Jurnal Rekam Medis dan Informasi Kesehatan最新文献

{"title":"Analisis Penyebab Tidak Digunakannya Sistem Informasi Manajemen Puskesmas (Simpus) dalam Penerimaan Pasien Rawat Jalan di Puskesmas Kalimas Kecamatan Randudongkal Kabupaten Pemalang","authors":"Linda Ida Tiara, Subinarto Subinarto","doi":"10.31983/jrmik.v2i2.5348","DOIUrl":"https://doi.org/10.31983/jrmik.v2i2.5348","url":null,"abstract":"Simpus is a system to improve the quality of puskesmas management and as a supporter in the smooth management of health information in Puskesmas. Based on the preliminary study of Kalimas Puskesmas in the process of admission an outpatient not use Simpus and still done manually The purpose of this research is to analyze the causal factors of the management Information System Puskesmas (Simpus) seen from the aspects of human resources, supporting materials, infrastructure facilities, implementation and fund source.The type of research used is descriptive research with qualitative approach. Methods of collection observation data and interview. Presentation of the data to be done ie in the form of fish bone diagram that contains about the factors of the cause of the not used SimpusThe results of the qualification study and the number of available medical record officers are not eligible. There has been no obligation from the Department of Health to use Simpus. Simpus from the Department of Health is integrated with Disduccapil and automatic numbering, the medical record number will differ from the number in the Family folder. There is only one computer in the registration. There has been no budget for such infrastructures for computers. Conclusion is not used Simpus seen from the aspect of human resources, the way of implementation, supporting materials, infrastructure and sources of funds have not been in accordance","PeriodicalId":305770,"journal":{"name":"Jurnal Rekam Medis dan Informasi Kesehatan","volume":"56 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-10-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"132742107","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}

{"title":"Keselamatan dan Kesehatan Kerja Pada Penyimpanan Rekam Medis di Instalasi Rekam Medis","authors":"Edy . Susanto, Rr. Sri Endang Pujiastuti, Rosita Dwi Cahyaningsih","doi":"10.31983/JRMIK.V2I1.4391","DOIUrl":"https://doi.org/10.31983/JRMIK.V2I1.4391","url":null,"abstract":"Penyimpanan rekam medis merupakan kegiatan untuk melindungi rekam medis dari kerusakan fisik dan isi dari rekam medis. Proses penyimpanan rekam medis mempunyai resiko yang dapat mengancam keselamatan dan kesehatan kerja petugas rekam medis. Salah satu upaya dalam keselamatan dan kesehatan kerja dengan memberikan perlindungan bagi petugas penyimpanan rekam medis dengan cara menggunakan alat pelindung diri. Berdasarkan studi pendahuluan di RSUD K.R.M.T Wongsonegoro Semarang penggunaan alat pelindung diri yang belum terlaksana dengan baik dan ruang penyimpanan yang berdebu serta resiko terjadi gesekan/tergores kertas atau map rekam medis yang tajam. Tujuan penelitian ini adalah untuk mengetahui keselamatan dan kesehatan kerja pada penyimpanan rekam medis. Jenis penelitian adalah penelitian deskriptif kualitatif yaitu penelitian dengan mendeskripsikan obyek dengan metode pengumpulan data menggunakan wawancara dan observasi. Penelitian ini menggunakan analisis data deskriptif yaitu mendeskripsikan dan menggambarkan hasil penelitian dalam bentuk narasi. Hasil penelitian menjelaskan bahwa keselamatan dan kesehatan kerja sudah berjalan namun belum secara maksimal. Hal ini dikarenakan belum terdapat SPO yang khusus mengatur keselamatan dan kesehatan kerja di rekam medis. Alat pelindung diri yang digunakan oleh petugas penyimpanan rekam medis meliputi alat pelindung pernapasan/ masker dan alat pelindung tangan/ sarung tangan. Pengetahuan petugas penyimpanan rekam medis bahwa alat pelindung diri merupakan hal yang penting digunakan sebagai perlindungan pada saat melakukan pekerjaan. Selain itu, sikap dan perilaku petugas penyimpanan rekam medis dalam penggunaan masker mencapai 91% dan sudah cukup baik, namun pada penggunaan sarung tangan hanya mencapai 41% sehngga perlu peningkatan. Abstract Storage of medical records is an activity to protect the medical records from physical damage and the content of the