Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI)最新文献_第3页

Analisis Perbedaan Kelengkapan Formulir Catatan Perkembangan Pasien Terintegrasi (CPPT) Berbasis Elektronik Dengan Berbasis Kertas Pada Diagnosis Skizofrenia Paranoid Di RSJD Surakarta 分析基于电子的、基于纸的综合患者发展记录(CPPT)与日记本上偏执狂型精神分裂症诊断的不一致意见

Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Pub Date : 2022-08-31 DOI: 10.52943/jipiki.v7i2.1078

Ardani Setiowati, Sri Sugiarsi

{"title":"Analisis Perbedaan Kelengkapan Formulir Catatan Perkembangan Pasien Terintegrasi (CPPT) Berbasis Elektronik Dengan Berbasis Kertas Pada Diagnosis Skizofrenia Paranoid Di RSJD Surakarta","authors":"Ardani Setiowati, Sri Sugiarsi","doi":"10.52943/jipiki.v7i2.1078","DOIUrl":"https://doi.org/10.52943/jipiki.v7i2.1078","url":null,"abstract":"Based on a preliminary survey at RSJD Surakarta, the completeness of filling out the electronic-based and paper-based Integrated Patient Development Record (CPPT) form with a total of 10 samples taken at random has 40% completeness on the electronic-based and 60% paper-based CPPT form. This type of research is comparative. The population in this study were all medical record documents of inpatients with a diagnosis of paranoid schizophrenia at the Surakarta Hospital in the first quarter of 2019 totaling 59 electronic patient medical record documents and 63 paper patient medical record documents in the first quarter of 2020. The sample size was obtained by the sample formula. a minimum of unpaired numerical comparative research and with a simple random sampling technique, the results obtained were 31 electronic medical record documents and 31 paper medical record documents. The results of the research on electronic-based CPPT forms on identification reviews are 100%, 100% authentication reviews, and 88% important report reviews. Meanwhile, in the paper-based CPPT form, the identification review is 97%, the authentication review is 90.5% and the important report review is 100%. In this study, the Mann-Whitney test was used as an alternative to the independent t-test which did not meet the requirements. Mann Whitney test results p-value <0.05 so ha is accepted which means there is a difference in the completeness of the electronic-based and paper-based CPPT forms. \u0000Keywords: Electronic and paper CPPT forms, identification review, authentication review, important report review","PeriodicalId":261208,"journal":{"name":"Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI)","volume":"28 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2022-08-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"121124865","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

Tinjauan Faktor-Faktor Penyebab Terjadinya Kerusakan Dokumen Rekam Medis Rawat Inap Di Rumah Sakit Putri Hijau Medan 回顾前线公主医院住院记录记录造成损害的因素

Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Pub Date : 2022-08-31 DOI: 10.52943/jipiki.v7i2.702

Khairani, Khairannisa Harefa

{"title":"Tinjauan Faktor-Faktor Penyebab Terjadinya Kerusakan Dokumen Rekam Medis Rawat Inap Di Rumah Sakit Putri Hijau Medan","authors":"Khairani, Khairannisa Harefa","doi":"10.52943/jipiki.v7i2.702","DOIUrl":"https://doi.org/10.52943/jipiki.v7i2.702","url":null,"abstract":"Medical Record is a file containing records and documents regarding patient identity, examination, treatment, actions and other services for patients at health care facilities. The factors that affect archive damage can be divided into two, namely intrinsic factors which are the cause of damage originating from the archive object itself, for example the quality of paper and the influence of ink. extrinsic factors are the causes of damage that come from external factors of archive objects, such as physical, biological and chemical environmental factors. cross-sectional approach, that is, each research subject is only observed once and measurements are made on the status of the character or variable of the subject at the time of examination. Intrinsic factors which include paper, ink and adhesive with the amount of damage to medical record documents caused by ink with a total of 89 (29.5%). Extrinsic factors include physical, biological and chemical factors with 72 (23.9%) damage caused by fungi. The conclusion is that the biggest damage is caused by intrinsic factors, namely chemical damage as many as 89 (29.5%) medical record documents \u0000 ","PeriodicalId":261208,"journal":{"name":"Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI)","volume":"18 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2022-08-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"125492742","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

Tinjauan Penyebab Terjadinya Misfile Dokumen Rekam Medis Rawat Jalan Di RSUD Kabupaten Jombang Tahun 2020 2020年马邦县病历记录不良原因概述

Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Pub Date : 2022-08-31 DOI: 10.52943/jipiki.v7i2.950

