Jurnal Rekam Medis dan Informasi Kesehatan Indonesia
Journal Title : Jurnal Rekam Medis dan Informasi Kesehatan Indonesia Initials : jurmiki Frequency : Desember dan Juni Print ISSN : 2829-341X Online ISSN : 2828-5867 Editor in Chief : Fita Rusdian Ikawati, SE., MM., M.Kes DOI : 10.62951 Publisher : program studi Rekam Medis dan Infomasi Kesehatan ITSK RS dr Soepraoen Malang jurmiki(Jurnal Rekam Medis dan Informasi Kesehatan Indonesia), e-ISSN ; 2828-5867, p-ISSN : 2829-341X, merupakan jurnal nasional yang diterbitkan oleh program studi Rekam Medis dan Infomasi Kesehatan ITSK RS dr Soepraoen Malang, Jurmiki menerbitkan makalah asli, artikel ilmiah dan laporan singkat yang terkait dengan keilmuan terkait kesehatan (hukum, sistem informasi, manajemen dan klinis). Jurmiki ini diperuntukkan bagi praktisi, peneliti dan mahasiswa rekam medis dan informasi kesehatan. Jurmiki diterbitkan 2kali dalam 1 Tahun (Juni dan Desember). Indexed by:
program studi Rekam Medis dan Infomasi Kesehatan ITSK RS dr Soepraoen Malang
Analysis of the Accuracy of Diagnosis and Coding in Patient Medical Records at the Mutiara Delima Clinic Sawoo, Ponorogo Regency
This research aims to analyze the accuracy of diagnosis and coding in patient medical records at Mutiara Delima Sawoo Clinic, Ponorogo Regency, and to identify the factors influencing it. The research uses a descriptive method with a qualitative approach. Data were obtained through interviews with 1 medical records officer, observations with 1 medical records officer, 1 doctor, 3 midwives, 3 nurses, and the analysis of 260 medical record documents using instruments in the form of observation and interview sheets. The results show that out of the 260 patient medical records analyzed over one month, 31.54% were accurately coded with diagnosis and coding, 59.62% were diagnosed without coding, and 8.85% were neither diagnosed nor coded. The researchers recommend enhancing the training of medical personnel and strengthening the monitoring system to support service quality and insurance claims.
Copyright (c) 2025 Jurnal Rekam Medis dan Informasi Kesehatan Indonesia https://creativecommons.org/licenses/by-sa/4.0
Medical Record Folder Design at Mazaya Clinic Pulung District, Ponorogo Regency
Medical records are a critical element in health services at the Mazaya Clinic. Field observations revealed that the clinic does not yet have a medical record folder; Patient documents are only stapled sheets without classification or physical protection. This condition poses risks of document damage, data loss, privacy violations, and operational inefficiency, with search times reaching 12 minutes—far from the standards of the Ministry of Health Regulation No. 24/2022. This study aims to design an integrated medical record folder by optimizing three aspects: (1) anatomical structure, (2) physical material, and (3) content completeness.This research used the Borg & Gall Research and Development (R&D) model through four stages: Define, Design, Development, and Dissemination. The prototype was made using 310 gsm art carton laminated with matte finishing. The design was validated by experts and evaluated through field testing at the clinic. The results showed the folder increased document protection (80% moisture resistance), reduced search time by 75% (from 12 to 3 minutes), and improved data accuracy by reducing input errors by 25%. The study concludes that this folder design is a practical solution for supporting clinical accreditation, patient safety, and cost efficiency. Recommendations include technical training for staff, digital system synchronization, and data backup strategies.
The Impact of Electronic Medical Record Implementation on Patient Waiting Time at Outpatient Clinics of Dr. Harjono S. Regional Hospital, Ponorogo
The implementation of Electronic Medical Records (EMR) in healthcare facilities is one of the digitalization strategies aimed at improving efficiency and accelerating administrative processes. This study aims to determine the impact of EMR implementation on patient waiting times in several outpatient clinics at Dr. Harjono S. Regional Hospital, Ponorogo. This research employed a descriptive qualitative approach using observation and interviews with staff in five clinics: Orthopedics, Obstetrics and Gynecology, ENT, Psychiatry, and Pediatrics. The analysis focused on comparing patient waiting times before and after the use of EMR. The results show that waiting times for returning patients decreased significantly due to quicker data access. However, waiting times for new patients remained relatively high due to the complexity of the data input process, including the entry of phone numbers and patient identification. Overall, EMR has had a positive impact by speeding up services and simplifying patient data retrieval. Nonetheless, simplifying the data input process for new patients and enhancing operator training remain necessary.
