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Contact Name
Erna Selviyanti
Contact Email
m.yunus@polije.ac.id
Phone
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Journal Mail Official
rammik@idpublishing.org
Editorial Address
RAMMIK : Jurnal Rekam Medik & Manajemen Informasi Kesehatan Gg. Broto Manunggal V, Brajan, Tamantirto, Kec. Kasihan, Bantul, Daerah Istimewa Yogyakarta 55184
Location
Kab. bantul,
Daerah istimewa yogyakarta
INDONESIA
Jurnal Rekam Medik & Manajemen Informasi Kesehatan (RAMMIK)
ISSN : -     EISSN : 28294777     DOI : 10.47134/rmik
Core Subject : Health,
RAMMIK : Jurnal Rekam Medik & Manajemen Informasi Kesehatan is an journal which provides a platform to scientist and researchers all over the world for the dissemination of knowledge in Health Information Management , medical record and related fields, especially in : Health information management studies Classification of Codification of Diseases and Actions Health Information Systems Health Information Technology Health Information Quality Management.
Articles 16 Documents
Strategi Pencegahan Missfile Pada Rekam Medis Dilihat Dari Unsur 5M di RSAU dr. Sukirman Lanud Roesmin Nurjadin Tahun 2021 Doni Jepisah; Putri Yahya
Jurnal Rekam Medik & Manajemen Informasi Kesehatan Vol. 1 No. 1 (2022): April
Publisher : Indonesian Journal Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (48.259 KB) | DOI: 10.47134/rmik.v1i1.2

Abstract

In the medical record filling section of RSAU dr. Sukirman Air Base Roesmin Nurjadin in the last few days found 5 missfile events. Missfile is an error in placing medical records, incorrectly storing medical records, or not finding medical records in the storage section. The purpose of this study was to determine the missfile prevention strategy based on the 5M element at RSAU dr. Sukirman Air Force Base Roesmin Nurjadin. This type of research is descriptive with a qualitative approach. Methods of data collection using interviews and observation. Informants in this study amounted to 3 people, namely the head and staff of medical records. From the research conducted in the filling section, it was found that two medical record officers with a D III education level in Medical Records and Health Information who had worked for a long time ranged from 4-5 years. But have never received training from a hospital. There is no use of tracers, color codes, and expedition books, only outpatient register books. There is a budget for facilities and infrastructure as well as shelves. SOP for storing and retrieving medical records has been going well. An open medical record shelf made of wood and a medical record folder that is quite thick and has bones in it. We recommend that the hospital filling section use tracers and expedition books in order to minimize missfile events, conduct training for officers and increase the number of existing shelves so that medical records do not pile up and missfile events do not occur again.
Analisis Kelengkapan Berkas Rekam Medis Elektronik Pada Pasien Covid-19 Di Rumah Sakit Muhlizardy Muhlizardy; Winda Azmi Meisari
Jurnal Rekam Medik & Manajemen Informasi Kesehatan Vol. 1 No. 1 (2022): April
Publisher : Indonesian Journal Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (167.753 KB) | DOI: 10.47134/rmik.v1i1.10

Abstract

The medical record as a record of the patient's illness is a file that must be filled in completely. The incomplete filling of the medical record file will result in the notes contained being out of sync and difficult to identify the previous patient's health information. Therefore, the completeness of filling out the medical record file must reach 100% for 1x24 hours after the patient leaves the hospital. This study aims to determine the level of completeness of filling out electronic medical records in Covid-19 patients at PKU Muhammadiyah Gamping Hospital. The design of this research is descriptive quantitative. The sample in this study was the medical record file for Covid-19 patients in a period of one month as many as 155 medical records. The method of data collection is in the form of a checklist. The results showed that 100% of the electronic medical record files were incomplete. The most complete indicators are the results of supporting the diagnosis (100%), nursing actions (98.9), and pain assessment (93.5%).
Analisis Prioritas Penyebab Masalah dalam Pemenuhan Standar Akreditasi 8.4 di Puskesmas Kraksaan Selvia Juwita Swari; Gamasiano Alfiansyah; Wahyu Hidayati
Jurnal Rekam Medik & Manajemen Informasi Kesehatan Vol. 1 No. 1 (2022): April
Publisher : Indonesian Journal Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (117.321 KB) | DOI: 10.47134/rmik.v1i1.11

