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JOURNAL OF MEDICAL RECORDS AND HELATH INFORMATION
Published by Sekolah Tinggi Ilmu Administrasi Malang
ISSN : 27159817     EISSN : 27229831     DOI : -
Core Subject : Humanities, Health, Education, Social,
Humanities Education Health Professions Public Health Social Sciences
Puji syukur kita panjatkan kehadirat Allah SWT, atas berkat dan rahmat Nya kamidapat kembali hadir untuk menyajikan artikel-artikel terkini pada JRMIK: Jurnal Rekam Medis & Informasi Kesehatan Volume 03 Nomor 02 Edisi Juni, Tahun 2022. Semua artikel yang dimuat pada Jurnal ini telah diseleksi dan ditelaah oleh Dewan Editor . Hanya artikel-artikel berkualitas baik dan sangat baik yang dapat dimuat pada JRMIK: Jurnal Rekam Medis & Informasi Kesehatan. Topik-topik yang disajikan pada edisi ini meliputi: klasifikasi dan kodefikasi rekam medis, komunikasi rekam medis, dan manajemen rekam medis. Kepada penulis yang telah berkontribusi pada penerbitan jurnal edisi ini, kami menyampaikan terima kasih yang mendalam, selanjutnya kami mengundang rekan sejawat peneliti perekam medis dan informasi kesehatan mengirimkan naskah untuk disajikan pada jurnal ini. Saran dan kritik yang membangun, pembaca dan para pihak lainnya sangat kami harapkan. Selamat membaca.
Arjuna Subject : Profesi Kesehatan - Menejmen Informasi Kesehatan
Articles 5 Documents
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Search results for , issue "Vol 1 No 1 (2020): JOURNAL OF MEDICAL RECORDS AND HELATH INFORMATION" : 5 Documents clear
Analysis Of Timeliness Return of Outpatient Medical Record Daily Document at Pandanwangi Community Health Centre (Puskesmas), Malang, Indonesia: Ali Hanafiah*, Femy Anggriyani, Ach. Choirul Anwar, Andhika Putra Eka Wijaya Ali Hanafiah; Femy Anggriyani; Ach. Choirul
JOURNAL OF MEDICAL RECORDS AND HEALTH INFORMATION Vol 1 No 1 (2020): JOURNAL OF MEDICAL RECORDS AND HELATH INFORMATION
Publisher : Malang: Sekolah Tinggi Ilmu Administrasi Malang

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Abstract

Medical Record is a written proof of the process of service provided to patients by doctors and medicalpersonnel, while with the existence of such written evidence the medical record can be justified therefore theaccuracy of the return of medical record files is very important for service and for data processing. Toconsistently improve doctors and medical personnel such as nurses in returning outpatient medical record filesto medical record units, good collaboration and high discipline of health workers is required. The purpose of thisstudy is to know in general the description and timeliness of daily document recording of outpatient medicalrecords to the unit of Medical Record at Puskesmas Pandanwangi and to identify the problem of non-timelinessof return of daily medical record document to the Medical Record Unit. The result of this research is a researchusing descriptive analysis method with qualitative approach. Data collection techniques used by researchers areobservation and interview. Methods Data analysis used is descriptive method that aims to create a description ofa situation objectively. The result of the research proves that in general the reason for the delay of return ofmedical record file is the lack of discipline factor from health officer like doctor or nurse. As a result ofthorough research, documents are returned on time (1x24 hours) 1846 documents and documents that are late(more than 1x24 hours) 136 documents. From the calculation it can be seen that the number of medical recorddocuments that return on time is greater than the late medical record and for the percentage of return of medicalrecord documents in July 2017 is for the Medical Record of Outpatient that is returned on time is 1x24 hours of93, 14% and for outpatient medical records returned over the specified time of 1x24 hours at 6.86%.Keyword : Timeliness, Daily Medical Record Document, Outpatient
Correlation of Filling Fitness for Discharge Summary of Inpatient with the Health Ministerial Regulation Number 269 Year 2008 in Baptis Hospital, Batu City, Indonesia Farah Adiba; Adi Santoso; Soraya
JOURNAL OF MEDICAL RECORDS AND HEALTH INFORMATION Vol 1 No 1 (2020): JOURNAL OF MEDICAL RECORDS AND HELATH INFORMATION
Publisher : Malang: Sekolah Tinggi Ilmu Administrasi Malang

