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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 4 No 2 (2023): JOURNAL OF MEDICAL RECORDS AND HEALTH INFORMATION" : 5 Documents clear
RANCANG BANGUN APLIKASI PELAYANAN KEBIDANAN BERBASIS WEB DENGAN METODE OOP (OBJECT ORIENTED PROGRAMMING) PADA PRAKTIK MANDIRI BIDAN NY.SARI Erlin Nur Fatma; Crismantoro Budi Saputro; Irmawati Mathar
JRMIK Vol 4 No 2 (2023): JOURNAL OF MEDICAL RECORDS AND HEALTH INFORMATION
Publisher : Malang: Sekolah Tinggi Ilmu Administrasi Malang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.58535/jrmik.v4i2.52

Abstract

The application of Information Technology in the field of Health has penetrated the obstetric sector. Butin reality there are still obstetric practices that have not had a positive impact on advances ininformation technology, one of them is the Ny.Sari’s Obstetric Clinic which in its service activities stillapplies a manual system and often encounters obstacles such as the difficulty of finding old patientdata, obstetric care documentation that meets storage, and report recapitulation takes a long time. Thegoal of this research is to develop a web-based midwifery service application that is expected tofacilitate the activities of midwifery services in the independent practice of Ny.Sari’s Obstetric Clinicmore effectively. The method used is OOP (Object Oriented Programming) method with UML (Unifiedmodeling Language) modeling to design Use Case Diagrams, Activity Diagrams, Class Diagrams, andSequence Diagrams. The stages of using the SDLC (System Development Life Cycle) method start fromthe requirement analysis, design, development, implementation and testing. The web-based obstetricsservice application requirements consist of the actors requirement, functional requirement, and nonfunctionals requirement. The results of the design of obstetric service application are currently madeattractive user interface design to facilitate the operation and implemented in the form of a website thatconsists of login menu, Dashboard, patient menu, service menu, queue menu and report menu. Withthe application of this obstetric service, service activities at Ny.Sari’s obstetric clinic become easier andmore effective
ANALISIS DESKRIPTIF KINERJA PETUGAS PENDAFTARAN DAN DUPLIKASI PENOMORAN REKAM MEDIS DI RSUD dr.R.SOEDARSONO KOTA PASURUAN: KINERJA PETUGAS PENDAFTARAN DAN DUPLIKASI PENOMORAN REKAM MEDIS Maulia Yasmin; Fitria Rakhmawati; Titis Eka Gusti
JRMIK Vol 4 No 2 (2023): JOURNAL OF MEDICAL RECORDS AND HEALTH INFORMATION
Publisher : Malang: Sekolah Tinggi Ilmu Administrasi Malang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.58535/jrmik.v4i2.54

Abstract

Angka kinerja petugas dan duplikasi penomoran rekam medis di Indonesia masih tergolong rendah. Salah satunya terjadi di RSUD dr.R.Soedarsono Kota Pasuruan. Dimana hasil studi pendahuluan menunjukkan bahwa selama empat bulan terakhir yaitu pada bulan Juli sampai bulan Oktober sebanyak 46 berkas rekam medis yang mengalami duplikasi dan untuk petugas pendaftaran masih banyak yang lulusan SMA. Tujuan penelitian ini untuk menganalisis kinerja petugas pendaftaran dan duplikasi penomoran rekam medis di Rumah Sakit Soedarsono Kota Pasuruan. Jenis penelitian adalah kuantitatif deskriptif dengan metode pendekatan studi retrospektif. Sampel penelitian ini berjumlah 148 berkas rekam medis pasien baru pada bulan Juli sampai Oktober dan 16 petugas pendaftaran. Teknik pengumpulan data menggunakan lembar kuesioner, wawancara, observasi dan analisis data menggunakan analisis univariat. Hasil penelitian menunjukkan kinerja petugas tidak baik 81,3% (13 petugas), dan baik 18,7% (3 petugas). Sedangkan duplikasi penomoran rekam medis 31,1% (46 berkas), dan tidak duplikasi 68,9% (102 berkas). Kesimpulan penelitian ini adalah kinerja petugas pendaftaran dan duplikasi penomoran rekam medis di RSUD dr.R.Soedarsono Kota Pasuruan masih cukup tinggi.
IMPLEMENTASI KOMUNIKASI EFEKTIF DALAM PENGISIAN GENERAL CONSENT DI TPP RSUD KABUPATEN JOMBANG Soraya Soraya; Hafiz Nayotama; Tri Murni
JRMIK Vol 4 No 2 (2023): JOURNAL OF MEDICAL RECORDS AND HEALTH INFORMATION
Publisher : Malang: Sekolah Tinggi Ilmu Administrasi Malang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.58535/jrmik.v4i2.57

