Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI)最新文献

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Dampak Penumpukan Dokumen Rekam Medis Terhadap Waktu Pengambilan Dokumen Rekam Medis Di RSU Sinar Husni Medan 前线日记本上堆积医疗记录文件的影响
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Pub Date : 2021-02-27 DOI: 10.2411/JIPIKI.V6I1.478
Valentina, Selvia Sari Ritonga
{"title":"Dampak Penumpukan Dokumen Rekam Medis Terhadap Waktu Pengambilan Dokumen Rekam Medis Di RSU Sinar Husni Medan","authors":"Valentina, Selvia Sari Ritonga","doi":"10.2411/JIPIKI.V6I1.478","DOIUrl":"https://doi.org/10.2411/JIPIKI.V6I1.478","url":null,"abstract":"The filling system is one of the administrators of medical records which is responsible for orderly administration in an effort to improve health services in hospitals. Accumulation of medical record documents will affect of work of officers in the filling section. The purpose of this study is to determine the impact of the bildup of medical records documents on the time of taking medical record documents at Sinar Husni Hospital. This research is a descriptive study with a qualitative approach. The population is all filling officers at the Sinar Husni Hospital and all patient medical records calculated on average in the third quarter of 2020, counted 719 documents. The samples in this study were 2 filling officers at the Sinar Husni Hospital and part of the medical record documents totaling 86 medical record documents that were taken incidentally. The instrument used was an interview guide. The measurement of time to take medical record documents uses a stopwatch. Data were analyzed descriptively. The results showed that the accumulation of medical record documents had an impact on the time to take medical record documents at the Sinar Husni Hospital, because the officers had difficulty carrying out filling activities because the access between shelves was narrower and the documents piled on the floor were not properly aligned, with an average of 10.05 minute. We recommend to add more storage space and shelves so that medical record documents that are stacked on the floor can be moved to the storage racks.","PeriodicalId":261208,"journal":{"name":"Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI)","volume":"16 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2021-02-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"127700309","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 Pengelolaan Data Berbasis Digital Bagian Registrasi Pendaftaran Di RSUP Haji Adam Malik Medan 哈吉·马利克·Medan RSUP哈吉注册登记部门的数字管理数据管理审查
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Pub Date : 2021-02-27 DOI: 10.2411/JIPIKI.V6I1.474
Puput Melati Hutauruk, Khairani
{"title":"Tinjauan Pengelolaan Data Berbasis Digital Bagian Registrasi Pendaftaran Di RSUP Haji Adam Malik Medan","authors":"Puput Melati Hutauruk, Khairani","doi":"10.2411/JIPIKI.V6I1.474","DOIUrl":"https://doi.org/10.2411/JIPIKI.V6I1.474","url":null,"abstract":"Data management is a data place that will become information which will later become health information. Where patient registration if done manually will be slow automatic management of data will have an impact on the quality of hospital services. Therefore digitization is required. The purpose of this study was to see how the implementation of digital-based data management at RSUP H. Adam Malik Medan. Subjects in this study were registration officers who entered 7 people, with the object being not 5M. This research was conducted with a descriptive method with a qualitative approach. Instrumentation of interview data and observation checklist. With the TOTAL 3 informants. The data analysis used in this research is descriptive qualitative to describe the implementation of data management. Based on the results of the research that there is no one who is not in accordance with the competence, the money is not yet available and adequate, the method is appropriate but has not worked well, the machine is not as expected while the material is in accordance with the competence. Suggestions from researchers are that officers should distribute leaflets (paper leaflets) to the public so that the public can register via cellphones (cellular) and that officers should change the internet speed to MBPS so that the registration process does not occur sluggishly.","PeriodicalId":261208,"journal":{"name":"Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI)","volume":"1 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2021-02-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"130134637","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
Ketidaktepatan Kode Diagnosis Kasus Neoplasma Menggunakan ICD-10 Di RSUP H.Adam Malik Medan Tahun 2019 新血浆诊断代码的错误使用ICD-10在RSUP H.Adam Malik Medan在2019年
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Pub Date : 2021-02-27 DOI: 10.2411/JIPIKI.V6I1.477
Johanna Christy, Evi Efriamta Siagian