Factors Causing Delays in BPJS Health Inpatient Claims at Dr. Harjono S Regional General Hospital in Ponorogo Regency
Pending inpatient BPJS Health claims pose a financial and operational challenge for hospitals. At RSUD Dr. Harjono S Ponorogo, 228 pending claims were identified in November 2024 out of 1,335 total claims. This issue was caused by incomplete supporting documents, coding errors, and non-specific medical diagnoses and procedures. This study used a descriptive qualitative approach through observation and interviews. The sample consisted of four claims officers and 228 inpatient pending claim files. The sampling technique used was purposive sampling. Data were analyzed through data reduction, presentation, and conclusion drawing. The study revealed several contributing factors: (1) Man lack of accuracy and training among staff; (2) Method suboptimal claim procedures; (3) Material incomplete supporting documents; (4) Machine information system disruptions; and (5) Money delayed claim payments. The primary causes of pending inpatient claims are incomplete medical documentation and inaccurate coding. Improvements are needed in staff training, claim procedures, and system integration between hospitals and BPJS Health.
Factors Causing Pending Claims on Health BPJS Patients with Fishbone Diagrams at Al–Hikmah Clinic Sukorejo Ponorogo Districrt
Pending BPJS Health claims are claim returns where there is no agreement between BPJS Health and FKRTL regarding coding or medical principles (claim disputes), but resolution is carried out in accordance with BPJS Law Number 7 of 2018. The purpose of this research is to identify the factors causing pending claims using the Fishbone diagram approach, which includes the aspects of Man, Money, Method, Machine, and Material. The type of this research is a qualitative descriptive method using interviews and observations. The population of this study consists of all inpatient and outpatient insurance officers at Al-Hikmah Clinic. The sampling techniques used are total sampling and purposive sampling. Data were analyzed descriptively. Based on the research results at Al-Hikmah Sukorejo Clinic, the factors causing pending claims include the absence of staff with a background in medical records, incomplete claim documents, system errors in the P-Care application, and internet network issues. Continuous training, improvement of the digital system, and adjustment of SOPs are needed to minimize pending claim cases and enhance service efficiency. The researchers' recommendation is to always check the completeness of claim documents for the BPJS insurance claim process and to conduct regular training for claim officers at the clinic.
Implementation of Electronic Medical Records at Balong Community Health Center, Ponorogo Regency
Electronic Medical Records (EMR) are a form of digitalization in healthcare services aimed at improving efficiency, accuracy, and integration of patient data. This study aims to identify the implementation of EMR based on ideal implementation indicators at Puskesmas Balong, Ponorogo Regency. Data were obtained through observation and interviews with registration officers, medical staff, and the head of the health center using the EPUS Klaster application system. The results showed that EMR implementation had a positive impact by accelerating services, facilitating access to patient data, and improving coordination between units. However, obstacles such as network disruptions, lack of training, and dependency on third-party vendors remain significant. Managerial support was also found to be suboptimal in providing necessary facilities and infrastructure. It is necessary to strengthen human resource training, improve IT infrastructure, and conduct regular evaluations to ensure that EMR implementation runs optimally and sustainably.
A Comparative Analysis of Patient Service Efficiency Using Electronic Medical Records and Conventional Medical Records at Dr. Harjono S. Ponorogo Regional General Hospital
Medical records are a crucial component in hospital health services. With technological advancement, Electronic Medical Records (EMR) are expected to improve service efficiency. This study aims to identify and compare the efficiency of patient services using EMR and Conventional Medical Records (CMR) at RSUD Dr. Harjono S. Ponorogo. This research employed a qualitative comparative method with data collected through observation and interviews. The study involved five informants: a doctor, a nurse, a conventional medical record officer, an electronic medical record officer, and an IT staff member involved in medical record management. The results show that EMR is more efficient in terms of time, cost, data security, information access, and reporting. CMR still holds advantages in direct physical access without relying on technology. It is concluded that EMR implementation supports faster and more integrated patient services. Therefore, hospitals are encouraged to adopt EMR systems comprehensively.