Abstract

Background: Effective communication is a communication that is able to produce attitude change in the people involvedin the communication. General Consent sheet is a consent sheet given to the patient or family after receiving a completeexplanation from the registration officer.Objective : The purpose of this study was to find out whether the officers at the Patient Registration Center had appliedeffective communication in explaining the content and purpose of the General Consent to patients.Methods : This type of research used a descriptive method with a quantitative approach. Researchers used data collectiontechniques with questionnaires which were distributed to 68 patients and 4 officers at TPP Jombang District Hospital.Results : The level of understanding of officers about the SOP for filling in General Consent only has a percentage of25%. The level of patient understanding of filling out the General Consent. related to filling in the Name on the GeneralConsent sheet has a percentage of 97%, filling in Medical Record Number Medical Record has a percentage of 88.2%,filling out a statement for payment has a percentage of 90%, filling in locqtion, date and time has a percentage of 85%,filling in a signature and clear name has a percentage of 88%, filling in the witness's signature has a percentage of 88%and finally the signature of witnesses from the patient's family has a percentage of 97%. The implementation of effectivecommunication between officers and patients in filling out General Consent was apparently has not optimal and onlyhad an average score below 50.Conclusion : From the results of the study, the researchers found that effective communication between staff andpatients at the TPP RSUD Jombang Regency had not been implemented properly. delivery of information or thoughtsregarding the patient's condition, medical and non-medical actions, treatment plans and the patient's rights andobligations while being treated or carrying out an examination at the hospital.
PENGARUH PEMANFAATAN APLIKASI GOOGLE FORM BAGI PETUGAS REKAM MEDIS UNTUK PELACAKAN ANTENATAL CARE TERHADAP WAKTU TUNGGU PELAYANAN RAWAT JALAN DI PUSKESMAS KEDUNG KANDANG KOTA MALANG femy anggryani; Melvianus Rato Mesang
JRMIK Vol 4 No 2 (2023): JOURNAL OF MEDICAL RECORDS AND HEALTH INFORMATION
Publisher : Malang: Sekolah Tinggi Ilmu Administrasi Malang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.58535/jrmik.v4i2.58

Abstract

Storage of medical record files of pregnant women patients is carried out in the outpatient buildingwith a centralized storage system meaning that the outpatient and inpatient medical record files arestored together in the same storage area, while the examination of pregnant women is carried out in theinpatient building or emergency room which has a distance of about 100 meters to the north of theoutpatient street. This causes officers, namely doctors or midwives, to have difficulty getting oraccessing the patient's visit history plus the patient concerned does not bring identity or KIA book whenthere are pregnant women patients with old patient status visiting suddenly to the inpatient buildingat night. this research method uses quantitative methods The purpose of this study is to make it easierfor officers, in this case doctors or midwives, to be able to access pregnant women's patient history datausing the Google Form application. With this Google Form, officers can also minimize delays in serviceto patients because the medical record data of pregnant women patients can be accessed quickly viacellphones or laptops from officers in the MCH clinic. The benefits of using Google Form are not onlyfelt by patients through effective and efficient services, but will improve the quality of service from theKedungkandang Health Center because patients feel satisfied with the services provided. Systemquality (X1) has a positive effect on waiting time (Y). Based on the SPSS output table "Coefficients"above, it is known that the Significance value (Sig) of the system quality variable is 0.553. Because thevalue of Sig. 0.553> 0.05, it can be concluded that H1 is accepted and Ho is rejected. This means that thesignificant influence between system quality (X1) on waiting time (Y). system quality, informationquality, service quality simultaneously have a significant effect on waiting time Based on the SPSS"Anova" output table above, it is known that the Significance value (Sig) is 0.625>0.05, it can beconcluded that the hypothesis is rejected or in other words, system quality (X1), information quality(X2), and service quality (X3) simultaneously have a significant effect on waiting time (Y). systemquality, information quality.
ANALISIS KEAKURATAN KODE EXTERNAL CAUSE KASUS KECELAKAAN LALU LINTAS BERDASARKAN ICD 10 DI RUMAH SAKIT BAPTIS KEDIRI Robiatud Daniyah; Karmelita Ardantik
JRMIK Vol 4 No 2 (2023): JOURNAL OF MEDICAL RECORDS AND HEALTH INFORMATION
Publisher : Malang: Sekolah Tinggi Ilmu Administrasi Malang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.58535/jrmik.v4i2.59