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Abstract

The summary of returning patients is a summary of all patient care and treatment periods as has been attemptedby health workers and related parties. This sheet should be signed by the treating physician. The patientsummary returns reflect all the important information that concerns the patient and can serve as a basis forfurther action. Based on PERMENKES 269 / MENKES / PER / III / 2008 in stage 4 states that the homesummary must be made by doctors and dentists who treat patients. Therefore, the summary of patients returninghome is said to be still not good because the filling in the Medical Resume that has not been filled completely.This study uses Descriptive research, which is one type of research method that tries to describe and interpretthe object in accordance with what it is. The method used in data collection is interview and observation. Thisstudy aims to review the suitability of filling patient summary returns on the inpatient medical records file atBaptist Batu Hospital. The data used are medical record data file of inpatients in January-March 2017. Theresults showed that the highest percentage in the filling summary of patients back home that is as much as 100%exist in the patient identity variable. The completeness of the completion of the outpatient patient summary formfound at inpatient in January had reached 84%, February 86%, and March reached 87%.Keyword : Patien home summary, conformity
Implementation of ICD-10 Codefication Precision in Diagnosis of Febric Observation of Inpatient Patients (Case Study of Febric Observation Diagnosis in Kanjuruhan Hospital, Malang, Indonesia) Sri Erna Utami; Ana Sugiati
JOURNAL OF MEDICAL RECORDS AND HEALTH INFORMATION Vol 1 No 1 (2020): JOURNAL OF MEDICAL RECORDS AND HELATH INFORMATION
Publisher : Malang: Sekolah Tinggi Ilmu Administrasi Malang

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Abstract

A medical record is a file containing records and documents about the patient's identity, examination, treatment,actions and other services provided to the patient at the health care facility. In principle the contents of themedical record are the property of the patient, while the medical record file (physically) belongs to a hospital orhealth institution. The provision of a good medical record system, one of which must be supported by theaccuracy of ICD-10 verification. the accuracy of codification is very important for hospital management.Factors determining the accuracy of the use of ICD-10 are the diagnosis of disease by the physician and thediagnosis of diagnosis by the medical recorder. Another factor that can lead to inaccuracy is that doctors oftenonly focus on the examination, management and evaluation of the patients they care for. Implementation ofICD-10 coding accuracy on diagnosis of inpatient febrile observation patients at RSUD Kanjuruhan Kepanjenon 50 in-patient medical record documents from August to November 2016. Correct codification of 5 files with10% percentage, incorrect codefication of 40 files with percentage 80% and unfilled codefication 5 files withpercentage 10%. and for patients treated for 2 days the percentage is 8%, the percentage of 3 days is 10%, thepercentage of 4 days is 34%, the percentage of 5 days is 32%, the percentage of 6 days is 10%, the percentage of7 days is 4%, and the percentage is 9 days is 1%. So for the average patient AVLOS patients febrile observationis 4hari. and supported from laboratory result hence normal patient is 33 with percentage 66% and result oflaboratory of abnormal patient is 17 with percentage 34%. It is desirable, the doctor to be able to determine thefinal diagnosis or primary diagnosis because under any circumstances the main diagnosis should be establishedespecially on the final examination. Because in this case, the diagnosis at the end of the examination affects therates and actions given to the patient.Keywords : Febric Observation Diagnosis, implementation, ICD-9 CM, ICD-10
Inpatient Service Efficiency Analysis Based On Inpatient Indicators (BOR, ALOS, TOI and BTO) (Study on Inpatient Indicators at Gondanglegi Islamic Hospital, Malang, Indonesia): Suhartinah*, Muhammad Arief Rachman, Muhammad Masyhur, Asrianni Rindha Wahyuningsih
JOURNAL OF MEDICAL RECORDS AND HEALTH INFORMATION Vol 1 No 1 (2020): JOURNAL OF MEDICAL RECORDS AND HELATH INFORMATION
Publisher : Malang: Sekolah Tinggi Ilmu Administrasi Malang