{"title":"Ketidaktepatan Kode Diagnosis Kasus Neoplasma Menggunakan ICD-10 Di RSUP H.Adam Malik Medan Tahun 2019","authors":"Johanna Christy, Evi Efriamta Siagian","doi":"10.2411/JIPIKI.V6I1.477","DOIUrl":"https://doi.org/10.2411/JIPIKI.V6I1.477","url":null,"abstract":"ABSTRAK \u0000                Informasi peyakit dirumah sakit tidak akan lengkap dan bermanfaat apabila belum diolah, maka untuk itu perlu dilakukan pengkodean. Penelitian ini bertujuan untuk mengetahui ketepatan kode diagnosis pada kasus neoplasma menggunakan ICD-10 di RSUP. H. Adam Malik tahun 2019. Penelitian ini menggunakan metode kuantitatif dengan pendekatan cross sectional, Jumlah sampel yang digunakan sebanyak 93 dokumen dan 4 orang responden. Ketepatan kode morfologi diagnosis neoplasma diperoleh hasil 88 (95%) kode tepat 6 karakter, 0 (0%) kode tepat 5 karakter, 0 (0%) kode tepat 4 karakter, 3 (3%) kode tidak tepat sama sekali dan 2 (2%) tidak dikode. Ketepatan kode topografi diperoleh hasil 79 (85%) kode tepat 4 karakter, 8 (9%) kode tepat 3 karakter, 4 (4%) kode tepat 2 karakter, 0 (0%) kode tepat 1 karakter, 0 (0%) kode tidak tepat sama sekali dan 0 (0%) kode tidak dikerjakan. Faktor yang menjadi penyebab ketidaktepatan dalam pengodean adalah petugas coding sulit untuk membaca tulisan dokter sehingga penulis menyarankan sebaiknya dalam pengkodingan diagnosis tetap mengikuti kaidah dan aturan yang ada pada ICD-10. \u0000  \u0000Kata Kunci: Ketepatan, Diagnosis, Neoplasma, Pengkodean \u0000  \u0000  \u0000Abstract \u0000Information for patients in hospitals will not be complete and useful if it has not been processed, so coding is necessary. This study aims to determine the accuracy of the diagnosis code in cases of neoplasm using ICD-10 in RSUP. H. Adam Malik in 2019. This study used a quantitative method with a cross sectional approach. The number of samples used was 93 documents and 4 respondents. The accuracy of the morphological code for the diagnosis of neoplasm was 88 (95%) the code was exactly 6 characters, 0 (0%) the code was exactly 5 characters, 0 (0%) the code was exactly 4 characters, 3 (3%) the code was not correct at all and 2 ( 2%) is not coded. The accuracy of the topographic code is 79 (85%) the code is exactly 4 characters, 8 (9%) the code is exactly 3 characters, 4 (4%) the code is exactly 2 characters, 0 (0%) the code is exactly 1 character, 0 (0%) code is not correct at all and code 0 (0%) is not working. The factor that caused the inaccuracy in coding was that it was difficult for coding officers to read the doctor's writings, so the authors suggested that the coding of the diagnosis should still follow the rules and regulations in the ICD-10. \u0000  \u0000Keywords: Accuracy, Diagnosis, Neoplasm, Encoding","PeriodicalId":261208,"journal":{"name":"Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI)","volume":"30 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2021-02-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"131224489","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 Alur Prosedur Pelayanan Pasien Rawat Jalan Peserta BPJS di RSU Imelda Pekerja Indonesia Medan 回顾印度尼西亚棉兰医保病人门诊服务程序的流程
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Pub Date : 2021-02-27 DOI: 10.2411/JIPIKI.V6I1.479
Yeyi Gusla Nengsih
{"title":"Tinjauan Alur Prosedur Pelayanan Pasien Rawat Jalan Peserta BPJS di RSU Imelda Pekerja Indonesia Medan","authors":"Yeyi Gusla Nengsih","doi":"10.2411/JIPIKI.V6I1.479","DOIUrl":"https://doi.org/10.2411/JIPIKI.V6I1.479","url":null,"abstract":"Rawat jalan merupakan pelayanan yang diberikan kepada pasien untuk berobat atau keperluan lainnya tanpa tinggal diruang rawat inap rumah sakit. RSU Imelda Pekerja Indonesia Medan juga berpotensi menjadi salah satu rumah sakit rujukan di Kota Medan Sumatera Utara. Tempat pendaftaran rawat jalan RSU Imelda Pekerja Indonesia Medan dimulai dari pendaftaran pasien hingga pasien mendapatkan pelayanan. Berdasarkan survey diketahui bahwa jika pasien BPJS tidak melengkapi persyaratan seperti foto copy KTP dan KK, surat rujukan, foto copy SKP dan foto copy kartu BPJS dalam sehari maka pasien tersebut tidak segera mendapatkan pelayanan lebih lanjut. RSU Imelda Pekerja Indonesia Medan belum mempunyai prosedur pendaftaran secara khusus untuk pasien rawat jalan BPJS sehingga masih sulit untuk menelusuri dokumen rekam medis diruang filling dan juga pendistribusian dokumen rekam medis ke poliklinik masih sangat lama. Hal ini menyebabkan pelayanan pasien BPJS tidak segera terpenuhi. Tujuan penelitian untuk mengetahui alur prosedur pelayanan pasien rawat jalan peserta BPJS. Jenis penelitian yaitu deskriptif, subyek yang diteliti yaitu pasien rawat jalan BPJS dengan obyek penelitian yaitu RSU Imelda Pekerja Indonesia Medan. Instrumen yang digunakan dengan wawancara dan observasi langsung ke lapangan.","PeriodicalId":261208,"journal":{"name":"Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI)","volume":"104 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2021-02-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"124636652","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
