Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI)

Evaluasi Penerapan Sistem Informasi Khanza Menggunakan Metode HOT-FIT Di Rumah Sakit Tentara Reksodiwiryo Kota Padang

2024-04-25T05:02:27+00:00

The transformation of changes from Manual Medical Records to Electronic Medical Records by the Government has been stipulated by the Minister of Health by issuing and stipulating Permenkes Number 24 of 2022 concerning Electronic Medical Records, in Permenkes no 24 of 2022 all Health Facilities will be implemented at the end of December 2023.
Simkes Khanza is one of the Electronic Medical Record (RME) Health Management Information System Application programs that can be used by Hospitals, Clinics, PUSKESMAS, as well as Independent Practices that are open in nature, the Khanza Program is a program for Hospital Information Systems designed so that the home hospitals in managing management and processing hospital data can make reports properly and correctly. In carrying out data processing, the method used is the HOT-FIT method where this method is a theoretical framework model used to evaluate information systems in the field of health services.
The purpose of this research is how much the benefits and programs of Khanza are in the Reksodowiryo Army Hospital, Padang City. From the results of research data processing consisting of 20 sample questionnaires with 32 questions obtained which were distributed and discussions with hospital staff, it was found that the use of the system in humans was a score of 64.83%, an average of 3 and a TCR of 81.4 which means that the human variable in using the system khanza, , User Satisfaction, trouble-free, user-friendliness means very good. Furthermore, for the organizational variable, the score was 64.83%, the average was 3.2 and the TCR was 81 with very good results. Then for the Technology variable, the score was 66.3%, the average was 3.3 and the TCR was 82.9 with very good results. Furthermore, the Benefit variable score is 65.3%, the average is 3.3 and the TCR is 81.9 with very good results. It can be concluded that the Khanza program is really needed in RST. Reksodowiryo City of Padang.

Analisis Kesesuaian Kode Diagnosis Utama Neoplasma Di Rumah Sakit Umum Daerah Dr. Soedirman Kebumen

2024-02-29T08:50:05+00:00

Neoplasm is a disease associated with abnormal tissue development due to neoplasia, which is the process of abnormal growth and development of body tissues that grow actively with the autonomic (uncontrolled) system. Information for a patient in a hospital will not be complete and useful if it has not been processed, then coding is required. Giving special diagnosis code of neoplasm should consider 3 things to get the right code, namely topography code, morphology, and behavior. However, in its implementation, there are still many errors in the coder's determination of the neoplasm diagnosis code. This has an impact on services to patients such as errors of Action, care and treatment. This study aims to determine the description of the accuracy of topography and morphology codes in neoplasm diagnosis at Dr. Sudirman Kebumen. The type of research used is descriptive quantitative. Based on the research obtained from 178 inpatient medical records in the case of neoplasms, the samples taken were as many as 39 C codes determined that the accuracy amounted to 8 (20.51%) inaccurate category amounted to 31 (79.49%). Inaccuracy in writing the neoplasm code due to the results of PA (anatomical pathology) that has not come out at the time of coding the disease, anatomical pathology Examination Result Sheet that often the results come late because the laboratory examination outside the hospital and the coding officer is less thorough, sometimes there is a doctor's writing that is less clear so that the difficulty of the officer in reading the diagnosis. This led to the inaccuracy of the neoplasm diagnosis code in Dr. Sudirman Kebumen in September 2020.

Implementasi Standar Interoperabilitas HL7-FHIR Pada Pertukaran Rekam Kesehatan Elektronik di Puskesmas

2024-02-29T08:50:05+00:00

Background: The electronic system used in the implementation of the Electronic Health Record (RKE) must have compatibility and/or interoperability capabilities. In RKE interoperability in Health Facilities must use a health data interoperability service platform managed by the Ministry of Health, namely Health Level Seven International-Fast Healthcare Interoperability Resources (HL7-FHIR). The use of the HL7-FHIR is an example of Apple connecting the Apple Health App to the RKE and Apple Watch. The biggest interoperability challenges of RKE are information stored in different databases which have different formats and data types that are not compatible with each other, making it difficult for different systems to interpret correctly, and there is no interoperability platform. This research was conducted with the aim of analyzing the application of HL7-FHIR on RKE interoperability at SIMPUS so that it is expected to facilitate the implementation of interoperability between health service information systems in Indonesia. Method: This type of research is descriptive qualitative with an action research design. Data collection was carried out using interviews and FGDs with 3 members of the Development Team, as well as document studies. Results: FHIR Resources used as needed in this study were 8 resources and 97 data elements. However, it requires the addition of 16% data elements in the HL7-FHIR data elements. Conclusion: In general, the HL7-FHIR standard can represent the RKE model for interoperability on SIMPUS.