Abstract

Kraksaan Public Health Center got basic accreditation in 2017. The results of the accreditation standard 8.4 regarding MIRM have not been reached and must be improved for the next accreditation assessment. The purpose of this study is to analyze the priority causes of problems in the 8.4 accreditation standards at the Kraksaan Public Health Center. The method used is the MCUA (Multiple Criteria Utility Assessment). The results of identification of the organization of medical records in fulfillment of the 8.4 accreditation standard were 53.85% (partially fulfilled) with the lowest results in criterion 8.4.4 related to the completeness and confidentiality of medical records (16.67%) while based on the results of priority analysis of the causes of the problem related to the implementation of medical records in compliance with accreditation standards shows that there is no SOP on the implementation of assessments of the completeness and accuracy of the contents of medical records to be a top priority. The results of the study are efforts to improve the organization of medical records in fulfillment of the 8.4 accreditation standards in the form of making SOP assessing the completeness and accuracy of the contents of the medical records.
Keterlambatan Pelaksanaan Retensi Dokumen Rekam Medis di Rumah Sakit: Literature Review Avid Wijaya; Fatimah Azzahro Nur Firdausiyah; Prima Soultoni Akbar
Jurnal Rekam Medik & Manajemen Informasi Kesehatan Vol. 1 No. 1 (2022): April
Publisher : Indonesian Journal Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (151.074 KB) | DOI: 10.47134/rmik.v1i1.12

Abstract

Retention of medical record documents in hospitals must be implemented to limit the number of documents that have been stored on storage shelves for five (five) years, so that they do not accumulate between active and inactive medical record documents. However, several variables contributed to the delay in the implementation of the medical record retention policy. The purpose of this study was to determine procedures, Standard Operating Procedures (SOP), and other factors that contributed to delays in retention of medical records in hospitals. The study was conducted with a literature review of searches on Google Scholar and Garuda. The literature data were analyzed according to the inclusion and exclusion criteria, namely through cross-sectional research methodologies, descriptive surveys, qualitative studies, and journals published between 2017 and 2021. Of all the journals that have been obtained, the procedure for implementing the retention of medical record documents in hospitals is still not implemented properly. The SOP that has been set does not fully explain the procedure for implementing the retention of medical record documents because there are no certain procedures. The delay in the implementation of retention of medical record documents in hospitals is due to differences in the characteristics of archiving officers, supporting facilities and infrastructure, and schedules for storing medical record documents. SOP is important to be made as a guideline to reduce officer errors, and there are several components that cause delays in the implementation of retention of medical record documents in hospitals.
Evaluasi Keakuratan Kodifikasi Diagnosis Penyakit Mata Menggunakan Aplikasi Kodifikasi Diagnosis Penyakit Mata Berbasis Dekstop Di Klinik Malang Eye Center Endang Sri Dewi Hastuti Suryandari Suryandari; Fristara Alintia; Hartaty Sarma Sangkot; Avid Wijaya
Jurnal Rekam Medik & Manajemen Informasi Kesehatan Vol. 1 No. 1 (2022): April
Publisher : Indonesian Journal Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (178.482 KB) | DOI: 10.47134/rmik.v1i1.13

