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MEDICORDHIF Jurnal Rekam Medis
Published by Akademi Perekam Medis dan Informasi Kesehatan Bhumi Husada Jakarta
ISSN : 26558955     EISSN : 22529616     DOI : 10.59300/mjrm.v7i0
Core Subject : Health, Education,
Education Health Professions Public Health Other
MEDICORDHIF Jurnal Rekam Medis is a Scientific Electronic Journal of the Medical Recorder and Health Information Academy of Bhumi Husada Jakarta (APIKES BHJ) in order to accommodate the research results of APIKES BHJ lecturers and students as well as other authors outside the APIKES BHJ institutions, as one of the goals of higher education institutions in Indonesia.The Medicordhif e-journal provides the widest opportunity for lecturers, researchers and authors in the scientific fields of medical records, health information, public health, hospital management and also health management to join in as an author in our MEDICORDHIF e-journal.
Arjuna Subject : Profesi Kesehatan - Profesi Kesehatan (Lain-Lain)
Articles 7 Documents
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Search results for , issue "Vol 10 No 1 (2023): MEDICORDHIF Jurnal Rekam Medis" : 7 Documents clear
TINJAUAN DESAIN FORMULIR REKAM MEDIS RAWAT INAP PELAYANAN BEDAH DI RUMAH SAKIT KHUSUS BEDAH RAWAMANGUN Indah Kristina; Dede Maysaroh
MEDICORDHIF Jurnal Rekam Medis Vol 10 No 1 (2023): MEDICORDHIF Jurnal Rekam Medis
Publisher : APIKES Bhumi Husada Jakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (11.033 KB) | DOI: 10.59300/mjrm.v10i1.90

Abstract

ABSTRACT This research was conducted to identify SOP (standart operasional procedure) governing the design of medical record forms, analyze components reviewed from anatomical, physical and content aspects contained in surgical hospitalization forms, and identify design constraints and use of surgical hospitalization forms. The research method used is a quantitative descriptive analysis method with percentage results to obtain an overview of the design review of surgical hospitalization forms at Rawamangun Special Hospital of Surgery East Jakarta. The data collection method is carried out by direct observation using checks and interviews to respondents using interview guidelines and informed consent interviews. The results of this study showed that the hospital already has a policy related to form design, namely SPO (standard operational procedure) form renewal. Guidelines for filling out medical records files and form design policies in the medical record service guidelines, fulfillment of anatomical, physical and fill aspects on surgical hospitalization forms have not been completed 100% fulfilled, from the average physical aspect of 79.20%, anatomical aspects 47.42% and content aspects 95.7%. For design constraints, the lack of knowledge about the rules of form design according to existing policies in hospitals for usage constraints is not too many obstacles, it's just that the instructions are diformed that are less clear. In conclusion, the hospital already has policies related to the design of medical record forms both SPO and guidelines governing aspects of form design, but there are still unmet aspects of the design of surgical hospitalization forms at Rawamangun Surgical Special Hospital. Existing forms do not meet the rules of the form design policy that has been created by the hospital. Bibliography: 14(2012 – 2021) Keywords: Review, Design, Form, SOP.
TINJAUAN KELENGKAPAN PENGISIAN FORMULIR PERSETUJUAN TINDAKAN KEDOKTERAN SECTIO CAESAREA DI PRIMAYA EVASARI HOSPITAL Indah Kristina; Muhamad Abdul Fatah
MEDICORDHIF Jurnal Rekam Medis Vol 10 No 1 (2023): MEDICORDHIF Jurnal Rekam Medis
Publisher : APIKES Bhumi Husada Jakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (11.033 KB) | DOI: 10.59300/mjrm.v10i1.91