Hubungan Keyakinan Manfaat dan Kemudahan Dengan Kelengkapan Pengisian Rekam Medis

2024-02-29T08:50:05+00:00

Confidence in convenience and confidence in the benefits of filling out medical records are important, if we feel confident about the benefits, automatically filling out medical records completely. Incomplete filling of medical records can cause harm to health services, if something unexpected happens. The medical record is said to be complete if all the indicators contained in the cheek list are filled out completely, the medical record is said to be incomplete if one indicator is not filled in, so there are still many hospitals that get incomplete scores below 100%. Based on this description, the purpose of this study is to determine the relationship between usefulness beliefs and convenience beliefs with the completeness of filling out medical records. This research is an observational study with a cross sectional study design. This research was conducted at Dharma Yadnya General Hospital, within a period of 3 months, namely, January 2022-March 2022, the population of this study were doctors and medical records. The sample selection used non-probability sampling method, for the selection of samples in the medical record using the accidential sampling method. Collecting data using a questionnaire and a cheek list completeness of filling out medical records. The results obtained in this study are that there is no relationship between the belief in the benefits and the belief in convenience with the completeness of filling out the medical record with a p value of 0.164 and a p value of 0.109. Based on the results of this study, even though the belief in the benefits and convenience is good, it does not mean that the health worker fills out the medical record completely, this of course requires consistency and time in filling out the medical record, if the hospital can provide SPO related to filling out the medical record.

Audit Rekam Medis dalam Upaya Peningkatan Kualitas Pengisian Rekam Medis di RSUD Sleman

2024-02-29T08:50:05+00:00

A hospital is a health service institution that provides complete individual health services for inpatient, outpatient, and emergency care. Hospitals as health service providers are required to maintain medical records. The administration of medical records for each hospital refers to the Regulation of the Minister of Health of the Republic of Indonesia. A medical record audit is needed to determine the completeness of data in medical records both in quantity and quality. The purpose of this study was to determine the medical record audit at RSUD Sleman. The type of research used is analytic observational with a cross-sectional study design. This research was conducted at RSUD Sleman, Special Region of Yogyakarta. The research was done from April to October 2022, during a period of 7 months. Simple random sampling was used to collect data from 94 medical records. The audit of 94 samples of medical records resulted in the following findings: completeness, patient identity 100%, professional identity in providing care 99.01%, date and time 70.21%, initial assessment 90.42%, subjective examination 98.84%, objective examination 66.01%, management plan 91.49%, clinical pathology examination 58.51%, radiological examination 75.53%, primary diagnosis 100%, secondary diagnosis 100%, and general agreement 100%. The lowest percentage of 58.51% was obtained for incomplete data.

Tinjauan Karakteristik Sumber Daya Manusia Di Unit Rekam Medis Dalam Meningkatkan Efisiensi Dan Efektivitas Pelayanan Di UPT Puskesmas Kedai Durian Tahun 2022

2024-02-29T08:50:05+00:00

To manage a medical records unit and produce quality health information, adequate resource support is needed, including human resources, facilities and infrastructure. The aim of this research is to determine the management of human resources in the medical records unit in improving the efficiency and effectiveness of services at the UPT Puskesmas Kedai Durian. This research uses a descriptive qualitative research type with a cross sectional approach where data collection was carried out by interviews in September 2022 with employees of the medical records unit at the Toko Durian Health Center, Medan City with the number of officers in the medical records unit being 4 people, including 1 D3 medical records person, 1 person D3 nursing, 1 person D4 midwifery, and 1 person S1 nursing. Based on research results, in managing human resources in the medical records unit to improve the efficiency and effectiveness of services at the UPT Puskesmas Kedai Durian, the majority of employees in the medical records unit do not have a medical records background and have never attended previous training. In conclusion, the UPT of the Kedai Durian Health Center in Medan City is still not efficient and effective in providing services in the Medical Records Unit.