K. Jayanti, Ratna Frenty Nurkhalim, Ninda Mulya Ike Ardila, B. Pranoto, I. Setyawan, I. Susilowati

{"title":"Tinjauan Penyebab Terjadinya Misfile Dokumen Rekam Medis Rawat Jalan Di RSUD Kabupaten Jombang Tahun 2020","authors":"K. Jayanti, Ratna Frenty Nurkhalim, Ninda Mulya Ike Ardila, B. Pranoto, I. Setyawan, I. Susilowati","doi":"10.52943/jipiki.v7i2.950","DOIUrl":"https://doi.org/10.52943/jipiki.v7i2.950","url":null,"abstract":"Rekam medis rawat jalan dan gawat darurat wajib dilengkapi dan diselesaikan setelah pelayanan kepada pasien hari itu juga. Penelitian ini bertujuan untuk mengetahui penyebab misfile dari aspek manjemen man, method, machine, dan material di RSUD Kabupaten Jombang. Penelitian bersifat deskriptif kuatilatif dengan pendekatan case study. Sampel pada penelitian ini adalah 11 orang petugas. Teknik pengumpulan data yang digunakan adalah lembar kuesioner dan observasi. Hasil penelitian menunjukkan bahwa pada unsur man, ditemukan masalah tidak adanya petugas rekam medis berlatar belakang pendidikan rekam medis dimana hal tersebut juga sebagai pemicu terjadinya misfile di ruang filing, tidak adanya pelatihan untuk petugas rekam medis dikarenakan belum adanya program terkait pelatihan rekam medis di RSUD Kabupaten Jombang, dan petugas belum pernah mendapatkan penghargaan dalam bentuk apapun seperti pujian atau insentif dan hukuman agar termotivasi bekerja lebih baik. Pada unsur method ditemukan masalah tidak adanya pelaksanaan kegiatan penyisiran dokumen rekam medis setiap hari secara berkala oleh petugas untuk mencegah terjadinya misfile. Pada unsur machine ditemukan masalah tidak digunakannya tracer dan outguide. Pada unsur material ditemukan masalah yaitu kode warna di RSUD Kabupaten Jombang tidak diterapkan secara keseluruhan karena kurangnya pengetahuan petugas akan pentingnya kode warna untuk mencegah terjadinya misfile. Dapat disarankan bahwa sebaiknya pimpinan memberikan reward dan punishment, mengikutsertakan pelatihan, menambah item dalam SOP pencarian dokumen rekam medik terkait penyisiran DRM, diterapkannya tracer, dan diberikannya kode warna pada seluruh sampul DRM.","PeriodicalId":261208,"journal":{"name":"Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI)","volume":"58 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2022-08-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"123027540","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

Review Rekam Medis Pasien Ruang Isolasi Covid-19 RSU Imelda Pekerja Indonesia Tahun 2020 2020年，印尼工人Covid-19 RSU Imelda的医疗记录回顾

Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Pub Date : 2022-08-31 DOI: 10.52943/jipiki.v7i2.988

Mei Sryendang Sitorus, Esraida Simanjuntak, Valentina Valentina

{"title":"Review Rekam Medis Pasien Ruang Isolasi Covid-19 RSU Imelda Pekerja Indonesia Tahun 2020","authors":"Mei Sryendang Sitorus, Esraida Simanjuntak, Valentina Valentina","doi":"10.52943/jipiki.v7i2.988","DOIUrl":"https://doi.org/10.52943/jipiki.v7i2.988","url":null,"abstract":"Quantitative Analysis is a review of certain parts of the contents of medical records to find deficiencies, especially those related to the documenting of medical records. Coronavirus Disease 2019 (Covid-19) is an infectious disease caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARSCoV-2). The purpose of this study is to find out the implementation of the Covid-19 Isolation Room Patient Medical Record Document Review at RSU Imelda Pekerja Indonesia in 2020. The population is all patients treated in the Covid-19 Isolation Room in 2020 as many as 182 people, the study sample is all patients treated in the Covid-19 Isolation Room in October as many as 48 people. The DRM review was conducted on four variables. From the results of the study obtained that the Review of Timeliness of appropriate DRM Returns as much as 35.41%; Review of the Accuracy of Filling out DRM for the exact Opname Warrant Form (SPO) 31.25%, the appropriate IGD Assessment Form 52.08%, the right Medical Resume Form 100%, and the proper Observation Form 66.67%; DRM Readability Review for Opname Warrant Form (SPO) which reads 100%, IGD Assessment Form that reads 77.08%, Medical Resume Form that reads 100%, and Observation Form that reads 72.92%; Drm Completeness Review for Screening Form found in 68.75% of documents, Triage Form found in 77.08% documents, Internal Transfer Form found on 89.58% of documents, Discharge Planning Form found on 81.25% of documents.For General Consent Forms, Inpatient Assessments, CPPT Forms, Observation Forms, and Information and Education Forms are found in all documents that are 100%. It is recommended that the existing SPO socialization prioritizes the accuracy of filling out medical records qualitatively, not limited to the completeness of the form only.","PeriodicalId":261208,"journal":{"name":"Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI)","volume":"1 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2022-08-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"128976967","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