medical records. The process of storing the medical records has risks that can threaten the occupational safety and health of medical records staff. One of the efforts in occupational safety and health is by providing protection for the medical records staff by using personal protective equipment. Based on the preliminary study in RSUD K.R.M.T Wongsonegoro Semarang, the use of personal protective equipment that has not been done well and dusty storage space and the risk of friction/ scraped paper or sharp medical record map. The purpose of this study is to determine the occupational safety and health on the medical records storage. The type of the research is descriptive qualitative research which is a research by describing an object with the data collection method using interview and observation. This study uses descriptive data analysis that describes the results of the research in the form of narrative.The result of the study explains that the occupational safety and health had been done but not maximally. This is because there is no SPO that specific","PeriodicalId":305770,"journal":{"name":"Jurnal Rekam Medis dan Informasi Kesehatan","volume":"1 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-06-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"131115289","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}

{"title":"Analisis Kebutuhan Sumber Daya Manusia Rekam Medis di Unit Filing","authors":"R. Fadila","doi":"10.31983/JRMIK.V2I1.4049","DOIUrl":"https://doi.org/10.31983/JRMIK.V2I1.4049","url":null,"abstract":"Peningkatan jumlah kunjungan pasien di RS Permata Bunda Malang menyebabkan penambahan beban kerja pegawai terutama petugas Rekam Medis di Unit Filing. Jumlah SDM di Unit Filing RS Permata Bunda Malang saat ini adalah 4 orang dengan kondisi ruangan Filing yang kurang memadai atau sempit serta kurangnya fasilitas rak penyimpanan dokumen rekam medis, sehingga pada saat pengambilan DRM, beberapa kali didapati petugas harus bekerja melebihi jam kerja. Penelitian ini bertujuan untuk mengetahui besarnya beban kerja perekam medis yang ada di unit Filing Rumah Sakit Permata Bunda , selanjutnya beban kerja digunakan untuk menganalisis kebutuhan jumlah tenaga perekam medis di Unit Filing Rumah Sakit Permata Bunda. Penelitian ini menggunakan pendekatan kualitatif dengan melakukan observasi, wawancara mendalam dan menggunakan teknik work sampling . Hasil penelitian didapatkan bahwa penggunaan waktu kerja staf untuk aktivitas produktif rata-rata 82,13%, aktivitas non produktif rata-rata 5,13% dan aktivitas pribadi 12,57%. Hasil perhitungan tenaga kerja dengan metode WISN didapatkan jumlah kebutuhan tenaga Perekam Medis di Unit Filing seharusnya adalah 6 orang dengan ratio 0,67. Dengan demikian sesuai dengan beban kerja yang ada, perlu adanya penambahan tenaga Perekam Medis di Unit Filing Rumah Sakit Permata Bunda Malang sebanyak 2 orang.","PeriodicalId":305770,"journal":{"name":"Jurnal Rekam Medis dan Informasi Kesehatan","volume":"139 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-06-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"116045543","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}

{"title":"Tinjauan Pelaksanaan Pelepasan Informasi Medis","authors":"Warijan Warijan, W. Widodo, Martha Marshynta Nur'afifah","doi":"10.31983/JRMIK.V2I1.4398","DOIUrl":"https://doi.org/10.31983/JRMIK.V2I1.4398","url":null,"abstract":"Pelepasan informasi medis harus mengikuti prosedur yang berlaku karena informasi rekam medis bersifat rahasia dan harus dilindungi dari pihak-pihak yang tidak berwenang. RSUD Kota Salatiga sudah melayani banyak permintaan pelepasan informasi medis, namun dalam proses pelaksanaannya masih ditemukan belum lengkapnya persyaratan dan penulisan formulir permintaan pelepasan informasi medis dan tetap diterima oleh petugas yang menangani. Hal ini belum sesuai dengan standar prosedur operasional yang ada. Tujuan penelitian ini adalah untuk mengetahui pelaksanaan pelepasan informasi medis di RSUD Kota Salatiga. Jenis penelitian ini adalah penelitian deskriptif kualitatif. Metode pengumpulan data dilakukan dengan  metode wawancara dan observasi/pengamatan. Data di analisis menggunakan analisa non statistik dan disajikan dalam bentuk narasi. Hasil penelitian menunjukkan bahwa di RSUD Kota Salatiga mempunyai 