Perancangan Sistem Informasi Pendaftaran Pasien Menggunakan Bahasa Pemrograman Visual Basic Pada Puskesmas Pelabuhan Sambas Sibolga

2024-02-29T08:50:05+00:00

The patient information system at the community health center is an information system that has activities such as queuing, registration and medical records. Registration services that are still manual make registration ineffective and inefficient. Officers needed a lot of time to search for documents and take notes and there was a buildup of patient queues at the registration unit. Apart from that, the manual system for making reports is not effective, so to improve registration services for patients, a health center information system is needed that is able to provide good and fast service to patients. The aim of this research is to design a registration information system application to assist registration officers in providing patient registration services. Data collection methods consist of observation methods, interview methods and documentation methods. This research approach is the SDLC (System Development Life Cycle) approach, which is a cycle used in creating or developing information systems that aims to solve problems effectively. The results obtained from this research are the design of a patient registration information system using the Visual Basic programming language. The results of the interface display from the design of the Sambas Port Health Center information system are login form, main menu form, user menu, patient registration form, patient data search menu, queue menu and patient data report menu. The conclusions obtained by this information system design can help officers in the registration unit at the Community Health Center to be more effective and efficient.

Analisis Kelengkapan dan Ketepatan Kodefikasi Penyakit Neoplasma Berdasarkan ICD-10

2024-02-29T08:50:06+00:00

Diagnosis coding in neoplasm diseases should be complete and precise in accordance to ICD-10 by providing topography codes and morphology codes. Incompleteness and inaccuracy of codes could have an impact on inaccuracies of morbidity reports and inappropriate treatment, as well as increased medical costs. Preliminary studies at UOBK RSUD Dokter Mohamad Saleh Probolinggo showed the percentage of topography code accuracy in 5 medical record documents (MRDs) for neoplasm diseaes was 100%, and the completeness of the neoplasm diagnosis code was 0%. This study objective was to ascertain the completeness and precision of codes in neoplasm diseases based on ICD-10. The research’s design was a quantitative descriptive study with a retrospective strategy using the population of all MRDs of neoplasm diseases in September-November 2022. The sample of 112 MRDs which taken utilizing the technique of total sampling. The factors in the research was the completeness and accuracy of neoplasm diagnosis codes based on ICD-10. Data were collected through observation in the coding section and checklist sheets. The outcome presented the precision of the topography codes was 90.18%, the precision of the morphology codes was 0%, and the precision and thoroughness of the codes in neoplasm diseases was 0%. The incompleteness and inaccuracy of the codes was caused by the absence of morphological code in the patient's medical resume and errors in selecting the topography code block. Coders should complete the morphological code on the patient's medical resume to obtain the neoplasma diagnosis code’s accuracy and completeness.

Tinjauan Faktor Yang Mempengaruhi Waktu Tunggu Pelayanan Pendaftaran Pasien Rawat Jalan Di RS DKT Sidoarjo

2024-02-29T08:50:06+00:00

One form of administrative service at the hospital is the medical record service. The problem in the medical record installation at DKT Sidoarjo Hospital is the waiting time for outpatient medical record services. Based on Permenkes RI No.129/Menkes/SK/II/2008 for patient medical record services at outpatient registration, namely > 10 minutes. This study aims to determine the factors that influence the waiting time for medical record services at outpatient registration at DKT Sidoarjo Hospital. The research method is descriptive with instruments in the form of observations and interviews conducted with the head of medical records and medical records officers in the registration section. The results of this study indicate that the factor that greatly influences the waiting time for medical record services at TPPRJ DKT Sidoarjo Hospital is medical record activities, namely the provision of medical records in the storage section. On the Man Factor, namely the number of officers and educational qualifications of officers who are not from medical records. On the Money Factor there are no funds for the education and training of registration officers and no rewards for officers who are disciplined and friendly in service. In the Methode Factor the use of Registration SOP is not optimal. In Material Factors there is no use of tracers on storage racks. On the Machine Factor, namely frequent errors on SIMRS when performing services.

