Jurnal Rekam Medis dan Informasi Kesehatan最新文献_第4页

TINJAUAN PELAKSANAAN PROSEDUR PELEPASAN INFORMASI REKAM MEDIS UNTUK KLAIM ASURANSI NON-JKN DI RSUD dr. R. SOETRASNO REMBANG SOETRASNO REMBANG的非处方保险索赔程序的执行过程

Jurnal Rekam Medis dan Informasi Kesehatan Pub Date : 2022-03-30 DOI: 10.31983/jrmik.v5i1.8422

Bayu Eko Wahyudi

{"title":"TINJAUAN PELAKSANAAN PROSEDUR PELEPASAN INFORMASI REKAM MEDIS UNTUK KLAIM ASURANSI NON-JKN DI RSUD dr. R. SOETRASNO REMBANG","authors":"Bayu Eko Wahyudi","doi":"10.31983/jrmik.v5i1.8422","DOIUrl":"https://doi.org/10.31983/jrmik.v5i1.8422","url":null,"abstract":"Pemanfaatan rekam medis untuk keperluan penggantian biaya kesehatan atau klaim asuransi yang menyebutkan identitas pasien harus mendapat persetujuan secara tertulis dari pasien atau ahli warisnya dan harus dijaga kerahasiaannya. Berdasarkan observasi awal di Rumah Sakit Umum Daerah dr. R. Soetrasno Rembang, diketahui permintaan informasi rekam medis untuk klaim asuransi non-JKN pada bulan April sampai dengan bulan Juni 2020 sebanyak 24 permintaan,sebesar75% ditemukan permintaan yang belum sesuai standar prosedur operasional, yaitu tidak adanya persetujuan tertulis dari pasien. Tujuan dari penelitian ini adalah mengetahui gambaran tentang pelaksanaan prosedur pelepasan informasi rekam medis untuk klaim asuransi non-JKN di RSUD dr. R. Soetrasno Rembang.Jenis penelitian berupa deskriptif kualitatif. Metode pengumpulan data yang digunakan adalah observasi dan wawancara. Subyek penelitian ini adalah petugas pelepasan informasi, kepala instalasi rekam medis dan agen asuransi serta sebagian proses pelepasan informasi rekam medis. Analisa data yang digunakan yaitu teknik analisa non statistik.Hasil penelitian menunjukkan bahwa pelaksanaan prosedur pelepasan informasi rekam medis untuk klaim asuransi non-JKN di RSUD dr. R. Soetrasno Rembang belum sesuai dengan SPO, ada prosedur yang tidak ditaati yaitu permintaan pelepasan informasi tetap dilayani meskipun tidak melampirkan persetujuan tertulis dari pasien. Persyaratan yang harus dipenuhi belum lengkap, yaitu kurang surat kuasa pasien. Proses pengambilan pelepasan informasi sudah sesuai dengan SPO dan pernyataan responden.","PeriodicalId":305770,"journal":{"name":"Jurnal Rekam Medis dan Informasi Kesehatan","volume":"1 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2022-03-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"128986578","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

Systematical Review: Faktor Penyebab Keterlambatan Penyediaan Rekam Medis Rawat Jalan 系统回顾:迟到的原因包括门诊医疗记录

Jurnal Rekam Medis dan Informasi Kesehatan Pub Date : 2022-03-30 DOI: 10.31983/jrmik.v5i1.7962