Gambaran Kepuasan Pasien Terhadap Penggunaan Anjungan Pendaftaran Mandiri (APM) Di RSU Pakuwon Sumedang Tahun 2022 患者对2022年Pakuwon Sumedang RSU上使用自动登记平台(APM)的满意度

Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Pub Date : 2022-08-31 DOI: 10.52943/jipiki.v7i2.1023

Shiila Nika Adiffa, Imas Masturoh

{"title":"Gambaran Kepuasan Pasien Terhadap Penggunaan Anjungan Pendaftaran Mandiri (APM) Di RSU Pakuwon Sumedang Tahun 2022","authors":"Shiila Nika Adiffa, Imas Masturoh","doi":"10.52943/jipiki.v7i2.1023","DOIUrl":"https://doi.org/10.52943/jipiki.v7i2.1023","url":null,"abstract":"APM merupakan mesin pendaftaran secara mandiri yang didalamnya terdapat layar touchscreen, barcode scanner, Printer atau alat tambahan lainnya. Terdapat beberapa masalah terkait penggunaan APM di RSU Pakuwon salah satunya adalah nomor antrian yang tidak bisa dicetak akibat jaringan SIMRS yang error. Keadaan tersebut membuat proses pelayanan yang diperoleh pasien terhambat. Kualitas pelayanan yang diberikan pihak rumah sakit kepada pasien dapat menimbulkan rasa puas pada pasiennya. Kepuasan pasien harus selalu diperhatikan karena mengandung nilai subjektif terhadap kualitas pelayanan yang diberikan. Tujuan dari penelitian ini untuk mengetahui tingkat kepuasan pasien pengguna APM di RSU Pakuwon Sumedang. Jenis penelitian yang dilaksanakan adalah kuantitatif dengan desain penelitian deskriptif. Pengukuran kepuasan menggunakan Metode End User Computing Satisfaction (EUCS) yang dilihat dari 5 dimensi EUCS. Populasi yang digunakan sebanyak 72.364 pasien dan sampel yang diambil sebanyak 110 pasien. Teknik pengumpulan data menggunakan kuesioner. Analisis data menggunakan skor kriterium. Karakteristik responden yang terdapat dalam penelitian ini berdasarkan usia, pendidikan, pekerjaan dan status kepesertaan. Tingkat kepuasan yang didapatkan berdasarkan aspek isi (content) adalah 89,22%, aspek keakuratan (accuracy) 87,60%, aspek tampilan (format) 88,37%, aspek ketepatan waktu (Timeliness) 86,98%, aspek kemudahan pengguna (ease of use) 88,50% serta total kepuasan pasien keseluruhan adalah 84,30%.","PeriodicalId":261208,"journal":{"name":"Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI)","volume":"24 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2022-08-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"127703807","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 1

Pelaksanaan Program Sistem Pencatatan dan Pelaporan Terpadu (SP2TP) Puskesmas Pesantren II 执行注册和综合报告系统计划(SP2TP) Puskesmas Pesantren II

Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Pub Date : 2022-08-31 DOI: 10.52943/jipiki.v7i2.719

Reny Nugraheni, Ananda Muchamad Syaiful

引用次数: 0

Pengaruh Akreditasi Untuk Meningkatkan Mutu Pelayanan dan Keselamatan Pasien di Rumah Sakit (Studi Sistematik Review) 改善病人护理和安全的认证效果(系统研究回顾)

Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Pub Date : 2022-02-26 DOI: 10.52943/jipiki.v7i1.712