Copyright (c) 2024 Jurnal Rekam Medis dan Informasi Kesehatan Indonesia https://creativecommons.org/licenses/by-sa/4.0
Implementation of Electronic Medical Records at the Registration Desk of Muhammadiyah Ponorogo General Hospital
Electronic Medical Records (EMR) are digital systems that play an important role in improving the efficiency and accuracy of healthcare services, particularly in the patient registration process. This study aims to understand the implementation process of EMR, identify the challenges faced, and evaluate the effectiveness of EMR usage at the registration desk of Rumah Sakit Umum Muhammadiyah Ponorogo. This research uses a qualitative method with a descriptive approach. The data collection techniques used include in-depth interviews with the head of medical records, registration officers, and the information technology team, as well as direct observation and documentation. Data analysis was conducted through the stages of data reduction, data presentation, and conclusion drawing. The research results show that the implementation of RME at Rumah Sakit Umum Muhammadiyah Ponorogo can accelerate the patient registration process from 10–15 minutes to less than 5 minutes, improve data accuracy, and facilitate coordination between units. The challenges faced include network disruptions, data input errors, and staff adaptation to the new system. Improvement efforts are carried out through regular training, periodic evaluations, and enhanced coordination with the information technology team. In conclusion, the implementation of RME at the registration desk of Muhammadiyah General Hospital has proven to support faster, more accurate, and intregated service, in line with the national policy of digital transformation in the health sector. This research recommends improving infrastructure quality, strengthening training for officers, and refining standard operating procedures to support the sustainability of the RME system.
Readiness of Electronic Medical Record Implementation at Budi Asih Trenggalek Hospital using the Fishbone Diagram Method
The electronic medical record (EMR) is an important step in supporting the digitization of health services, with the aim of improving the effectiveness, efficiency and accuracy of the management of patient medical data in hospitals. This study aims to determine the readiness of the implementation of RME in BUDIASIH Hospital Trenggalek by using the Fishbone Diagram method as an analytical tool in identifying the factors that influence.This study uses a descriptive method with a qualitative approach to explore the implementation process in depth. The Data was obtained through in-depth interviews and direct observation to 20 informants who actively use the RME system in the implementation of daily tasks.The results showed that the readiness of RME implementation in Budi Asih Hospital was influenced by five main factors, namely man (Human Resources), matherial (tools), machine (data), method (methods), and money (budget). Health workers and administrative staff have been able to operate RME well, accompanied by regular training and workshops to improve understanding related to System updates. Equipment and support systems are available and functioning properly, along with scheduled maintenance to keep the system running stably. Data management has been done accurately and timely, supported by periodic audits to maintain the quality and validity of the data. The hospital also has a clear Standard Operating Procedure (SOP) I n the implementation of RME and has allocated a budget to support the sustainability of this system. Overall, Budi Asih Trenggalek Hospital has shown good readiness in the implementation of RME and is ready to develop this system to support the improvement of the quality of health services in the future.This study recommends increased maintenance of software and hardware as well as regular training of human resources to support the sustainability of the RME system.
Analysis of Electronic Medical Record Implementation Based on HOT- FIT Factors at Ngebel Health Center, Ponorogo Regency
The implementation of Electronic Medical Records (EMR) is a requirement in the digital transformation of healthcare services in accordance with the Indonesian Ministry of Health Regulation No. 24 of 2022. However, EMR implementation still faces several obstacles in healthcare facilities, including at the Ngebel Public Health Center in Ponorogo Regency. This study aims to analyze the implementation of EMR based on the HOT-FIT framework, which includes four components: Human resources (Human), Organization, Technology, and Net Benefits.This research uses a qualitative descriptive approach with analysis based on the HOT-FIT framework. Data collection techniques include observation, interviews, and documentation. The subjects of this study were seven EMR users.The results show that the EMR has been implemented at the Ngebel Public Health Center since April 2023. The implementation process has been fairly good, however, challenges remain, such as internet connectivity issues and limitations in system features.This study recommends improving internet infrastructure to optimize the benefits of health services, as well as adding a digital signature (TTE) feature to the EMR system at the Ngebel Public Health Center.
Qualitative Analysis of the Completeness of Medical Resume Documentation at Dr. Harjono S Regional Public Hospital, Ponorogo Regency
A medical resume is a summary of patient care that plays a vital role in administrative, clinical, legal, and hospital accreditation aspects. This document serves as a crucial component in ensuring service quality and acts as legal medical evidence. This study aims to analyze the completeness of medical resume documentation at Dr. Harjono S Regional Public Hospital and identify the contributing factors to incomplete documentation. This research employed a qualitative descriptive method with a cross-sectional approach. Data were collected through observation of 15 inpatient medical resume documents from two departments (Pediatrics and Orthopedics) and interviews with medical record officers. The research instrument included an observation checklist assessing seven documentation components. Results showed that supporting examination results were the most complete component (100%), while patient identity data had the lowest completeness (67%). Contributing factors to incompleteness included high workload, lack of supervision, and low awareness among staff regarding the importance of complete documentation. Moreover, the absence of an internal quality control system was also identified as a challenge. This study recommends enhancing training, conducting regular supervision, and implementing electronic medical record systems to improve documentation quality.