Analisis Efisiensi Penggunaan Tempat Tidur Di RSJD Dr. Arif Zainudin Surakarta

2024-02-29T08:50:06+00:00

Health Statistics provide information about people’s health and use of health services. The percentage of bed use in health service facilities been formulated consists of 4 parameters, namely BOR, LOS, TOI, BTO which can be depicted in a graphic known as Barber Johnson. The purpose of this study is to analyze the efficiency of bed use based on Barber Johnson at RSJD Dr. Arif Zainudin Surakarta in 2021. The type of research used is quantitative descriptive with Cross sectional design. Population in the form of monthly SHRI recapitulation. The results of this study show that the BOR calculation in 2021 was 48.43% in (Quarter 1), 58.82% (Quarter II), 46.56% (Quarter III), 42.63% (Quarter IV). 20-day AVLOS (Quarter I), 20 days (Quarter II), 18 days (Quarter III), 19 days (Quarter IV), TOI 21 days (Quarter I), 14 days (Quarter II), 21 days (Quarter III), 26 days (Quarter IV), BTO 2 times (Quarter I), 3 times (Quarter II), 2 times (Quarter III and IV). From the analysis conducted, the use of beds in RSJD has not been efficient. To improve the efficiency of bed use, hospital management further improves quality of service and limits value of inpatient indicators according to mental hospitals.

Faktor-Faktor Penyebab Pending Klaim BPJS Rawat Inap Di RSUD Dr. Pirngadi Kota Medan Tahun 2022

2024-02-29T08:50:06+00:00

BPJS claims are submissions for patient care costs for BPJS participants in claiming that there are problems pending claims which are influenced by several factors. The implementation of BPJS claims in submitting files is still delayed so it must be pending, and there are still patient BPJS claim files that are returned for repair, as a result of delays in submitting BPJS claims causing delays in disbursing funds that should be received by the hospital. the factors that cause pending BPJS claims at RSUD Dr. Pirngadi Medan City. The purpose of this study was to determine the factors causing pending claims of BPJS Inpatients at RSUD Dr. Pirngadi Medan City in 2022. This type of research uses a qualitative descriptive method, in this study the population used by officers in the medical record amounted to 4 people and 49 pending files. The results of this study indicate that the cause of pending BPJS claims is caused by differences in perceptions between INA CBG's officers and Verifiers in filling out patient diagnoses, causing obstacles for hospitals, incomplete BPJS claim requirements, diagnoses that are not in accordance with the action, drugs that are not in accordance with diagnostics and the hospital network which is sometimes slow, resulting in errors in the INA-CBGs application and the computer takes a long time to load. Suggestions from this study should be routine checking of the completeness of medical record documents, so that the requirements for submitting BPJS claims have been filled out correctly. The hospital network is further developed so that the work using computer networks is more effective. To equate the perception between the coder and the verifier, it is recommended that officers collaborate more often with doctors regarding diagnosis and disease codes.

Tinjauan Pemberian Kompensasi Terhadap Produktifitas Kerja Petugas Rekam Medis Di Rumah Sakit Tere Margareth Tahun 2022

2024-02-29T08:50:06+00:00

An employee can be said to be productive if he is able to produce goods or services as expected in a short or precise time. The population of this study is medical records officers in the medical records room at RSU Tere Margareth. The sample size is 5 RM employees. The instrument in this research used interviews with respondents who were RM officers at RSU Tere Margareth. The research results showed that the distribution of respondents' answers based on interviews showed that the identification of the Main Duties of Officers in the Hospital Medical Records Unit. Tere Margareth already has a medical record service manual No. Kep/095/I/2019 as follows regarding working time arrangements at Tere Margareth Medan Hospital, divided into 2 work shifts. The performance of medical records officers at Tere Margareth Hospital has two meanings, where first, compensation and performance are directly proportional to the implementation of the quality of work of medical records officers, where from the results of interviews it was found that officers felt very happy, enthusiastic and eager to carry out their responsibilities if their work compensation was increased. However, in the second aspect, whether or not there is compensation for medical records officers, they are still enthusiastic about doing their work because it is their responsibility to do daily work without having to be lured by high compensation. This indicates that awareness of the work responsibilities of medical records officers in Tere Margareth Hospital is good. Based on the results of the research conducted, it can be concluded that RSU.Tere Margareth should pay attention to officer compensation, so that it can help in increasing the productivity of medical records officers at Tere Margareth Hospital, Medan City and officers must also be aware that without compensation, officers continue to work and are responsible for his job.