Abstract

ABSTRACT Approval for medical action is the approval given by the patient or his closest family after receiving a complete explanation regarding the medical or dental action to be performed on the patient. recording of approval for medical action as evidence that the patient agrees to the action to be taken and must be filled in completely because it can be used as legal evidence in the event of a claim from the patient. This study was conducted to identify standard operating procedures (SOPs) for completing the approval form for sectio caesarea medical action, identify the completeness of filling out the approval form for planned and emergency sectio caesarea medical actions, identify the factors causing incomplete completion of the consent form for medical action at Primaya Evasari Hospital. The research method used is descriptive method with a sample of 103 medical treatment consent forms. The results of the study, standard operating procedures for filling out approval forms for medical actions are available, completeness of filling out approval forms for medical actions 64% are completely filled out and 36% are incomplete, factors that cause incomplete filling of consent forms for medical actions include not knowing that standard operating procedures are available for filling 20% , did not receive socialization of filling out the 20% form, did not understand how to revise 60%, the impact of incomplete filling in the consent form Medical action is that it cannot make valid evidence in the event of a lawsuit. Keywords: completeness of filling out the consent form for medical action. 
ANALISA KEPUASAN PASIEN PADA PELAYANAN DI TEMPAT PENDAFTARAN PASIEN RAWAT JALAN DI RUMAH SAKIT DIK PUSDIKKES TAHUN 2022 Yayah Sya'diah,SST,MKes.; Adika Dwi Prasetyo
MEDICORDHIF Jurnal Rekam Medis Vol 10 No 1 (2023): MEDICORDHIF Jurnal Rekam Medis
Publisher : APIKES Bhumi Husada Jakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (11.033 KB) | DOI: 10.59300/mjrm.v10i1.95

Abstract

ABSTRACT Patient satisfaction is the level of patient feelings that arise from the results of the performance of health services obtained after comparing them with what is expected. . The purpose of this study was to describe the level of patient satisfaction with services at the registration of outpatients at the Pusdikkes Education Hospital in 2022. This research is a descriptive quantitative study to get a picture of the level of patient satisfaction at the Dik Pusdikkes Hospital based on 5 dimensions, namely Tangible, Responsiveness, Reliability, Empathy, Assurance. The results of this study showed that patient satisfaction was 84.07%, tangibles was 16.89%, reliability was 16.57%, responsiveness was 16.86%, assurance was 16.79%, and empathy was 16.96%. To overcome this dissatisfaction, officers should improve services such as directing patients after registering because sometimes patients are still confused, officers should explain information in a voice that is not too loud so that patients are not offended, and so on. Keywords: Outpatient., registration, satisfaction level, service.
Tinjauan kebutuhan rak dan luas ruang penyimpanan rekam medis 5 tahun yang akan datang periode 2021 - 2025 di Rumah Sakit Ibu dan Anak ASIH Garis Gemilang; Ambarwati; Nur Soleh
MEDICORDHIF Jurnal Rekam Medis Vol 10 No 1 (2023): MEDICORDHIF Jurnal Rekam Medis
Publisher : APIKES Bhumi Husada Jakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (11.033 KB) | DOI: 10.59300/mjrm.v10i1.96

Abstract

Penyimpanan rekam medis bertujuan untuk mempercepat dan memudahkan petugas dalam pengambilan kembali rekam medis pada saat rekam medis dibutuhkan ,serta menjaga kerahasian rekam medis.oleh karena itu ,ruang penyimpanan rekam medis harus dilengkapi dengan fasilitas yang memadai untuk mencapai pelayan rekam medis yang baik. Tujuan penelitian ini adalah untuk mengetahui berapakah kebutuhan rak dan luas ruang penyimpanan rekam medis tahun 2021 – 2025 di Rumah Sakit ibu dan anak asih. Didalam penelitian ini penulis menggunakan metode penelitian deskriptif yaitu memperoleh gambaran dan melihat langsung kebutuhan rak rekam medis rumah sakit ibu dan anak asih tahun 2025. Berdasarkan hasil perhitungan didapatkan jumlah rekam medis pada tahun 2020 sebanyak 20.907 rekam medis dan jumlah rekam medis pada tahun 2025 sebanyak 24.603 rekam medis dengan rata-rata pertumbuhan volume rekam medis sebesar 3,31%. Rumah Sakit ibu dan anak asih saat ini memiliki 22 unit rak penyimpanan rekam medis dan luas ruang penyimpanan sebesar 10 m². Pada tahun dibutuhkan 42 unit rak penyimpanan rekam medis serta luas ruang penyimpanan sebesar 17,4 m², sehingga memerlukan tambahan 20 unit rak penyimpanan rekam medis serta ruangan tambahan sekitar 7,4 m².
Tinjauan ketepatan kode diagnosa diabetes melitus pasien rawat inap di Rumah Sakit Umum Universitas Kristen Indonesia Hudiyati Agustini; Atikah Ramadhani
MEDICORDHIF Jurnal Rekam Medis Vol 10 No 1 (2023): MEDICORDHIF Jurnal Rekam Medis
Publisher : APIKES Bhumi Husada Jakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (11.033 KB) | DOI: 10.59300/mjrm.v10i1.97