Raysella Khaulla Miandi, Yuly Peristiowati

{"title":"Pengaruh Akreditasi Untuk Meningkatkan Mutu Pelayanan dan Keselamatan Pasien di Rumah Sakit (Studi Sistematik Review)","authors":"Raysella Khaulla Miandi, Yuly Peristiowati","doi":"10.52943/jipiki.v7i1.712","DOIUrl":"https://doi.org/10.52943/jipiki.v7i1.712","url":null,"abstract":"Hospital accreditation is a government recognition of hospitals that have met the standards that have been set to get an idea of the extent of meeting hospital standards in Indonesia, so that the quality of service can be accounted for. The purpose of review research is systematic to find out the influence of accreditation in improving the quality of service and patient safety in hospitals. The research design used in this study is Systematic Review. The purpose of this method is to help researchers better understand the background of the research that is the subject of the topic sought and understand why and how the results of the study so that it can be a reference for new research. Independent variables are accreditation and variable dependents, namely the quality of hospital services and the safety of hospital patients. Researchers conducted a search for data through the websites of accessible journal portals such as PubMed, Elsevier, Springer, and Google Schoolar. The results showed after the collection of journals using accredited journal sites such as PubMed, Elsevier, Springer, and Google Schoolar. 496 journals were identified and eligibility criteria were carried out. Then after it was filtered obtained 23 journals, then excluded studies were obtained 3 journals met the exclusion criteria, after that based on inclusion criteria so that the total number of articles eligible for review was 20 articles. Quality improvement in all fields, especially in the field of health, one of which is through Hospital Accreditation towards the quality of International services. In the accreditation system that refers to the Standards of the Joint Commission International (JCI) obtained the most relevant standards related to the quality of hospital services International Patient Safety Goals (international targets of patient safety) which includes six hospital patient safety goals.","PeriodicalId":261208,"journal":{"name":"Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI)","volume":"4 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2022-02-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"114179355","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 2

Tinjauan Peranan Koder Dalam Pengajuan Berkas Klaim BPJS Kesehatan Pasien Rawat Inap Di RSUD DR. R.M. Djoelham Kota Binjai 在Binjai市r.m. Djoelham镇住院病人BPJS索赔文件提交过程中的角色审查

Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Pub Date : 2022-02-26 DOI: 10.52943/jipiki.v7i1.722

Mordekhai Immanuel Sitorus, Noor Yulia, Puteri Fannya, N. Rumana

{"title":"Tinjauan Peranan Koder Dalam Pengajuan Berkas Klaim BPJS Kesehatan Pasien Rawat Inap Di RSUD DR. R.M. Djoelham Kota Binjai","authors":"Mordekhai Immanuel Sitorus, Noor Yulia, Puteri Fannya, N. Rumana","doi":"10.52943/jipiki.v7i1.722","DOIUrl":"https://doi.org/10.52943/jipiki.v7i1.722","url":null,"abstract":"Submission of claim files to BPJS Health is carried out every 10th of the month, BPJS Health will provide information whether the claim file is feasible or not. If the claim file is not feasible, it needs to be corrected. The purpose of the research is to describe the role of the coder in filing claims for BPJS Health inpatients at RSUD Dr. R.M. Djoelham Binjai City. The research method used is descriptive method with a quantitative approach. The sample uses 43 claim files returned by BPJS Health in April and May 2021 and also interviews with two coders. Data is collected by using observation with a checklist instrument and interviews with interview guidelines. The result shows that the hospital does not have standard operating procedures related to the submission of BPJS Health claim files, from 276 files (100%) submitted in April and May 2021, there were 233 files (84,42%) that deserve to be claimed and 43 files (15,58%) that were returned (not eligible). The reasons for the return were due to confirmation of diagnosis (18,60%), medical support (25,58%), indications for hospitalization (16,28%), coding (11,63%), purification failure (6,98%) and other causes (20,93%). The roles of the coder in handling claim files are assembling, determining the primary diagnosis code and secondary diagnosis based on ICD-10, determining the code of action (procedure) based on the ICD-9-CM, and coordinating with various internal parties for the completeness of the BPJS Health claim file. Suggestions for hospital to make standard operating procedures related to claim files submission and coders to be more thorough in preparing the complete claim files.","PeriodicalId":261208,"journal":{"name":"Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI)","volume":"19 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2022-02-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"127661799","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 1

Pengaruh Pemberian Tracer Terhadap Ketepatan Penyimpanan Berkas Rekam Medis Di RSU Purbowangi Tracer对Purbowangi医疗记录文件的精确存储的影响

Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Pub Date : 2022-02-26 DOI: 10.52943/jipiki.v7i1.603

Citra Wiguna Bakti Bakhtiar, S. Rohmah, G. Panuntun

引用次数: 0

Faktor yang Memengaruhi Penggunaan Sistem Informasi Rumah Sakit Berdasarkan Metode Technology Acceptance Model di RSU Advent Kota Medan 影响医院信息系统使用的因素是棉兰市RSU气候技术模型

Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Pub Date : 2022-02-26 DOI: 10.52943/jipiki.v7i1.680

A. Fitriani, Adistia Maulidiah

引用次数: 0