Arief Tarmansyah Iman, Nursanie Puspita

{"title":"Systematical Review: Faktor Penyebab Keterlambatan Penyediaan Rekam Medis Rawat Jalan","authors":"Arief Tarmansyah Iman, Nursanie Puspita","doi":"10.31983/jrmik.v5i1.7962","DOIUrl":"https://doi.org/10.31983/jrmik.v5i1.7962","url":null,"abstract":"Background: The provision of outpatient Medical Records (MR) affects the length of waiting time for patient services. The time of providing outpatient MR in several hospitals was more than the standard average time of ≤10 minutes. This study aims to analyse the factors causing the delay in providing outpatient medical records.Method: The research design was systematic review uses Google Scholar and Garuda Databases with topics related to factors causing delays in the provision of outpatient MR. Two reviewers were screening and found articles which match the criteria and have 13 full-length articles included to final review.Result: The average time for providing outpatient MR was in range of 11-20 minutes. The causes of delays in providing outpatient MR were grouped based on 5M factors including lack of MR educated officers, indiscipline, lack of knowledge, train and motivation (Man), unavailability of funds (Money), unavailability of MR, storage and folder, easily damaged material, infrastructure unavailability and technical problems (Machine), as well as unavailability and not maximized SOP use, no evaluation and outpatient registration flow (Method).Conclusion: The time delay in providing outpatient MR was still high, the main cause was the unavailability of infrastructure and the lack of MR educated officers.Keywords: Delay, provision, medical records outpatient, systematical review","PeriodicalId":305770,"journal":{"name":"Jurnal Rekam Medis dan Informasi Kesehatan","volume":"91 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2022-03-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"126047355","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

Ketepatan Kodifikasi Klinis Berdasarkan ICD-10 di Puskesmas dan Rumah Sakit di Indonesia: Sebuah Studi Literatur 以溪立医院ICD-10为基础的临床协调:一项文献研究

Jurnal Rekam Medis dan Informasi Kesehatan Pub Date : 2021-10-31 DOI: 10.31983/jrmik.v4i2.7688

A. Pramono, Nuryati Nuryati, Dian Budi Santoso, Marko Ferdian Salim

{"title":"Ketepatan Kodifikasi Klinis Berdasarkan ICD-10 di Puskesmas dan Rumah Sakit di Indonesia: Sebuah Studi Literatur","authors":"A. Pramono, Nuryati Nuryati, Dian Budi Santoso, Marko Ferdian Salim","doi":"10.31983/jrmik.v4i2.7688","DOIUrl":"https://doi.org/10.31983/jrmik.v4i2.7688","url":null,"abstract":"The disease classification system is a grouping of similar diseases based on the International Statistical Classification of Diseases and Related Health Problem Tenth Revisions (ICD-10). The coding application must comply with ICD-10 to get the correct code so that it reflects the actual health condition. This study aimed to identify the level of accuracy of clinical classification and its influence factors at primary health facilities and referral health facilities (hospitals) in Indonesia. This study used a systematic literature review to a number of published research articles in 2009-2019. Literatures were obtained from 3 online databases, 19 journals, Google Scholar, and online proceedings. The total number of literatures obtained was 458 articles and 45 articles met the research criteria. Most of the articles show that the accuracy rate of diagnosis code at primary health center is 26 – 45% and in hospital is 21 – 81%. The previous studies also show that the availability of adequate standard operating procedure and facilities, as well as the coding audit are also a determining factor for the code accuracy. It is necessary to increase the accuracy of the diagnosis code to support a quality health reporting system. Efforts to improve should not only be on some factors but must be carried out thoroughly in all aspects.","PeriodicalId":305770,"journal":{"name":"Jurnal Rekam Medis dan Informasi Kesehatan","volume":"384 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2021-10-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"124776628","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

STUDI TENTANG KINERJA PETUGAS REKAM MEDIS DI RUMAH SAKIT 研究医院记录工作人员的工作

Jurnal Rekam Medis dan Informasi Kesehatan Pub Date : 2021-10-31 DOI: 10.31983/jrmik.v4i2.7711

Syamsuriansyah Sadakah, Reni Chairunnisah, Helmina Andriani, Yannuar Permana, Jihadil Qudsi, Nik Azliza Binti Nik Arifin