Preparation of Retention of Manual to Electronic Medical Record Documents using Fishbone Diagram at Puskesmas Kauman Baru Ponorogo
Retention preparation is the process of identifying, assessing, and grouping archives in accordance with the applicable retention schedule, before final action is taken on the archive. This study aims to determine the obstacles to retention preparation from manual to electronic at the Kauman Baru Ponorogo Health Center and the challenges of retention preparation. The research used descriptive qualitative method with data collection method. Data were obtained through observation of 33,445 medical record documents, as well as interviews with medical record officers. The research instrument included an observation sheet with five assessment components. The results showed that retention preparation still faced obstacles, especially in terms of facilities and infrastructure. One of the main obstacles is the limited storage space, which is narrow and not suitable to support the process of digitizing medical records. This study recommends increasing training, providing a new building that is suitable and safe for storage and the process of digitizing medical record documents can run effectively and in accordance with regulations.
Poster Design Planning to Increase Community Motivation in using the Satu Sehat Application at Harapan Bunda Clinic Ngampel
The Satu Sehat application was developed as an integrated electronic medical record platform. However, low public awareness and the absence of visual promotional media at Klinik Harapan Bunda Ngampel have resulted in minimal application usage. Therefore, a poster design is needed to increase public motivation to use the application. The study was conducted at Klinik Harapan Bunda Ngampel with participants including clinic staff, patients/family members, and a design expert. The method used was Research and Development (R&D) with a 3D model: Define (needs identification), Design (poster design), and Development (product testing and revision). The research took place from April to May 2025. The results showed that the designed poster contained essential information about Satu Sehat and was considered effective as a promotional medium. Validation by clinic staff and the design expert yielded scores of 84,28% and 90%, respectively, categorized as “good.” The poster was found to be attractive, easy to understand, and capable of increasing public motivation. The design of the poster to increase public motivation in using the Satu Sehat application at Klinik Harapan Bunda Ngampel proved effective in conveying information visually and can serve as a communication strategy to support digital transformation in healthcare services at the clinic.
The Use of JKN Mobile Application in Improving Patient Satisfaction in Registration Services at Kauman Baru Health Center, Ponorogo Regency
Digital transformation in healthcare services encourages technology-based innovations, one of which is the Mobile JKN application. This application is expected to improve service efficiency and patient satisfaction, especially in the registration process at healthcare facilities. However, the extent to which this application positively impacts patient satisfaction still needs further investigation. This study aims to determine the relationship between the use of the Mobile JKN application and patient satisfaction, as well as to identify influencing factors and usage barriers at Puskesmas Kauman Baru, Ponorogo Regency. This research is a descriptive quantitative study involving 50 respondents selected using purposive sampling. Data collection was conducted through questionnaires, observation, and interviews. Data were analyzed descriptively and using Spearman correlation tests with the assistance of SPSS software. The results showed a significant relationship between the use of Mobile JKN and patient satisfaction (ρ = 0.318; p = 0.025). The use of the Mobile JKN application contributed positively to satisfaction, mainly due to ease of access, time efficiency, and the majority of respondents being in the productive age range (20-40 years). The main barriers in using the Mobile JKN application included difficulties faced by the elderly, technical issues, and limited network access. Education and technical support are needed to ensure more optimal implementation across all age groups.
Review of the Preparation for the Implementation of Electronic Signatures for the Authentication of Medical Records Based on a Fishbone Diagram at the Ngebel Community Health Center
Background: The application of electronic signatures (TTE) is an essential step in supporting digitalization efforts to authenticate medical record documents (RME) in a secure and efficient manner. This study aims to review the readiness for TTE implementation at Puskesmas Ngebel using the Fishbone Diagram analysis (5M: Man, Method, Material, Machine, Money). Subjects and Methods: This research uses a qualitative method with data collection conducted through interviews with respondents including the Head of Puskesmas (for triangulation), medical record officers, registration staff, doctors, and nurses. Research Results: The results show that Puskesmas Ngebel is still in the initial stage of implementation and faces various obstacles as identified through the Fishbone Diagram analysis. This study is expected to review the level of readiness for TTE implementation and offer solutions to overcome the identified challenges. By applying the Fishbone Diagram approach, this research successfully identifies institutional barriers in preparing for the implementation of electronic signatures for authenticating medical record documents. The findings are expected to contribute to strategic planning for digitalization in community health centers.
