-10 code is 26.2% and the ICD-9 CM was 32.2%. The analysis results showed that there was no significant relationship between the completeness of medical record documents and the accuracy of the ICD-10 and ICD-9 coding (P-Value > 0.05). Complete medical records tend to have more accurate coding, while incomplete medical records often cause errors in coding. The importance of maintaining the completeness of medical records to increase coding accuracy has a positive impact on the management of health data, clinical decision-making, and health insurance claims. Efforts to increase the completeness of medical records, such as training in medical staff and effective electronic system implementation, are recommended to ensure better coding quality.

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