3 alur pelepasan informasi medis, namun masih ada yang belum sesuai dengan standar prosedur operasional yang ada. Petugas yang terkait dalam proses pelepasan informasi medis yaitu Direktur Rumah Sakit, Petugas Bagian Tata Usaha/ Sekretariat, Petugas Rekam Medis dan Informasi Kesehatan, serta Dokter. Terdapat 3 standar prosedur operasional yang mengatur untuk menjamin aspek hukum kerahasiaan rekam medis pada pelaksanaan pelepasan informasi medis. Perlu adanya penegasan untuk memperketat persyaratan yang harus dibawa oleh pasien untuk permintaan pelepasan informasi medis agar tidak disalahgunakan oleh pihak yang tidak bertanggung jawab. Abstract The release of medical information have to follow applicable procedures  because information of the medical record is confidential and should be protected from unauthorized persons. RSUD Kota Salatiga who gives many services for the release of medical information, but in the process of implementation is still found incomplete of requirements and writing of request form the release of medical information and still received by the officer in charge. This is not accordance with standart operating procedure. The purpose of this study was to determine the implementation of the release of medical information in RSUD Kota Salatiga. This type of research is descriptive qualitative. The methods of data collection is done by interview and observation. Data analysis using non-statistical analysis and presentation of data in narrative form. Research shows that RSUD Kota Semarang possessed 3 flow for release medical information, but there are still not yet approoriate with standart operating procedurre that available. Officers involved in the process of the release of medical information is Director of Hospital, Administration Officer/Secretariat, Medical Record and Health Information Officer, and Doctor. There are 3 standard operating procedures that govern to ensure the legal aspect of confidentially of medical record in the implementation of the release of medical information. It needs affirmation and tighten requirements re","PeriodicalId":305770,"journal":{"name":"Jurnal Rekam Medis dan Informasi Kesehatan","volume":"23 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-06-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"121646415","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}

{"title":"Tinjauan Pelaksanaan Pemberian Kode Diagnosa dan Tindakan pada Pasien Rawat Inap","authors":"I. Irmawati, S. Sugiharto, Rozalia Mayasari","doi":"10.31983/JRMIK.V2I1.4397","DOIUrl":"https://doi.org/10.31983/JRMIK.V2I1.4397","url":null,"abstract":"Penelitian ini menggunakan penelitian deskriptif dengan pendekatan cross sectional melalui kuesioner yang diberikan kepada semua petugas koding rawat inap dan checklist yang untuk prosedur dan sarana prasarana koding. Penelitian dilakukan di Bagian Koding Rawat Inap RSUD Kota Salatiga pada bulan Mei - Juni. Analisis data menggunakan analisis univariate yaitu berupa distribusi frekuensi.Berdasarkan hasil penelitian, semua petugas koding rawat inap di RSUD Kota Salatiga berlatar belakang pendidikan DIII Rekam Medis dan sudah pernah mengikuti pelatihan tentang koding . Semua petugas koding rawat inap RSUD Kota Salatiga memiliki pengetahuan dan sikap yang baik dalam pelaksanaan pemberian kode diagnosa dan tindakan. Namun kelengkapan sarana prasarana koding bagi setiap petugas koding belum lengkap serta kepatuhan melaksanakan prosedur koding belum sesuai dan belum semua dilaksanakan. Abstract This research uses descriptive research with cross sectional approach through a questionnaire given to all officers inpatient coding and checklist for procedures and infrastructure coding. Research conducted at the Hospital Inpatient Coding Part of Salatiga in May-June. Data analysis using univariate analysis in the form of a frequency distribution.Based on the results of the study, all officers in the hospital inpatient coding Salatiga educational background DIII Medical Records and have completed training on coding. All inpatient hospital coding clerk in RSUD Kota Salatiga have knowledge and a good attitude in the implementation of the diagnose and the procedure code. However, the completeness of the infrastructure coding for each officer incomplete coding and compliance implement coding procedure is not appropriate and not all implemented.","PeriodicalId":305770,"journal":{"name":"Jurnal Rekam Medis dan Informasi Kesehatan","volume":"7 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-06-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"116245888","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}