Abstract

An accuration code of diagnosis disease should match ICD-10 classification. The accuration of diagnosis code of eye diseases at Malang Eye Center Clinic by using code list in excel program was 30%. The purpose of this study was to determine the level of accuracy of the coding of eye diseases before and after using the application of Desktop-based Eye Disease Codes, at Malang Eye Center Clinic. The research design used the Research and Development (R&D) method with the One Group Pretest Posttest approach. This research used 200 outpatient medical record documents (MRD) of eye disease (100 MRD for pretest and 100 MRD for posttest), that were taken using simple random sampling method. The percentage result of the accuracy of the codification of eye disease diagnosis using a desktop-based application is 96%. The results showed that there was a difference in the accuration of diagnosis code of eye diseases before and after using the application of Desktop-based Eye Disease Codes (the Z calculated value was -4.76). This application can be used as a tool for coding officers to code eye diseases at the Malang Eye Center Clinic
Determinan Ketepatan Kode Diagnosis Utama di RS Pusat Pertamina Jakarta Selatan Nada Savira Nurjannah; Demiawan Rachmatta Putro Mudiono; Sustin Farlinda; Djasmanto Djasmanto
Jurnal Rekam Medik & Manajemen Informasi Kesehatan Vol. 1 No. 1 (2022): April
Publisher : Indonesian Journal Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (217.023 KB) | DOI: 10.47134/rmik.v1i1.14

Abstract

The inaccuracy of the main diagnosis code will have an impact on the hospital in terms of financing and the quality of the information produced. This can also be influenced by the accuracy of writing the main diagnosis. The purpose of this study was to determinants of the accuracy of the main diagnosis code in the discharged summary of inpatient in February 2022 at Pertamina Central Hospital by paying attention to several components, namely the clarity of writing the main diagnosis and the accuracy of the main diagnosis code. The method used is descriptive qualitative. The total sample is 130 of inpatient discharged summary sheets from a total of 463 medical record files in February 2022. The results showed that 42% discharge summary sheets were not clear in writing the main diagnosis and 86% the main diagnosis code did not correct. It is suggested that the hospital can improve the evaluation of the accuracy of filling in the code and writing the main diagnosis in the summary of discharge, holding training and seminars related to doctor's compliance with the ICD-10 code, and socializing how to enforce the code and write a diagnosis according to the ICD-10 rules.
Analisis Singkatan Dan Simbol Terhadap Formulir Discharge Summary Rawat Inap Untuk Penilaian Akreditasi Snars Mirm (12) Periode Februari Di Rumah Sakit Pusat Pertamina Jakarta Selatan Livia Nuri Syafitri; Demiawan Rachmatta Putro Mudiono; Sustin Farlinda; Djasmanto Djasmanto
Jurnal Rekam Medik & Manajemen Informasi Kesehatan Vol. 1 No. 1 (2022): April
Publisher : Indonesian Journal Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (309.794 KB) | DOI: 10.47134/rmik.v1i1.16

Abstract

Recording in SNARS Edition 1 is included in the Hospital Management Standards group on Information and Record Management (MIRM), one of the medical standards in MIRM, namely the standardization of diagnosis codes, procedure/action codes, symbols, abbreviations, and their meanings contained in the MIRM 12 standard. Where in the assessment element, the hospital must have regulations on standardizing diagnosis codes, procedure/action codes, definitions, symbols used and which should not be used, abbreviations used and which should not be used, and monitored their implementation. Pertamina Central Hospital is a referral hospital and accredited B. Where this hospital becomes the Presidential Hospital. Medical Records used in the form of Electronic and Manual Medical Records. On the Medical Record Form in the application there are abbreviations and symbols. In the use of abbreviations and symbols, socialization has been carried out which contains a guideline entitled "The RSPP abbreviation list book" but in its implementation no evaluation has been carried out. And also there are SOPs that state the existence of abbreviations, symbols, actions and diagnostic codes. In the period of February, there were 463 hospitalized patients. And researchers took samples of medical record number 132 medical records from 30% of the number of inpatients using the formula of slovin. This is a qualitative research using direct observation and documentation methods. The results of observation and study documentation show that the abbreviations that are not appropriate are 45%, 67% for symbols and 55% appropriate for summary form releases, The book of abbreviations and symbols belonging to Pertamina Central Hospital has not yet been legalized and socialized legally. And there is no SOP in accordance with SNARS MIRM 12 for abbreviations and symbols at Pertamina Central Hospital. There is also no evaluation in the implementation of the use of abbreviations and symbols as well as the books used, there are still not several symbols and abbreviations listed in the abbreviation and symbol guidelines in the Rspp.
Analisis Kelengkapan Pengisian Formulir Informed Consent Pada Pasien Rawat Inap Di RS Pusat Pertamina Jonathan Wicaksono; Sustin Farlinda; Thomas M. Purba Purba
Jurnal Rekam Medik & Manajemen Informasi Kesehatan Vol. 1 No. 1 (2022): April
Publisher : Indonesian Journal Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (442.64 KB) | DOI: 10.47134/rmik.v1i1.17