Analysis of Medical Record Documentation and Reporting in Health Service Facilities
Abstrak . Latar Belakang: Fasilitas layanan kesehatan memegang peranan penting dalam memberikan layanan kesehatan yang bermutu, termasuk pencatatan dan pelaporan rekam medis yang terpadu. Sistem pencatatan dan pelaporan yang andal sangat penting untuk memastikan ketersediaan data medis yang akurat, mendukung evaluasi layanan kesehatan, dan menyederhanakan proses administrasi. Tujuan: Penelitian ini bertujuan untuk menganalisis sistem pencatatan dan pelaporan rekam medis di fasilitas layanan kesehatan, dengan fokus khusus pada struktur dan implementasi sistem tersebut. Metode: Penelitian ini menggunakan pendekatan kajian pustaka naratif. Data dikumpulkan dari 10 artikel ilmiah yang diambil melalui Google Scholar berdasarkan kriteria inklusi dan eksklusi yang telah ditetapkan sebelumnya. Ekstraksi dan sintesis data dilakukan untuk menjawab pertanyaan penelitian. Hasil: Temuan penelitian menunjukkan bahwa sistem pencatatan dan pelaporan rekam medis di fasilitas layanan kesehatan menghadapi berbagai tantangan, termasuk keterbatasan sumber daya manusia, prevalensi dokumentasi manual yang rentan terhadap kehilangan data, dan implementasi teknologi informasi yang belum optimal. Beberapa fasilitas kesehatan telah memulai adopsi sistem digital untuk meningkatkan akurasi dan efisiensi pelaporan. Kesimpulan: Pelatihan yang efektif, regulasi yang lebih kuat, dan peningkatan kapasitas teknologi diperlukan untuk meningkatkan implementasi sistem rekam medis di fasilitas kesehatan.
NORMATIVE LAW REVIEW: PMIK WORKLOAD CHALLENGES IN FACING THE RME ERA
In carrying out the process of processing health data and information, Medical Recorder and Health Information (PMIK) personnel are needed who have the ability to provide services to patients. The emergence of the Minister of Health Regulation Number 24 of 2022 concerning electronic medical records requires every health care facility to run electronic medical records, this makes the workload owned by PMIK reduced. So it is necessary to analyze the challenges of PMIK workload in facing the RME era. The method used is qualitative with a normative law study approach. The approach used for data collection is based on documentation studies through regulations, journals, and news. The tool used for data collection is a notebook. Data processing techniques using secondary data. In carrying out their duties, many Medical Recorders and Health Information (PMIK) still do not understand the use of existing systems properly, this causes delays in the processing of medical data. The abilities possessed by PMIK personnel in the RME era greatly affect the patient data processing process so that it is necessary to conduct training and skill development related to the correct use of the RME system in order to reduce the workload faced by officers.
Copyright (c) 2024 Jurnal Rekam Medis dan Informasi Kesehatan Indonesia
Mortality Reporting Management in Electronic Medical Recprd at Hospital X
Mortality reporting is an important aspect of evaluating the quality of health services. At Hospital X, the still manual mortality reporting system faces challenges such as slow processes and vulnerability to errors, therefore this study aims to analyze the input, process, and output in mortality reporting. The method used in this study uses a qualitative approach with interview and observation techniques, data were collected from medical record and administrative staff involved in the mortality reporting process, as well as analysis of related documents. The results of this study indicate that the implementation of electronic medical records has increased efficiency in mortality reporting. However, data accuracy is still a significant problem caused by data input errors and lack of training for system users. These research findings indicate that ongoing training and improved technology infrastructure are essential to support the EMR system at Hospital X. With an optimal ERM system, it is expected that the quality of mortality reporting will improve, which will later have an impact on improving the overall quality of health services. This study recommends further development in the management of mortality reporting using EMR
LITERATURE REVIEW: EVALUASI KUALITAS KELENGKAPAN DATA PADA FORMULIR REKAM MEDIS PASIEN DI RUMAH SAKIT
This study aims to analyze the completeness of inpatient medical record filing using a literature review method. A total of 10 articles were selected from journal databases, grey literature, and hand searching. The research findings indicate variation in the percentage of medical record completeness among the analyzed articles, with some showing high completeness rates and others showing low completeness rates. Factors contributing to incompleteness include errors in form filling and insufficient understanding among medical staff regarding the importance of medical record completeness. Recommendations from this study include the necessity to enhance medical staff's understanding of the medical record filling process, as well as the implementation of better policies and training to ensure optimal completeness in medical documentation. This research contributes to understanding the factors influencing the completeness of inpatient medical records and provides a basis for developing strategies to improve the quality of healthcare services in hospitals.