Analisis Kelengkapan Formulir A (Evaluasi Awal MPP) Dan Formulir B (Catatan Implementasi) Pasien Rumah Sakit 分析完整的表格A(初始评估MPP)和表格B(执行记录)医院患者
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Pub Date : 2021-02-27 DOI: 10.2411/JIPIKI.V6I1.469
Dicho Zhurhriano Yasli, Devid Leonard, Berly Nisa Srimayarti
{"title":"Analisis Kelengkapan Formulir A (Evaluasi Awal MPP) Dan Formulir B (Catatan Implementasi) Pasien Rumah Sakit","authors":"Dicho Zhurhriano Yasli, Devid Leonard, Berly Nisa Srimayarti","doi":"10.2411/JIPIKI.V6I1.469","DOIUrl":"https://doi.org/10.2411/JIPIKI.V6I1.469","url":null,"abstract":"Completeness of the Inpatient Examination Form is a problem that often causes complaints in several hospitals. The purpose of this study was to conduct a literature review related to the incomplete analysis of filling in form A, MPP Initial Evaluation and Form B Implementation Notes. The collection method is secondary data, the steps are determining keywords, exploration and title selection, reading articles that have not been eliminated. At that stage, the reference list of selected articles is reviewed to determine other related studies. The articles contained in the summary list The results of the literature review, namely, still found incompleteness in filling out medical record forms, the responsibilities and attitudes of officers in filling out medical record files can be said to be still not optimal. The human resources involved are still lacking, for example the assembling officer also serves the file preparation so that the assembly function is not optimal. Based on the literature review of several related articles, further research is needed on other causes of incompleteness in filling out medical record file forms and the obstacles experienced by doctors in filling out medical record files.","PeriodicalId":261208,"journal":{"name":"Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI)","volume":"79 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2021-02-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"133107754","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: 3
TINJAUAN PELAKSANAAN PEMELIHARAAN DOKUMEN REKAM MEDIS DI RUANGAN FILLING RUMAH SAKIT DR.PIRNGADI MEDAN TAHUN 2019 2019年,在棉兰的PIRNGADI医生的病房里进行医疗记录的维护审查
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Pub Date : 2020-08-31 DOI: 10.2411/JIPIKI.V5I2.394
Esraida Simanjuntak, Rizka Mei Shella
{"title":"TINJAUAN PELAKSANAAN PEMELIHARAAN DOKUMEN REKAM MEDIS DI RUANGAN FILLING RUMAH SAKIT DR.PIRNGADI MEDAN TAHUN 2019","authors":"Esraida Simanjuntak, Rizka Mei Shella","doi":"10.2411/JIPIKI.V5I2.394","DOIUrl":"https://doi.org/10.2411/JIPIKI.V5I2.394","url":null,"abstract":"Maintenance of medical record documents is a combination of various activities undertaken to maintain documents and production facilities including other production equipment or to repair them to a condition that is well accepted. Physical danger is damage to documents caused by sunlight, rain, flood, heat and humidity. Chemical hazard is document damage caused by food, beverages, and chemicals. Biological hazard is document damage caused by rats, cockroaches, and termites. The purpose of this study is to describe the implementation of maintenance of medical record documents in the room Dr. hospital filling Pirngadi Medan in 2019. This type of research is a description of the interview and observation methods. The place of research was conducted at Dr. Pirngadi Medan due to the inability of maintaining medical record documents. When the study was conducted in March-April 2019. Population and samples used were all medical record storage officers, amounting to 3 people. Based on the results of the study, there were still racks that used wood and did not use rool o'pack cabinets, there are damaged medical record documents that have not been replaced with new ones due to lack of cover inventory. The temperature and humidity of the room in the storage room are less controlled. The conclusion of this study is that the maintenance of medical record documents has not been carried out because the shelves are still made from wood and the lack of storage rack facilities make medical records documents partially placed under the floor. The suggestion from this research is that it is better to use a rool o'pack cupboard and keep the air conditioner on for 24 hours according to the theory.","PeriodicalId":261208,"journal":{"name":"Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI)","volume":"24 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2020-08-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"134242240","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
SISTEM ANTRIAN REKAM MEDIS PASIEN DI RUMAH SAKIT MENGGUNAKAN MODEL MULTI CHANNEL DENGAN POLA POISSON 医院记录病人的医疗记录系统使用的是一个多频道模式的泊森模式
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Pub Date : 2020-08-31 DOI: 10.52943/jipiki.v5i2.414
Yeyi Gusla Nengsih