Abstract

Pemberian kode terhadap diagnosis pasien harus tepat, karena akan memengaruhi informasi laporan morbiditas dan mortalitas, serta administrasi rumah sakit termasuk data klaim biaya pengobatan. Penelitian ini bertujuan untuk mengetahui ketepatan kode diagnosa diabetes melitus di RSU UKI, sesuai dengan standar WHO berdasarkan ICD 10. Penelitian dimulai bulan April−Juni 2022, berdasarkan metode penelitian deskriptif kuantitatif dengan teknik pengumpulan data secara observasi, lembar checklist, dan wawancara. Penelitian ini mengambil sampel 75 ringkasan pulang dari pasien yang dirawat inap dengan diagnosis diabetes melitus. Hasil penelitian mendapatkan 25 kode tidak tepat (33,33%) dan 50 kode tepat (66,67%). Dapat disimpulkan bahwa RSU UKI sudah memiliki standar prosedur operasional pengkodean diagnosa. Namun, masih terdapat pengkodean yang tidak tepat. Faktor utama menjadi ketidaktepatan kode disebabkan oleh dokter yang tidak lengkap menulis diagnosa, dan petugas koding yang tidak tepat dalam menetapkan digit ke-4. Kata kunci: Ketepatan kode diagnosa, Diabetes Melitus, Ringkasan Pulang
TINJAUAN KEBUTUHAN TENAGA INSTALASI REKAM MEDIS BERDASARKAN ANALISIS BEBAN KERJA KESEHATAN DI RUMAH SAKIT PUSAT OTAK NASIONAL PROF. DR. dr. MAHAR MARDJONO JAKARTA Meliana; Adhe Ramadhan
MEDICORDHIF Jurnal Rekam Medis Vol 10 No 1 (2023): MEDICORDHIF Jurnal Rekam Medis
Publisher : APIKES Bhumi Husada Jakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (11.033 KB) | DOI: 10.59300/mjrm.v10i1.98

Abstract

Workload analysis is a method used to determine the amount of time, effort and resources required to carry out organizational tasks and functions. The results of the initial observations. Researchers took the example of a monthly report in October, November, December 2021, it was found that the monthly report for that month experienced a delay in completion. The report that was supposed to be completed at the beginning of the following month was only completed in the middle of the following month, because some work from the medical record installation had not been completed, such as from the coding and analysis of the completeness of the medical record. Research objectives is To calculate the need for personnel in the medical record installation at the Rumah Sakit Pusat Otak Nasional Prof. Dr, dr. Mahar Mardjono Jakarta. Research methodology is Descriptive with a quantitative approach with research subjects 11 medical record officers and the object of research is a review of the needs of medical record installation personnel based on workload analysis. The results of the study Every job in the medical record installation already has an SOP, the available working time is 5 working days in 72000 minutes / year, the result of calculating the number of Human Resouce Health needed is 12 people.Human Resouce Healt needs in medical record installations are 12 people., Keywords : Medical Record , Work Loard Analysis , Human Resouce Health
TINJAUAN KELENGKAPAN PENGISIAN CATATAN PERKEMBANGAN PASIEN TERINTEGRASI ( CPPT ) DALAM MENINGKATKAN KOMUNIKASI EFEKTIF ANTAR TENAGA KESEHATAN DI RUANG RAWAT OBGYN RUMAH SAKIT UMUM UNIVER Meliana; Kanjeng Gamas Brajamusti
MEDICORDHIF Jurnal Rekam Medis Vol 10 No 1 (2023): MEDICORDHIF Jurnal Rekam Medis
Publisher : APIKES Bhumi Husada Jakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (11.033 KB) | DOI: 10.59300/mjrm.v10i1.99

Abstract

The integrated patient progress record (CPPT) form contains information about the patient's identity, important notes, authentication, and good notes in the form of writings on the health services that have been provided to the patient. To coordinate or collaborate between health workers in documenting health services for patients in all polys / clinics in the Hospital, one of which is the Obgyn Room. This study aims to get an overview of the Completeness of Filling in the Integrity Patient Development Record (CPPT) in the Obgyn Inpatient Room of UKI Hospital. The study starts in June – August 2022. The research design used, namely the descriptive method, is to describe the research by conducting interviews and observations with Qualitative and Quantitative approaches. In this scientific paper study, researchers sampled 77 CPPT forms. The results of the study obtained 77 samples studied, obtained complete as many as 27 (35%) CPPT forms and incomplete ones as many as 50 (69.9%) CPPT forms. It can be concluded that UKI General Hospital already has Standard Operating Procedures for filling cppt. We recommend that the doctor again check the instructions that have been given to find out if it has gone right Keywords : Effective Communication, Completeness, Integrated Patient Development Record.

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