{"title":"Komputerisasi Pendaftaran Pasien Rawat Jalan Berbasis Web Di Praktek Dokter","authors":"Yunita Wisda Tumarta Arif","doi":"10.31983/JRMIK.V2I1.4088","DOIUrl":"https://doi.org/10.31983/JRMIK.V2I1.4088","url":null,"abstract":"ABSTRAK      Praktek dokter umum merupakan pusat layanan tingkat pertama maka dari itu banyak pasien yang berobat. Praktek dokter umum adalah dokter yang memiliki kemampuan mengobati berbagai penyakit dan melakukan praktik medis untuk umum.     Peran rekam medis di dokter prakter sama dengan peran rekam medis di Rumah Sakit. Di Praktek dokter Agung Sutopo yang terletak di Jln. Prof. Soeharso No. 28 Boyolali membuka praktek dokter 2 kali dalam satu hari. Pukul 06.00-11.00 terdapat kunjungan rata-rata 80 pasien dan pukul 16.00-22.00 terdapat kunjungan rata-rata sebanyak 100 pasien.  Pendaftaran di praktek umum dokter Agung Sutopo masih dilakukan secara manual. Hal ini menyebabkan pelayanan dan pengolahan data pendaftaran pasien menjadi  kurang efektif dan efisien karena menyebabkan resiko ketidaklengkapan atau kesalahan penulisan identitas pasien serta terjadi duplikasi data pasien karena ditulis berulang-ulang. Berdasarkan permasalahan tersebut  maka perlu adanya Komputerisasi Pendaftaran Pasien Rawat Jalan Berbasis Web di Praktek dokter Agung Sutopo Boyolali dengan tujuan dapat menghasilkan informasi yang cepat, tepat dan akurat demi meningkatkan kualitas pelayanan kesehatan dalam pendaftaran rawat jalan. Metode pengembangan sistem yang digunakan yaitu System Development Life Cycle (SDLC). Metode SDLC ini seringkali dinamakan juga sebagai proses pemecahan masalah. Dalam pembangunan sistem megguakan PHP untuk membuat tampilan web menjadi lebih dinamis. Penelitian ini diharapkan dapat memberikan manfaat di Unit Rekam Medis khususnya di bagian pendaftaran pasien rawat jalan dalam pengembangan Praktek dokter Agung Sutopo Boyolali. Kata kunci: sistem, pedaftaran, rekam medis ABSTRACT The practice of general practitioners is a first-rate service center and therefore many patients seek treatment. The practice of general practitioners is a doctor who has the ability to treat various diseases and conduct medical practices for the public. The role of the medical record in the physician is the same as the role of the medical record in the hospital. At Agung Sutopo doctor's practice located at Jln. Prof. Soeharso No. 28 Boyolali opens a doctor's practice 2 times a day. At 6:00 a.m. to 11:00 there were an average visit of 80 patients and at 16:00 to 22:00 there were an average of 100 patients. Registration in the general practice of Agung's doctor Sutopo is still done manually. This causes the service and processing of patient registration data to be less effective and efficient because it causes the risk of incomplete or incorrect writing of the patient's identity as well as duplication of patient data because it is written repeatedly. Based on these problems, it is necessary to have a Computerized Registration of Web-Based Outpatient Patients in Practice Agung Agung Sutopo Boyolali with the aim of producing fast, precise and accurate information in order to improve the quality of health services in outpatient registration. The system development method used","PeriodicalId":305770,"journal":{"name":"Jurnal Rekam Medis dan Informasi Kesehatan","volume":"1 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-06-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"127699175","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}