{"title":"SISTEM ANTRIAN REKAM MEDIS PASIEN DI RUMAH SAKIT MENGGUNAKAN MODEL MULTI CHANNEL DENGAN POLA POISSON","authors":"Yeyi Gusla Nengsih","doi":"10.52943/jipiki.v5i2.414","DOIUrl":"https://doi.org/10.52943/jipiki.v5i2.414","url":null,"abstract":"Queue is an occurrence where someone has to wait their turn to get service. Queuing processes in hospitals when processing outpatient registration medical records at the hospital often occur especially during peak hours. To overcome this problem, a solution is needed to improve service performance at the hospital. The queuing model used is the Multi Channel-single phase queuing model which has one or more services flowing by a single queue. The variables to be observed are time between arrivals, service time data and number of services assuming a Poisson distribution pattern. The results of this study will show the operator's busy time is 83.33%, the number of queues in a certain period (Lq) is 13 patients, the number of registrants in the system (L) is 14 patients, the waiting time in the queue (Wq) is 24 minutes, and waiting time in the system (W) is 30.06 minutes.","PeriodicalId":261208,"journal":{"name":"Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI)","volume":"46 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2020-08-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"130311742","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
MUTU PELAYANAN PETUGAS REKAM MEDIS TERHADAP TINGKAT KEPUASAN PASIEN BPJS RAWAT JALAN DI RUMAH SAKIT UMUM IPI MEDAN TAHUN 2019 2019年,IPI MEDAN公立医院的非营业部门诊病人满意度的医疗记录质量
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Pub Date : 2020-08-31 DOI: 10.2411/JIPIKI.V5I2.419
Johanna Christy
{"title":"MUTU PELAYANAN PETUGAS REKAM MEDIS TERHADAP TINGKAT KEPUASAN PASIEN BPJS RAWAT JALAN DI RUMAH SAKIT UMUM IPI MEDAN TAHUN 2019","authors":"Johanna Christy","doi":"10.2411/JIPIKI.V5I2.419","DOIUrl":"https://doi.org/10.2411/JIPIKI.V5I2.419","url":null,"abstract":"Quality of service is the overall characteristics of the service that shows its ability to satisfy the needs of consumers, and the Health BPJS is a legal entity formed to carry out a health insurance program, and patient satisfaction is the level of patient feelings that arise as a result of the performance of health services obtained after the patient compares it with what he hoped for. The purpose of this study was to determine the quality of medical record officer services to the level of satisfaction of outpatient BPJS patients in General Hospital. IPI Medan 2018. This research uses Analytical research design. The independent variable is BPJS Health service quality and the dependent variable is patient satisfaction. Samples taken using the Slovin Formula found 33 patients in the Outpatient Installation at the General Hospital. IPI. Medan in 2018. The research instrument used a questionnaire. The results showed that 28 respondents (84.8%) stated that the quality of BPJS Health services was good, and 32% of respondents (97.0%) expressed satisfaction with BPJS Health services. Chi Square statistical test results state there is a relationship between the quality of BPJS Health services with patient satisfaction Outpatient Installation at the General Hospital. IPI. Medan Year 2018 (pValue = 0,000). The implication of the results of the study shows that the quality of BPJS Health services has an important role in influencing patient satisfaction.","PeriodicalId":261208,"journal":{"name":"Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI)","volume":"195 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2020-08-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"132582269","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
TINJAUAN SISTEM PENDAFTARAN PASIEN RAWAT INAP DI RSU MITRA SEJATI MEDAN 病房注册系统审查
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Pub Date : 2020-08-31 DOI: 10.2411/JIPIKI.V5I2.421
Suheri Parulian Gultom, Febri Yani Friska Ginting
{"title":"TINJAUAN SISTEM PENDAFTARAN PASIEN RAWAT INAP DI RSU MITRA SEJATI MEDAN","authors":"Suheri Parulian Gultom, Febri Yani Friska Ginting","doi":"10.2411/JIPIKI.V5I2.421","DOIUrl":"https://doi.org/10.2411/JIPIKI.V5I2.421","url":null,"abstract":"Patient registration is the foremost part of Hospital service, because the patient registration records the identity and requirements of his visit to the hospital, and at the time of registration the patient gets the first impression of the hospital's services. The purpose of this study was to determine the stages of admission of inpatients at Mitra Sejati Hospital Medan and to find out the obstacles in the implementation of inpatient admissions at Mitra Sejati Hospital in Medan in 2017. The type of research used is descriptive using a quantitative approach, the research sample is 5 inpatient registration officers, data collection was done by interviewing the inpatient registration officer. The results showed that the registration stages of inpatients at Mitra Sejati Hospital Medan had not met the regulations of the PERMENKES (2008) on the naming and use of KIB and KIUP. It