Copyright (c) 2025 Jurnal Rekam Medis dan Informasi Kesehatan Indonesia
EVALUASI SISTEM E-RESERVASI RAWAT JALAN DENGAN PIECES FRAMEWORK DI RUMAH SAKIT UMUM DAERAH KOTA MATARAM
The implementation of the e-reservation system at the Regional General Hospital of Mataram has not been maximized due to several obstacles such as errors and long loading times. The purpose of this study is to describe the results of the evaluation of the outpatient e-reservation system at the Mataram Hospital with the PIECES Framework. This type of qualitative research presents the results of interviews and observations conducted by researchers and evaluated with the PIECES Framework. There were 15 informants in this study. The sampling technique used was purposive sampling. The results obtained from this study are the performance of the e-reservation system has produced data according to user needs, makes it easier for users, and still occurs errors, long loading, and failure. Information can already provide accurate, consistent, and relevant information but still get inconsistent information with the services obtained. Economic human resources and supporting resources have supported and helped minimize hospital expenses. Control every employee has access rights and system security is good. Efficiency can already provide convenience in registering through the e-reservation system. The e-reservation system service can already help officers accurately input and output data and reduce waiting time. The conclusion is that the e-reservation system can help users in the service process and facilitate registration so as not to wait long.
TINJAUAN KEPUASAN PASIEN TERHADAP PELAYANAN PENDAFTARAN ONLINE BERBASIS WHATSAPP DAN TELEPON PASIEN RAWAT JALAN DI RSU ANNA MEDIKA MADURA
At Anna Medika Madura's Hospital, patients still claim to be less content with online registration services with whatsapp online registration services and outpatient phones at Anna Medika Madura General Hospital. The type of research used was quantitative descriptive research. The population of this research were all the old outpatient who were online registration at Anna Medika Madura General Hospital and the determination of the number of samples using accidental sampling based on time using 5 dimension. Based on the results of the analysis on each dimension it be seen that of the 82 respondents, on the tangibles dimension expressed satisfaction with a percentage of 79,67%. On the reliability dimension, stated that they were very satisfied with a percentage of 80,63%. On the responsiveness dimension, stated that they were satisfied with a percentage of 76,26%. On the assurance dimension, stated that they were very satisfied with a percentage of 82,85%. On the empathy dimension, stated that they were very satisfied with a percentage of 81,71%. Thus the assurance dimension had the highest level of satisfaction. The average overall patient satisfaction is 80,22% in the satisfied category. The clarity and ease of the service are essential to improving the quality and level of the satisfaction of the patient, the quality of service having an effect on the patient’s satisfaction. Online registration can make it easier for the patient and is shown to be able to support hospital activities in the registration process and also to have the ability to reduce waiting times which will increase patient satisfaction.
GAMBARAN PERSEPSI PENGGUNA REKAM MEDIS ELEKTRONIK RAWAT JALAN DI PUSKESMAS
The digitalization of health services is developing very rapidly, marked by the existence of electronic medical records. The implementation of electronic medical records has been required by the government in Minister of Health Regulation number 24 of 2022. Based on the results of a preliminary study at the Berbah Sleman Primary Health Center, there were several obstacles to its implementation, namely related to the internet network and errors in the software which caused the outpatient registration process is stopped. The object of this research is to describe the perceptions of users of outpatient electronic medical records from the perspective of the Technology Acceptance Model (TAM). This type of research is quantitative descriptive by distributing questionnaires to 18 respondents. The results obtained showed that 15 respondents (83%) said it was very good in terms of perceived usefulness, 10 respondents (56%) said it was very easy in terms of perceived ease of use, 18 respondents (100%) said it was very good in terms of perceived behavior intention to use, and as many as 16 respondents (89%) stated that it was very good in terms of actual usage perception. Of the four perceptions which include usefulness, ease of use, behavior intention to use, and actual usage in implementing electronic medical records, users receive it very well.