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Abstract

Statistics are a description of a condition poured down in numbers and can be taken from reports, research or medical record sources. Statistics can be used to calculate various indicators one of which is an inpatient indicator. These indicators are BOR (Bed Occupancy Rate), ALOS (Average Lenght Of Stay), TOI (Turn Over Interval) and BTO (Bed Turn Over). The inpatient indicator can be presented in a Barber-Johnson chart showing the point to be in an efficient area or outside. This research uses quantitative method with descriptive approach. Because this research describes and presents systematically data in Gondanglegi Islamic Hospital. Based on collecting data, the data will be applied in the Barber-Johnson formula and in the figure on the Barber-Johnson chart. The result of the calculation of the inpatient indicator at Gondanglegi Islam Hospital in January 2017 obtained BOR value of 38.46%; ALOS of 2.55 days; TOI of 4.1 days and BTO of 4.7 times. Then in February 2017 obtained a BOR value of 43.29%; ALOS of 2.75 days; TOI of 3.6 days and BTO of 4.4 times. And in March 2017 obtained BOR value of 44.44%; AVLOS of 2.87%; TOI of 3.6 days and BTO of 4.8 times. the result of the calculation of the points or lines of the inpatient indicator on the Barber-Johnson chart are outside the efficient area. Based on Barber-Johnson's efficiency standards indicates that Gondanglegi Islamic Hospital has not met the predetermined efficiency standards because the Barber-Johnson chart shows that the indicator's points and lines are outside the efficient area. Keyword : Efficiency, Indicators of Inpatient, Barber-Johnson.
ANALISIS KELENGKAPAN PENGISIAN FORM REKAM MEDIS UNTUK MENINGKATKAN MUTU DI PUSKESMAS PANDANWANGI MALANG TAHUN 2017 Suhartina
JOURNAL OF MEDICAL RECORDS AND HEALTH INFORMATION Vol 1 No 1 (2020): JOURNAL OF MEDICAL RECORDS AND HELATH INFORMATION
Publisher : Malang: Sekolah Tinggi Ilmu Administrasi Malang

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Abstract

Kelengkapan pengisian Dokumen Rekam Medis (DRM) sangat berpengaruh terhadap informasi yang dibutuhkan pasien dan laporan yang dibuat oleh puskesmas tersebut. Pada penelitian sebelumnya diperoleh hasil yang dapat menggambarkan tingkat kelengkapan dan ketidaklengkapan form rekam medis pada bulan april, mei dan juni 2017. Tujuan dari penelitian ini adalah untuk mengetahui angka kelengkapan pengisian form rekam medis, mengidentifikasi setiap lembar form dan untuk mengidentifikasi faktor-faktor yang menyebabkan ketidaklengkapan form rekam medis. Penelitian ini dilakukan dengan menggunakan teknik observasi pada dokumen rekam medis dan wawancara. Sampel dalam penelitian ini sebanyak 279 berkas rekam medis rawat jalan (RJ) pada bulan april, mei dan juni 2017, dengan teknik pengambilan sampel menggunakan simple random sampling dengan rumus slovin tingkat kesalahan 10%. Hasil penelitian menunjukkan bahwa tingkat kelengkapan DRM pada bulan April, Mei dan Juni berdasarkan identifikasi adalah bulan Juni (form 2 identitas pasien) sebanyak 94,4% sedangkan ketidaklengkapan DRM adalah bulan Mei (form 3 identitas pasien) sebanyak 35,1%. Kelengkapan pengisian pada form 1A (tanggal) sebesar 100%, sedangkan ketidaklengkapan tertinggi adalah bulan April (form 3 data penunjang) sebanyak 58,94%. Berdasarkan autentifikasi adalah bulan Mei (form 5 tandatangan) sebanyak 94,6% sedangkan ketidaklengkapan tertinggi sebanyak 30,52% di bulan April. Dengan demikian dapat disimpulkan bahwa tingkat kelengkapan cukup baik namun perlu adanya evaluasi dan sosialisasi secara berkala dalam upaya peningkatan kelengkapan sehingga dapat meningkatkan mutu rekam medis dan mutu di Puskesmas tersebut. Keyword : Pengisian Form, Mutu Pelayanan Kesehatan. The completeness of the filling of the Medical Record Document (DRM) is very influential on the information needed by the patient and the report made by the Puskesmas. In the previous research, it can be obtained that can describe the completeness and incompleteness of medical record form in April, May and June 2017. The purpose of this research is to know the number of completion of medical record form filling, to identify each sheet form and to identify the factors causing incomplete medical record form. This research was conducted by using observation technique on medical record document and interview. The samples in this study were 279 outpatient medical record (RJ) records in April, May and June 2017, with sampling technique using simple random sampling with slovin formula error rate of 10%. The results showed that the level of completeness of DRM in April, May and June based on identification was June (form 2 patient identity) of 94.4% while the incompleteness of DRM was May (form 3 patient identity) of 35.1%. Completeness of filling in form 1A (date) of 100%, while the highest incompleteness is April (form 3 supporting data) as much as 58.94%. Based on the authentication is the month of May (form 5 signatures) of 94.6% while the highest incompleteness of 30.52% in April. Thus it can be concluded that the level of completeness is quite good but the need for regular evaluation and socialization in an effort to improve the completeness so as to improve the quality of medical records and quality at the Puskesmas. Keyword : Form Filling, Quality of Health Services.

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