Abstract

The completeness of filling out the informed consent form at Pertamina Central Hospital Jakarta is still less than the Hospital Minimum Service Standard, which is 100%. This is based on the researcher's preliminary study that the completeness of filling out the informed consent form at Pertamina Central Hospital Jakarta was recorded at 73%, while the remaining 27% were incomplete. The purpose of this study was to review the completeness of filling out the informed consent form at Pertamina Central Hospital. This research uses quantitative research with descriptive approach method. Data collection was carried out by observing and documenting the informed consent form as well as interviews with medical record officers. The results showed that the analysis component with the highest completeness was 98%, namely the patient's/guardian's name and patient's signature, while the analysis component with the lowest completeness was 38%, namely the signatures and names of witnesses I and II. The cause of the incomplete informed consent form is the lack of explanation and emphasis by PPA officers on the patient or patient's family to fill out and complete the data that is part of it to be filled and completed.
Analisis Berkas Rekam Medis Rawat Inap Pada Kasus Operasi Di Rumah Sakit Pusat Pertamina Jakarta Selatan Nungki Annisa Pratiwi; Demiawan Rachmatta Putro Mudiono; Djasmanto Djasmanto
Jurnal Rekam Medik & Manajemen Informasi Kesehatan Vol. 1 No. 1 (2022): April
Publisher : Indonesian Journal Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (185.598 KB) | DOI: 10.47134/rmik.v1i1.18

Abstract

Based on the results of observations made at Pertamina Central Hospital, it was found that several inpatient medical record file forms, especially in cases of surgery, were related to filling out forms that were not 100% complete and there was no evaluation of the completeness of inpatient medical record files in surgical cases. The purpose of this study was to analyze the completeness of inpatient medical record files, especially cases of surgery at Pertamina Central Hospital in February 2022. This research method used qualitative descriptive. Sampling using the Slovin formula with a population of 200 and the sample results obtained 67 samples. The results of this study obtained that the completeness of filling out the medical record file operation form in the complete category was 43 medical record files (64%) and 24 medical record files were incomplete (36%). The conclusion of this study is that the completeness of inpatient medical record files in surgical cases, especially related to filling out forms at Pertamina Central Hospital is categorized as incomplete because filling out forms is not 100% complete.
Analisis Kebutuhan Tempat Tidur Di Bangsal Merak RSUP Dr. Kariadi Semarang Tahun 2022-2024 SABRAN SABRAN; M. Kurniawan; S Deddy Setiadi
Jurnal Rekam Medik & Manajemen Informasi Kesehatan Vol. 1 No. 1 (2022): April
Publisher : Indonesian Journal Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (232.39 KB) | DOI: 10.47134/rmik.v1i1.19

Abstract

The hospital as a complete health service unit is currently undergoing development where various standards are used to see the effectiveness and efficiency of health services, some of which are. are BOR and LOS. This research was conducted at RSUSP Dr. Kariadi Semarang, namely in three wards; Basic Peacock, Peacock 1, and Peacock 2. The data used in this study are data from 2017 to 2019. The method used in this study is a quantitative descriptive research method. It is known that the number of bed capacities in Dr. Kariadi did not experience an increase in the study year. In addition, the number of effective days in the three wards varied with the condition that the number of treatment days was predicted to decrease. On the other hand, the BOR is too high so it is necessary to add more beds.

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