Abstract

Latar Belakang : Pengkodean pada diagnosa Cedera, Keracunan, dan akibat lain penyebab external(S00-T98) yang tertera pada Bab XIX ICD-10 harus diikuti dengan pengkodean pada Bab XX penyebabpenyebab luar morbiditas dan mortalitas (V01-Y98). Pengkodean dilakukan untuk menggambarkansifat kondisi dan keadaan yang menimbulkannya. Pengkodean eksternal cause dilakukan secaraterpisah pada BAB XX (penyebab luar) morbiditas dan 2 mortalitas (V01-Y98). Kode kasus kecelakaandikatakan lengkap apabila terdapat kode diagnosa cedera dan kode external cause penyebabkecelakaan.Tujuan : Mengetahui keakuratan pemberian kode external cause pada berkas rekam medis pasienkecelakaan lalu lintas pasien rawat inap berdasarkan ICD-10 di Rumah Sakit Baptis Kediri.Metode : Penelitian ini menggunakan metode deskriptif dengan analisis kuantitatif. Tekhnikpengumpulan data dilakukan dengan melakukan observasi dan wawancara.Hasil : Penelitian ini menggunakan 30 sampel berkas rekam medis kasus kecelakaan lalu lintas pasienrawat inap dan mendapatkan hasil 2 dokumen rekam medis dengan kode external cause yang akuratsedangkan 28 dokumen rekam medis lainnya tidak akurat. Ketidakakuratan kode tersebut diantaranyatidak dikode pada karakter ke 5 yang menunjukkan aktivitas korban, salah kode pada karakter ke 4dan, salah kode pada karakter ke 2 sampai karakter ke 4.Kesimpulan : Faktor- faktor yang berkaitan dengan keakuratan dan ketidakakuratan kode externalcause kasus kecelakaan lalu lintas yaitu informasi medis yang tidak lengkap terdapat ketidakjelasandiagnosa yang ditulis oleh dokter. Selain itu faktor yang menyebabkan ketidakakuratan kode externalcause yaitu tidak adanya Standar Operasional Prosedur khusus yang mengatur pengkodean externalcause.Kata Kunci: Kode Penyebab Luar, Pengkodean Diagnosa Kecelakaan Lalu Lintas, Diagnosa Cidera AbstractBackground : Coding for the diagnosis of Injury, Poisoning and other consequences of external causes(S00-T98) listed in Chapter XIX ICD-10 must be followed by coding in Chapter XX for external causesof morbidity and mortality (V01-Y98). Coding is done to describe the nature of the conditions andcircumstances that give rise to them. External cause coding was carried out separately in CHAPTER XX(external causes) morbidity and 2 mortality (V01-Y98). An accident case code is said to be complete ifthere is an injury diagnosis code and an external cause code for the accident.Objective: Observation of healing by assigning an external cause code to the medical record file ofinpatient traffic accident patients based on ICD-10 at the Baptist Hospital of Kediri.Methods: This study uses a descriptive method with quantitative analysis. Data collection techniqueswere carried out by observing and interviewing.Results: This study used 30 samples of medical record files for inpatient traffic accident cases andobtained 2 medical record documents with accurate external cause codes, while the other 28 medicalrecord documents were inaccurate. The inaccuracies of the code include not being coded on the 5thcharacter which indicates the victim's activity, wrong code on the 4th character and, wrong code on the2nd to 4th characters.Conclusion: Factors related to the accuracy and inaccuracy of external cause codes for traffic accidentcases where medical information is incomplete, there is an ambiguity in the diagnosis written by thedoctor. In addition, the factor that causes the inaccuracy of the external cause code is the absence of a special Standard Operating Procedure that regulates the external cause coding.Keywords: External Cause Code, Traffic Accident Diagnostic Coding, Injury Diagnosis

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