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Muhammad Yunus
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m.yunus@polije.ac.id
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+628123413933
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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 191 Documents
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Analisis Faktor Penyebab Terjadinya Duplikasi Nomor Rekam Medis Rawat Jalan di Puskesmas Kencong Kabupaten Jember Esa Amanda Setiawan; Rossalina Adi Wijayanti; Atma Deharja; Selvia Juwita Swari
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 3 (2020): June
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v1i3.2005

Abstract

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.
ANALISIS KUANTITATIF KELENGKAPAN PENGISIAN RESUME MEDIS DI RUMKITAL DR. RAMELAN SURABAYA Nofitalia Sawondari; Gamasiano Alfiansyah; Indah Muflihatin
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 2 No 2 (2021): March
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v2i2.2008

Abstract

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.
ANALISIS KUANTITATIF KELENGKAPAN PENGISIAN FORMULIR INFORMED CONSENT RUMKITAL DR. RAMELAN SURABAYA Aditya Dwi Arimbi; Indah Muflihatin; Niyalatul Muna
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 2 No 2 (2021): March
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v2i2.2009

Abstract

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.
ANALISIS SISTEM PENGENDALIAN BERKAS REKAM MEDIS DI RUMAH SAKIT UNIVERSITAS AIRLANGGA SURABAYA Septiya Atik Cahyani; Andri Permana Wicaksono; Novita Nuraini
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 2 No 2 (2021): March
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v2i2.2010

Abstract

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.
Analisis Pelaksanaan Retensi dan Pemusnahan Berkas Rekam Medis di Rumkital dr Ramelan Surabaya Eltigeka Devi Apriliani; Indah Muflihatin; Niyalatul Muna
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 4 (2020): September
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v1i4.2012

Abstract

The first time retention at RUMKITAL Dr. Ramelan Surabaya were conducted in 2008. Based on data patient visits of Dr. RUMKITAL Ramelan Surabaya from 2015 to 2019 had increased it caused the storage shelf could not accommodate medical record files. SPO (Standard Procedure Operational) about implementation of retention and destruction of medical records in Dr. RUMKITAL Ramelan Surabaya not found provisions of the storage inaktif medical record file. The aim of this research was to analyze the implementation of retention and destruction medical record files in Dr. Ramelan Surabaya with identifying using 5M (Man, Money, Material, Machine, Method) and the USG method (Urgency, Seriousness, Growth) to determine the priority of problem. This research is qualitative research and collecting the data using observations, interview, and documentation. The subject of study is 1 scan officer of medical record and 2 officer of medical record. The results of this research is got 3 priority cause of problem the implementation of retention and destruction of medical record are elements of method, material and machine. The suggestion of this problem are improving the SPO (Standard Procedure Operational) and implementation the system information of retention.
ANALISIS FAKTOR PENYEBAB KETERLAMBATAN PENGEMBALIAN BERKAS REKAM MEDIS RAWAT INAP RUMAH SAKIT PUSAT PERTAMINA Anggia Lutfi Rohmawati; Feby Erawantini; Mochammad Choirur Roziqin
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 2 No 2 (2021): March
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v2i2.2013

Abstract

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.
Evaluasi Kesuksesan Sistem Informasi Manajemen Rumah Sakit dengan Metode Delone and Mclean Mochammad Arief Darmawan; Dony Setiawan Hendyca Putra
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 3 (2020): June
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v1i3.2020

Abstract

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.
Desain Tata Ruang Filing Poliklinik JKN Berdasarkan Lingkungan Fisik yang Ergonomis Mochammad Arief Darmawan; Mochammad Choirur Roziqin; Feby Erawantini
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 3 (2020): June
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v1i3.2021

Abstract

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.
Tinjauan Keterlambatan Klaim Berkas BPJS Rawat Inap di RSUP dr. Hasan Sadikin Lutfiatun Nadibah Herman; Sustin Farlinda; Efri Tri Ardianto; Agus Setiawan Abdurachman
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 4 (2020): September
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v1i4.2030

Abstract

The implementation of the National Health Insurance program in hospitals as referral Health Service Provider in collaborate with the Indonesia Health Insurance Implementing Agency to provided public health services by using a prospective payment system. Based on preliminary study, it known the inpatient claim file had delayed as much 11.38%. It’s not according to hospital standards that claimed should be 100%. This research aimed to provided a preview the causing factors of delayed inpatient claims at RSUP Dr. Hasan Sadikin Bandung based on 5M management elements. This research was descriptive qualitative with expose the results of interviews and observations that had been done in comparison of the theories available. The results showed that the officers still found difficulties to read the diagnosis and the patient's actions due to doctor’s handwrinting difficult to read, incorrect diagnosis codes and actions due to differences in perception between the coder and the doctor, incomplete claimed files such as the result of the patient's supporting examination. There was no standard operational procedure as regulation of inpatient BPJS claimed requirements, computers that been used in the process of filing claims often experiencing long loading and often experiencing network disruptions so it could reduce the performance of officers. In response to those factors, it needs to make a standar operational procedure for completing claim files, to conduct training specifically about National Health Insurance coding at least once a year and doing maintenance on the computer at least once a month. 
Analisis Penyebab Lama Penyediaan Berkas Rekam Medis Rawat Jalan di Puskesmas Mangaran Lutfiatun Nadibah Herman; Rossalina Adi Wijayanti; Atma Deharja; Mochammad Choirur Roziqin
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 2 No 1 (2020): December
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v2i1.2031

Abstract

The provision of long-term patient outpatient medical record files in Mangaran Public Health Center is one type of service provided to patients. Based on pre-research survey, it known that the time for providing the medical record files that exceed the established standards is 17.70%. This researched aim is to analyze the caused factors of the long duration for supplying medical file records of long-term patient based on individual and situational factors which will the priority causes of the main problems using the Reinke method. This research is qualitative research. The results showed that long waited for supplying medical record files of long-term patient is the searching process of the medical file records that takes a long time due to the attitude of the officer while handling misfile is not optimal, there is no training related to the medical records, less detailed SOP registration does not contain the standard time to provide the medical file records and the absence of SOP to return the medical records, and also the computers that often error and unavailability of tracers in the storage room. In response to those factors, it is necessary to make an improvement and socialization about the registration SOP’s, requesting propose of the medical record file map/folders and the use of tracers, and also held a training specifically about the medical file records at least 2 or 3 times a year and also doing the computer maintenance at least once a month.

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