ANALISIS KESIAPAN PENGGUNA SIMRS & REKAM MEDIS ELEKTRONIK (RME) DENGAN METODE TRI 2.0 DI RSGM UNIVERSITAS JEMBER
Healthcare 4.0 presents a promising new vision for the healthcare industry, including hospitals. Its objective is to offer superior, value added health services, while simultaneously enhancing the effectiveness and efficiency of the healthcare industry. Consequently, it will effectively boost the quality, significance, productivity, cost-effectiveness, and efficiency of healthcare services and elevate patient satisfaction. Electronic Medical Records (EMR) and SIMRS are two technologies undergoing implementation and advancement. However, numerous hospitals have yet to realize optimal implementation. The Technology Readiness Index (TRI) serves as a user readiness parameter for adopting and utilizing new technology. The questionnaire comprised 44 items to assess users' readiness. The validity test demonstrated that all items were valid (r count > r table) and the questionnaire Cronbach's Alpha respectively indicating reliability. The questionnaire design can be used to evaluate the preparedness of SIMRS and electronic medical record (RME) users in hospitals using the technology readiness index approach. Further research is necessary to implement the questionnaire design.
TINJAUAN TERKINI PENANGGULANGAN HIV DI PROVINSI NTB TAHUN 2020
HIV and AIDS are very dangerous diseases, and they are a serious concern for the government of the NTB province. The spread of this disease is almost throughout the NTB province. Data from the NTB Provincial Health Office in 2021 shows that the health centers with the highest number of HIV and AIDS cases are among males. This research aims to determine the percentage of the population who died due to HIV/AIDS based on age and gender in the NTB province in 2020. The research method used is a qualitative descriptive research method. Qualitative descriptive research is used to determine the percentage of the population who died due to HIV/AIDS based on age and gender in the NTB province in 2020. Researchers used interviews and documentation. Respondents were selected using purposive random sampling, where the researchers themselves determined who would be the informants for the study. The results of the research show that there are people who are concerned and active in dealing with AIDS, but many are not involved in AIDS prevention due to various factors. Combating AIDS requires active participation from multiple parties, including the government, the community, those who are infected, and those who are affected.
ANALISIS PERSENTASE PENDUDUK PENDERITA HIPERTENSI YANG MENDAPATKAN PELAYANAN KESEHATAN DI NUSA TENGGARA BARAT TAHUN 2019-2021
Hypertension is a problem throughout the world and is one of the main risk factors for cardiovascular disease. Hypertension or high blood pressure can be caused by several factors, both factors that can be changed and cannot be changed. This study aims to find out the percentage of the population with hypertension who receive health services in each region in West Nusa Tenggara province based on age and gender. This research method uses a descriptive research type with samples, namely data on residents suffering from hypertension in 10 districts in West Nusa Tenggara (NTB) Province in 2019-2021 with a sampling technique, namely a non-probability technique of purposive sampling type. The research results showed that of the 119,500 participants consisting of men and women, the majority of participants were over 18 years old. male participants numbered 135,453 while the number of women was 142,889. The results of the research obtained a distribution of respondents based on gender between men (62,09%) and women (74,79%). Hypertension in teenagers needs to be watched out for. Suggestions, it is necessary to carry out early prevention efforts related to diet and lifestyle in adolescents, including: changing diet, limiting the use of salt to 4-6 grams per day, foods containing baking soda, seasonings and food preservatives, reducing food intake. which contains high cholesterol, stop smoking, drinking alcohol, and exercise regularly.
STUDI KOMPARASI DAN PREDIKSI PENYAKIT DIABETES MELLITUS DI PROVINSI NUSA TENGGARA BARAT MENGGUNAKAN TREND
This study aims to compare and predict the prevalence of Diabetes Mellitus (DM) in various sub-districts and healthcenters in West Nusa Tenggara (NTB) between 2018 and 2022. The data was sourced from the Disease Management Section of the West Nusa Tenggara Provincial Health Office. The research examines the number of individuals with DM and the percentage of DM patients receiving healthcare services according to established standards. In 2018, 2019, and 2020, there was an increase in the number of patients with DM in across West Nusa Tenggara. The population of DM patients increased annually from 2018 to 2022, with the most significant increase in 2018 and 2019. However, the number of DM patients who received healthcare services according to standards was decreased in 2019. This suggests a pressing need to enhance the healthcare system in West Nusa Tenggara to improve access and the quality of care for individuals with DM. This study offers valuable insights into the challenges and advancements in healthcare services for DM patients in West Nusa Tenggara. The findings of this study serve as a foundation for improved policies and more effective health programs aimed at the issue of Diabetes Mellitus in the West Nusa Tenggara region.