{"title":"STUDI TENTANG KINERJA PETUGAS REKAM MEDIS DI RUMAH SAKIT","authors":"Syamsuriansyah Sadakah, Reni Chairunnisah, Helmina Andriani, Yannuar Permana, Jihadil Qudsi, Nik Azliza Binti Nik Arifin","doi":"10.31983/jrmik.v4i2.7711","DOIUrl":"https://doi.org/10.31983/jrmik.v4i2.7711","url":null,"abstract":"Medical record is written evidence about the service process which contains patient clinical data during the process of diagnosis and treatment. The management of medical records in hospitals is to support the achievement of administrative order of the efforts to achieve hospital goals, improving the quality of health services in hospitals. The purpose of this study is to describe the performance of medical record data management officers in the storage room of the Hospital. This research method using descriptive method. The study population was all medical record officers with a sample of 11 respondents using census techniques. The analysis technique uses descriptive analysis. The results of the research on the educational level of the Hospital officers were part of the DIII Medical Records as many as 7 people (63.6%). The minimum working period of the respondent is 1 year and the maximum is 9 years. The average working period of medical record officers at Hospital was 5.14 years. The results showed that the performance of medical record officers consisting of job quality, work quantity, attendance, supervision and conservation showed that there were 7 officers (63.6%). have a good performance while as many as 4 medical record officers (36.4%) have poor performance. Key word: level of education, work length, performance","PeriodicalId":305770,"journal":{"name":"Jurnal Rekam Medis dan Informasi Kesehatan","volume":"23 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2021-10-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"128237682","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

Pelaksanaan Assembling Rekam Medis di Rumah Sakit 医院记录医疗记录

Jurnal Rekam Medis dan Informasi Kesehatan Pub Date : 2021-10-31 DOI: 10.31983/jrmik.v4i2.6708

Henny Maria Ulfa

引用次数: 1

GAMBARAN PELAKSANAAN PROSEDUR PENGEMBALIAN DOKUMEN REKAM MEDIS RAWAT INAP COVID 19 DI INSTALASI REKAM MEDIS RUMAH SAKIT 在医院医疗记录安装中，COVID - 19住院记录文件的执行过程概述

Jurnal Rekam Medis dan Informasi Kesehatan Pub Date : 2021-10-31 DOI: 10.31983/jrmik.v4i2.7676

Ira Indriyani Indriyani, Mohamad Daeroby Abi Yusya

{"title":"GAMBARAN PELAKSANAAN PROSEDUR PENGEMBALIAN DOKUMEN REKAM MEDIS RAWAT INAP COVID 19 DI INSTALASI REKAM MEDIS RUMAH SAKIT","authors":"Ira Indriyani Indriyani, Mohamad Daeroby Abi Yusya","doi":"10.31983/jrmik.v4i2.7676","DOIUrl":"https://doi.org/10.31983/jrmik.v4i2.7676","url":null,"abstract":"Covid 19 merupakan virus yg melanda seluruh negara di dunia, termasuk Indonesia. Indonesia menerapkan masa pembatasan Berskala Besar (PSBB) yang termaktub dalam Peraturan Pemerintah Nomor 21 Tahun 2020. Pada masa pembatasan infasilitas layanan kesehatan pun mengurangi layanan kesehatan untuk pasien umum (pasien non COVID-19) agar fokus dalam memberikan layanan pandemi COVID-19 serta untuk mengurangi risiko penularan di fasilitas kesehatan. Rumah sakit ini merupakan salah satu fasilitas pelayanan kesehatan rujukan covid-19. Instalasi rekam medis menerapkan prosedur kerja dengan menggunakan protokol kesehatan covid-19. Salah satunya adalah pada pengembalian dokumen rekam medis rawat inap dari ruangan. Metode Penelitian yang digunakan dalam penelitian ini adalah metode deskriptif kualitatif. Hasil dari penelitian ini adalah didapatkan mengenai gambaran Prosedur Pelaksanaan Pengembalian Dokumen Rekam Medis Rawat Inap Covid 19 Di Instalasi Rekam Medis Rumah Sakit, yakni kualifikasi pendidikan petugas assembling yang sudah sesuai, penerapan surat edaran prosedur Pengembalian Dokumen Rekam Medis Rawat Inap Covid 19, dan penggunaan sarana penyimpanan dan Standar Prosedur Operasional terkait.","PeriodicalId":305770,"journal":{"name":"Jurnal Rekam Medis dan Informasi Kesehatan","volume":"151 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2021-10-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"123229817","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