can be concluded that Mitra Sejati Hospital Medan has not implemented the naming rules according to the PERMENKES and has not implemented the use of KIB and KIUP. It can be suggested that registration officers should have implemented a naming system according to the PERMENKES rules and already have to implement the use of KIB and KIUP to make it easier for officers to register patients and find patient medical record files. For education, to explain more to students how the stages of inpatient registration are. For inpatient registration officers at Mitra Sejati Hospital Medan, it is better if they need to carry out training on the stages of patient acceptance / registration to improve a more effective way of working.Patient registration is the foremost part of Hospital service, because the patient registration records the identity and requirements of his visit to the hospital, and at the time of registration the patient gets the first impression of the hospital's services. The purpose of this study was to determine the stages of admission of inpatients at Mitra Sejati Hospital Medan and to find out the obstacles in the implementation of inpatient admissions at Mitra Sejati Hospital in Medan in 2017. The type of research used is descriptive using a quantitative approach, the research sample is 5 inpatient registration officers, data collection was done by interviewing the inpatient registration officer. The results showed that the registration stages of inpatients at Mitra Sejati Hospital Medan had not met the regulations of the PERMENKES (2008) on the naming and use of KIB and KIUP. It can be concluded that Mitra Sejati Hospital Medan has not implemented the naming rules according to the PERMENKES and has not implemented the use of KIB and KIUP. It can be suggested that registration officers should have implemented a naming system according to the PERMENKES rules and already have to implement the use of KIB and KIUP to make it easier for officers to register patients and find patient medical record files. For education, to explain more to students how the stages of inpatient ","PeriodicalId":261208,"journal":{"name":"Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI)","volume":"19 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2020-08-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"121571525","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 KETIDAKLELENGKAPAN PENGISIAN FORMULIR LAPORAN ANESTESI KASUS BEDAH DI RSU IMELDA PEKERJA INDONESIA MEDAN 印度尼西亚MEDAN RSU IMELDA公司的外科麻醉报告不完整
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Pub Date : 2020-08-31 DOI: 10.2411/JIPIKI.V5I2.415
Valentina, Sri Mulia Melayu
{"title":"GAMBARAN KETIDAKLELENGKAPAN PENGISIAN FORMULIR LAPORAN ANESTESI KASUS BEDAH DI RSU IMELDA PEKERJA INDONESIA MEDAN","authors":"Valentina, Sri Mulia Melayu","doi":"10.2411/JIPIKI.V5I2.415","DOIUrl":"https://doi.org/10.2411/JIPIKI.V5I2.415","url":null,"abstract":"Every health service provided to patients must recorded in the medical records completely because the completeness of filling the medical record is used as an indicator of the quality of health services in the hospital. The purpose of this study is to determine the incomplete picture of filling out an anesthetic case report form in a surgical case at the Imelda Indonesian Workers Hospital in Medan. The type of research is descriptive. The populations of this study are all forms of anesthesia patient case reports for the first quarter of 2020 with a total of 728 forms. The samples are 88 forms taken using systematic random sampling. Data collection was carried out using the checklist sheet. Data were analyzed univariate to describe the characteristics of each research variable by producing a frequency distribution and percentage of each variable. The results showed that there were 24 anesthetized report forms that were completely filled and 64 anesthetic report forms that were not completely filled. The highest percentage of incompleteness of filling in the patient identity component on the item date of birth was 10 forms (11%), on the anesthesia time component on the old surgical item by 39 forms (44%), on the diagnostic component on the post-surgical diagnostic item by 28 forms (32%), the examination component on the preoperative state item was 63 forms (72%) and the signature component was 2 forms (2%). It is recommended that every health worker who provides health services to surgical case patients fill out the anesthetic report form in accordance with the SPO authorizing the medical record filling, and to the medical record officer to conduct an assembling or complete analysis of medical record documents.","PeriodicalId":261208,"journal":{"name":"Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI)","volume":"1 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2020-08-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"132610542","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}
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