TINJAUAN PENGGUNAAN KOMPUTER TERKAIT GEJALA COMPUTER VISION SYNDROME (CVS) PADA PETUGAS REKAM MEDIS DI RUMAH SAKIT X KEDIRI TAHUN 2023
Information technology is currently developing very rapidly. The development of this technology is evidenced by the use of computers in Electronic Medical Records. Computer use can have both positive and negative impacts on its users. One of the negative impacts is Computer Vision Syndrome. The design of this research is quantitative research with descriptive method. The study population consisted of 24 medical record officers who used computers using a purposive sampling technique, with a sample of 6 officers who met the inclusion criteria. Data collection was carried out by interview and observation sheets. The results of this study found that the number of medical record officers at the X Hospital in Kediri City who were more at risk of experiencing symptoms of Computer Vision Syndrome were 6 officers with age ≤45 years, 4 officers with ≤5 years of service and 2 officers >5 years, staring at the computer monitor for a long time of the 6 officers included in the >2 hour time category, the distance between the computer monitor and the eyes of 3 officers was 45-60 cm and the other 3 officers were<45->60 cm. It is recommended that officers can blink their eyes periodically, adjust the brightness of the computer monitor, check visual acuity, take regular eye breaks according to the 20-20-20 rule and use the zoom in or zoom out technique to adjust the writing on the computer screen.
PERSEPSI PERAWAT DALAM PENERAPAN BUDAYA KESELAMATAN PASIEN DI RS X KOTA MALANG
The quarterly report in 2022 shows that the incidence rate is not expected to reach 99 cases. One effort that can be made to prevent patient safety incidents is to implement a patient safety culture. Nurses as health workers who interact most with patients are the main component who are required to carry out their work in accordance with standard operational procedures to avoid patient safety incidents. Perception is very important in the success of communication, when all nurses have the same perception about the importance of implementing patient safety culture then patient safety incidents can also be prevented. The aim of this research was to measure nurses' perceptions of patient safety culture. The research instrument used a questionnaire based on the HSOPSC which was distributed to 55 nurses as research respondents. This type of research uses descriptive analysis to describe 12 dimensions of patient safety culture. The results show that the cooperation dimension within the unit has the highest positive perception, namely 87% in the good category, while the staffing dimension has the lowest positive perception, namely 61% in the medium category. RS X Kota Malang in its commitment to preventing patient safety incidents can focus on staffing dimensions.
EVALUASI KEGIATAN PELAYANAN PENDAFTARAN PASIEN DI RS X MALANG
The registration service is the first service and directly interacts with the patient and the place where they will register at the polyclinic they are going to. Observational data has revealed that a number of issues, including SIMRS and the network, continue to impede patient registration services. Evaluating patient registration service activities is one approach taken to address this issue. The aim of this research is to evaluate activities in patient registration services. The instrument used was an interview sheet. This type of research uses qualitative descriptive analysis to describe the results of evaluation of patient registration services. The study's findings indicate that although RS X Malang's registration service is functioning effectively, a number of issues continue to arise. Patient registration is frequently hampered by sluggish and unreliable internet connections. Delays in the registration procedure are possible, and SIMRS disruptions happen frequently. In addition, the tracer is still manual, which increases the possibility that the registration officer will overlook recording the patient's medical record information. Another issue is that there is currently no bridging between SIMRS and BPJS, which makes BPJS patient registration more time-consuming due to its multiple steps.
ANALISIS DAMPAK KERUSAKAN REKAM MEDIS PASIEN RAWAT JALAN TERHADAP KEJADIAN PATIENT SAFETY, RESPONSE TIME PELAYANAN PASIEN DAN PENGAJUAN KLAIM BERKAS PASIEN RAWAT JALAN PESERTA BPJS KESEHATAN DI RUMAH SAKIT ISLAM IBNU SINA SIMPANG EMPAT KABUPATEN PASAMAN BARAT
Based on initial observations in November 2022-January 2023, 375 damaged medical records were found at RSI. Ibn Sina Simpang Empat. The impact of tampering with medical records on the incidence of patient safety in target I was 124, target II was 36, and target III was 56. Impact on service response time that was not appropriate was 235 patients. The impact on submitting BPJS claims was delayed by 157 patients. The research objective was to determine the impact of damage to outpatient medical records at RSI Ibnu Sina Simpang Empat.The research method is descriptive qualitative analysis. Respondents who were interviewed were 8 respondents with a supporting sample of 826 damaged outpatient medical records. Data collection techniques used are interviews and observation. The results showed that damaged medical records had an impact on the incidence of patient safety, target I resulted in an error in identifying the patient, target II broke the communication between the service provider and the patient and target III resulted in an error in administering medication to the patient. Impact on inappropriate service response time (> 10 minutes). The impact on the delayed submission of BPJS claims is that the workload increases. The impact of damage to medical records on patient safety, service response time, and submission of BPJS claims. have patient data backups, provide standard time for providing medical records, and provide roll o pack cabinets.