Analisis Perbandingan Jumlah Pasien Sebelum dan Setelah Pandemi Covid-19 UPT Puskesmas Tahun 2019-2020 分析2011 -2020年Covid-19 uskesmas大流行前后的患者数量

Jurnal Rekam Medis dan Informasi Kesehatan Pub Date : 2021-10-31 DOI: 10.31983/jrmik.v4i2.7679

Aflahul Tsaqif

{"title":"Analisis Perbandingan Jumlah Pasien Sebelum dan Setelah Pandemi Covid-19 UPT Puskesmas Tahun 2019-2020","authors":"Aflahul Tsaqif","doi":"10.31983/jrmik.v4i2.7679","DOIUrl":"https://doi.org/10.31983/jrmik.v4i2.7679","url":null,"abstract":"Rekam medis adalah rekaman mengenai siapa, apa, mengapa bilamana, dan bagaimana pelayanan yang diberikan kepada pasien selama masa perawatan, yang memuat pengetahuan mengenai pasien dan pelayanan yang diperoleh serta memuat informasi yang cukup untuk mengidentifikasi pasien, membenarkan diagnosis dan pengobatan serta merekam hasilnya. Informasi didalam rekam medis juga memuat jumlah kunjungan pasien. Penelitian ini dimaksud untuk membandingkan jumlah kunjungan pasien sebelum dan setelah adanya Pandemi Covid-19. Sifat penelitian ini adalah deskriptif dengan menggambarkan dan menjelaskan berapa jumlah pasien, dan pedekatan dalam penelitian penelitian ini menggunakan pendekatan yang bersifat kuantitatif. Pendekatan kuantitatif menunjukan perbandingan jumlah pasien. Penelitian ini menggunakan data primer dan sekunder di UPT Puskesmas Data primer dalam penelitian ini adalah peneliti mewawancarai secara langsung pasien yang pernah berkunjungan sebelum dan setelah adanya Pandemi Covid-19 sedangkan data sekundernya adalah peneliti menggunakan data dari Unit Rekam Medis berupa jumlah kunjungan pasien dari bulan Maret – Desember 2019 dan Maret – Desember 2020. Hasil analisis dari penelitian ini adalah terdapat penurunan jumlah pasien sebanyak 1401 pasien. Dan faktor yang mempengaruhi kunjungan pasien adalah tingkat kepercayaan pasien terhadap Pandemi Covid-19, pasien merasa khawatir apabila berkunjung ke Puskesmas maka akan tertular Covid-19.","PeriodicalId":305770,"journal":{"name":"Jurnal Rekam Medis dan Informasi Kesehatan","volume":"26 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2021-10-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"114189258","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

Faktor Risiko Burnout pada Petugas di Instalasi Rekam Medis dan Informasi Kesehatan RSUD K.R.M.T Wongsonegoro 在k.r.m. T . Wongsonegoro的医疗记录和健康信息安装的官员身上存在倦醇的危险因素

Jurnal Rekam Medis dan Informasi Kesehatan Pub Date : 2021-10-31 DOI: 10.31983/jrmik.v4i2.7858

Zefan Adiputra Golo, Eliyah Eliyah, Eiska Rohmania Zein

引用次数: 0

Prosedur Kerja Perekam Medis dan Informasi Kesehatan dalam Masa Pandemi Covid-19 di Rumah Sakit 在医院的Covid-19大流行期间，医疗记录和健康信息的工作程序

Jurnal Rekam Medis dan Informasi Kesehatan Pub Date : 2021-10-31 DOI: 10.31983/jrmik.v4i2.7677