{"title":"Efektifitas Penempatan Penanggung Jawab Rekam Medis Pada Setiap Bangsal Terhadap Pengelolaan Rekam Medis","authors":"Subinarto Subinarto, M. Monalisa, Anton Kristijono","doi":"10.31983/JRMIK.V2I1.4638","DOIUrl":"https://doi.org/10.31983/JRMIK.V2I1.4638","url":null,"abstract":"Rekam Medis merupakan bagian yang sangat penting dalam suatu sarana pelayanan jesehatan karena rekam medis memuat segala informasi selama pasien diberikan perawatan di sarana pelayanan kesehatan. Penanggung Jawab Rekam Medis (PJRM) adalah perekam medis yang ditempatkan di bangsal untuk mengerjakan kegiatan rekam medis ketika pasien masih dirawat. Dampak jika tidak adanya perekam medis di bangsal adalah menumpukknya rekam medis di unit kerja rekam medis, kejadian overcost yang tinggi, pelayanan yang tidak terkontrol, ketidak lengkapan rekam medis tinggi. Penelitian ini adalah analisis kuantitatif, dengan rancangan cross sectional yaitu, untuk mengetahui efektifitas dari penanggung jawab rekam medis yang berada di setiap bangsal terhadap pengelolaan rekam medis artinya setiap subyek penelitian diobservasi, faktor risiko serta dampak diukur menurut keadaan atau status pada saat observasi dan seberapa besar potensi kerugian atau keuntungan yang akan diterima oleh rumah sakit.","PeriodicalId":305770,"journal":{"name":"Jurnal Rekam Medis dan Informasi Kesehatan","volume":"7 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-06-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"131186397","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}

{"title":"Sistem Informasi Pencatatan dan Pelaporan Pelayanan Kesehatan Berbasis Android di Kawasan Terpencil dan Sangat Terpencil","authors":"Syefira Salsabila","doi":"10.31983/JRMIK.V2I1.3962","DOIUrl":"https://doi.org/10.31983/JRMIK.V2I1.3962","url":null,"abstract":"Health care is the right of every community to get service without exception, even though it is in an area that is difficult to reach due to geographical access. Mobile Health Services (PKB) is one of the innovations in equitable health services in remote and very remote areas. The process of recording and processing data is generally held also on PKB is still done manually. Recording that is still running in handwriting causes many obstacles in the process of processing, searching, and making reports on health service activities. The purpose of this study is to identify and develop information systems for recording and reporting on maternal and child health service activities at PKB. This research method uses Action Research. This design was chosen because it would delve deeply into the process and management of the development of Android-based applications for PKB. The results of this study present that the use of android-based mobile phones as a tool in data collection for the implementation of recording and reporting of mother and child activities can be carried out offline. This prototype information system made the process more efficient in term of time, especially when the data is uploaded to a properly administered server, makes the data much more secure, more effective to use for mobile health clinic team or health provider for data reporting.","PeriodicalId":305770,"journal":{"name":"Jurnal Rekam Medis dan Informasi Kesehatan","volume":"83 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-03-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"117259150","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}

{"title":"Ketepatan Penggunaan Singkatan Dan Simbol Pada Dokumen Rekam Medis Rawat Inap Diagnosis Schizophrenia","authors":"Harjanti Janti","doi":"10.31983/JRMIK.V2I1.3916","DOIUrl":"https://doi.org/10.31983/JRMIK.V2I1.3916","url":null,"abstract":"Hasil penelitian pada formulir Catatan Perkembangan Pasien Terintegrasi (CPPT) bahwa terdapat simbol yang terdapat pada buku pedoman yaitu 10 simbol atau 93,41%. Selain itu dalam penggunaan singkatan yang tidak tepat ada 11, 75% dan yang tidak terdapat dalam buku pedoman ada 10, 41%.  Maka dilakukan penelitian lanjutan dengan menggunakan dokumen rekam medis diagnosis schizophrenia. Tujuan penelitian yaitu mengidentifikasi ketepatan penggunaan simbol dan singkatan pada dokumen schizophrenia.. Jenis penelitian yaitu deskriptif dengan pendekatan retrospectif. Populasi dalam penelitian yaitu Dokumen Rekam Medis Rawat Inap dengan Diagnosis Schizophrenia pada Tribulan III (Tiga) pada tahun 2017 sejumlah 163 Dokumen. Besar sampel yaitu 62 dokumen rekam medis dengan sampling sistematis. Instrumen penelitian checklist dengan metode observasi dan studi Dokumentasi. Tehnik pengolahan data dengan pengumpulan, edit, klasifikasi, tabulasi dan penyajian data. Analisis data yaitu analisis deskriptif. Berdasarkan hasil observasi dan studi dokumentasi bahwa singkatan yang tidak tepat 