Luthfiana Cahya Safitri, Arief Nabhan, F. Fatmawati, Tatu Siti Husnul Khotimah

{"title":"Prosedur Kerja Perekam Medis dan Informasi Kesehatan dalam Masa Pandemi Covid-19 di Rumah Sakit","authors":"Luthfiana Cahya Safitri, Arief Nabhan, F. Fatmawati, Tatu Siti Husnul Khotimah","doi":"10.31983/jrmik.v4i2.7677","DOIUrl":"https://doi.org/10.31983/jrmik.v4i2.7677","url":null,"abstract":"Personal protective equipment (PPE) is a set of safety tools used by workers to protect all or part of their body from possible exposure to potential hazards of the work environment to work-related accidents and diseases. Medical Record and Health Information Officers are at risk of being exposed to the Covid-19 virus. The Covid-19 virus that can survive in inanimate objects indirectly also have the potential to infect the medical recorder. This study aims to determine the working procedures of medical recorders during Covid-19 pandemic at the hospital based on the PORMIKI circular letter No.HM.01.01/002/III/2020. The method used in this research is descriptive research method using a qualitative approach. The sample in this study were all Medical Records and Health Information officers at hospital. The results showed that the work procedures for medical recorder during the Covid-19 pandemic at the hospital, starting from Personal Protective Equipment (PPE) for medical recorders and Health Information to maintenance procedures for the overall medical record of Covid19 patients. In accordance with work procedures recommended by PORMIKI in a circular.","PeriodicalId":305770,"journal":{"name":"Jurnal Rekam Medis dan Informasi Kesehatan","volume":"273275 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2021-10-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"123153452","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

Analisis Tarif Rumah Sakit dan Tarif Ina CBGs Kasus Gagal Jantung Kongestif 分析住院率和充血性心力衰竭病例CBGs

Jurnal Rekam Medis dan Informasi Kesehatan Pub Date : 2021-03-29 DOI: 10.31983/JRMIK.V4I1.6788

Nina Dwi Astuti, Irmawati Irmawati, Apifah Apifah

{"title":"Analisis Tarif Rumah Sakit dan Tarif Ina CBGs Kasus Gagal Jantung Kongestif","authors":"Nina Dwi Astuti, Irmawati Irmawati, Apifah Apifah","doi":"10.31983/JRMIK.V4I1.6788","DOIUrl":"https://doi.org/10.31983/JRMIK.V4I1.6788","url":null,"abstract":"Tarif rumah sakit dan tarif Ina CBGs mengalami perbedaan karena perhitungan kedua tarif tersebut menggunakan parameter yang berbeda. Namun jika perbedaan tersebut menyebabkan selisih yang besar, dapat menimbulkan dampak kerugian bagi rumah sakit. Permasalahan ini terutama pada rumah sakit swasta yang harus memperhatikan profit. Penelitian pada kasus Gagal Jantung Kongestif dengan studi cross sectional dilakukan pada salah satu rumah sakit swasta tipe C di Jawa Tengah. Sebanyak 70 kasus gagal jantung kongesif dianalisis secara univariat untuk mengetahui karakteristik sampel, perbedaan tarif rumah sakit dengan tarif Ina CBGs, dan komponen tarif rumah sakit. Analisis faktor yang dapat menyebabkan perbedaan tarif dilakukan dengan menghitung angka indeks tertimbang berdasarkan severity level, kelas rawat, lama hari rawat, jumlah tindakan dan diagnosa sekunder. Hasil menunjukkan bahwa perbedaan tarif yang tinggi terdapat pada lama hari rawat 5 hari dan jumlah tindakan 1. Lama hari rawat 5 hari menjadi faktor yang menyebabkan tarif rumah sakit lebih tinggi 102% dari pada tarif Ina CBGs, sedangkan jumlah tindakan lebih dari satu (ada tindakan selain EKG) menyebabkan tarif rumah sakit lebih tinggi 65% dari pada tarif Ina CBGs. Penerapan clinical pathway dapat dilakukan untuk efisiensi pelayanan. Penggunaan clinical pathway dapat menurunkan lama hari rawat dan tindakan yang kurang diperlukan tanpa mengurangi kualitas pelayanan.","PeriodicalId":305770,"journal":{"name":"Jurnal Rekam Medis dan Informasi Kesehatan","volume":"44 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2021-03-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"114466230","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