13%, tidak ada di buku pedoman ada 17%. Sedangkan simbol yang tidak ada dalam buku pedoman ada 83%. Buku simbol dan singkatan yang dimiliki RSJD Dr. Arif Zainudin Surakarta hanya 1 dan tidak diklasifikasikan menjadi simbol, singkatan dan tanda lainya yang boleh digunakan dan tidak boleh digunakan. Sebaiknya buku dipisahkan antara simbol dan singkatan yang boleh digunakan dan tidak boleh digunaikan. Selain itu dilaksanakan evaluasi dalam pelaksanaan penggunaan simbol dan singkatan serta buku yang digunakan karena masih ada beberapa simbol dan singkatan yang belum tercantum dalam buku.","PeriodicalId":305770,"journal":{"name":"Jurnal Rekam Medis dan Informasi Kesehatan","volume":"11 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2019-03-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"125836308","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}

{"title":"PELAKSANAAN PENGISIAN DAN KELENGKAPAN FORMULIR INFORMED CONSENT TINDAKAN OPERASI","authors":"Edy Susanto, I. Irmawati, Widodo Widodo, Yolanda Dinarka Dea","doi":"10.31983/jrmik.v1i2.3848","DOIUrl":"https://doi.org/10.31983/jrmik.v1i2.3848","url":null,"abstract":"Abstrak Karya tulis ilmiah ini dilatarbelakangi oleh pentingnya pelaksanaan pengisian formulir informed consent yang baik dan benar. Serta pentingnya kelengkapan pengisian formulir informed consent , salah satunya untuk tindakan operasi. Penelitian ini bertujuan untuk menggambarkan pelaksanaan pengisian dan kelengkapan formulir informed consent tindakan operasi di RSUD K.R.M.T Wongsonegoro Semarang.Jenis penelitian adalah deskriptif, studi kasus. Menggunakan metode pendekatan cross sectional . Menggunakan instrumen penelitian berupa pedoman observasi, pedoman wawancara dan checklist kelengkapan pengisian. Jenis data yang terkumpul adalah data primer dan sekunder. Data diolah dalam bentuk transkrip dan tabel. Kemudian data dianalisis dan disajikan dalam bentuk grafik koding dan tabel. Hasil penelitian menunjukkan bahwa pelaksanaan pengisian formulir informed consent tindakan operasi di RSUD K.R.M.T Wongsonegoro Semarang sudah sesuai dengan Permenkes 290 tahun 2008, karena pelaksanaan pengisian formulir informed consent dimulai dari pasien diberikan informasi terkait tindakan operasi yang akan dilakukan, pengisian formulir informed consent , sampai dengan proses penandatanganan formulir informed consent . Serta untuk kelengkapan pengisian formulir informed consent tindakan operasi di RSUD K.R.M.T Wongsonegoro Semarang juga sudah lengkap, karena semua kolom pengisian sudah terisi secara lengkap.  Abstract [English Title : Implementation of Filling and Completeness of Informed Consent Form of The Act Surgery in RSUD K.R.M.T Wongsonegoro Semarang] A piece of writing scientific were created because the importance of filling informed consent forms that is good and right. And the importance of completeness informed consent forms, such as to the act of surgery. This research aims to describe the implementation of filling and completeness of informed consent forms the act of surgery in RSUD K.R.M.T Wongsonegoro Semarang.The type of research is descriptive, case study. Using cross sectional approach. Using research instruments of observation guidelines, interview guidelines and completeness checklist. The types of data collected are primary and secondary data. Data is processed in the form of transcript and table. Then the data is analyzed and presented in the form of coding chart and table.The result of the research shows that the implementation of filling of informed consent form of operation in RSUD KRMT Wongsonegoro Semarang was in accordance with Permenkes 290 year 2008, because the implementation of filling the form started from the patient given information related to the act of surgery to be performed, the filling of the informed consent form, signing informed consent form. As well as for completeness of the form of informed consent form operation in hospitals RSUD K.R.M.T Wongsonegoro Semarang is also complete, because all of columns are fully filled.","PeriodicalId":305770,"journal":{"name":"Jurnal Rekam Medis dan Informasi Kesehatan","volume":"23 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2018-12-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"125817168","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}