scholarly journals Identifikasi Prioritas Masalah Unit Rekam Medis di Puskesmas Nusukan

2020 ◽  
Vol 3 (1) ◽  
pp. 24-28
Author(s):  
Puguh Ika Listyorini
Keyword(s):  
Health Center ◽  
Medical Record ◽  
Medical Records ◽  
Group Discussion ◽  
Multiple Criteria ◽  
Medical Services ◽  
Utility Assessment ◽  
Descriptive Research ◽  
Workforce Needs

Health services consist of two kinds, namely medical and non-medical services. One of the non-medical services provided by the medical record unit. In providing medical record unit services do not always run well, therefore it is necessary to identify the priority determination of the problem to find out what problems must be solved first. The Multiple Criteria Utility Assessment (MCUA) method is a method of determining priority problems with scoring techniques. The purpose of this study was to determine the priority of problems in the medical record unit of the Nusukan Health Center using the MCUA Method. This research uses descriptive research design with 4 speakers. According to the results of the identification of problems carried out by the Group Group Discussion (FGD) that there are 3 problems in the medical record unit of the Nusukan Public Health Center, namely the lack of resources for medical records, medical record documents, and the availability of rooms for managing medical records that are still limited. The priority problem with the MCUA method shows that the problem with the highest value is the lack of medical record personnel. Before making additional workforce, it is recommended to calculate the workforce needs in the medical record unit according to the workload of the medical record officer so that the additional workforce is in accordance with the workload of the officer.AbstrakPelayanan kesehatan terdiri dari dua macam yaitu pelayanan medis dan non medis. Pelayanan non medis salah satunya diberikan  oleh unit rekam medis.  Dalam memberikan pelayanan unit rekam medis tidak selalu berjalan dengan baik, oleh karena itu perlu dilakukan identifikasi penentuan prioritas masalah untuk mengetahui masalah apa saja yang harus diselesaikan terlebih dahulu. Metode Multiple Criteria Utility Assessment (MCUA) adalah salah satu metode penentuan prioritas masalah dengan tekhnik scoring. Tujuan penelitian ini untuk mengetahui prioritas masalah di unit rekam medis Puskesmas Nusukan menggunakan Metode MCUA. Penelitian ini menggunakan desain penelitian deskriptif dengan 4 orang narasumber. Menurut hasil identifikasi masalah yang dilakukan dengan Forum Group Discussion (FGD) bahwa terdapat 3 masalah di unit rekam medis Puskesmas Nusukan, yaitu kurangnya sumber daya tenaga rekam medis, missfile dokumen rekam medis, dan ketersediaan ruagan untuk penggelolaan rekam medis yang masih terbatas. Prioritas masalah dengan metode MCUA menunjukkan masalah dengan nilai paling tinggi adalah kurangnya sumber daya tenaga rekam medis. Sebelum melakukan penambahan tenaga kerja, maka disarankan agar menghitung kebutuhan tenaga kerja di unit rekam medis menurut beban kerja petugas rekam medis agar penambahan tenaga kerja sesuai dengan beban kerja petugas.

scholarly journals Analisis Kelengkapan Penulisan Soap, KIE, dan ICD X pada Rekam Medis di Poli Umum dan KIA-KB Puskesmas X Surabaya

2018 ◽  
Vol 5 (2) ◽  
pp. 139
Author(s):  
Ayunda Zilul Gosanti ◽  
Ernawaty Ernawaty
Keyword(s):  
Public Health ◽  
Family Planning ◽  
Health Center ◽  
Medical Record ◽  
Medical Records ◽  
Random Sampling ◽  
Health Workers ◽  
Public Health Center ◽  
Descriptive Research ◽  
Mother And Child

Based on the standart that Public Health Center “X” completeness of SOAP, KIE, and ICD X must be 100%. The aim of research was to analyze how the completeness of writing SOAP, KIE, and ICD X inGeneral Poly and Health of Mother and Child Family Planning Public Health Center “X”. This study was descriptive research with 500 medical records that consist of 260 for January and 240 for February as sample and they taken by random sampling. The result showed that completeness of SOAP, KIE, and ICD X on January in General Poly were 48% and decrease on February became 45,8%.While Health Mother and Child Family Planning Poly showed that completeness on January were 97,8% and increase on February became 98,6%. The incompleteness of medical records can be influenced by several factors is compliance the health workers who responsible in filling the medical records and they have multi job in Public Health Center “X” also the patient was increase. To minimize the incompleteness of SOAP, KIE, and ICD X, medical staff needs to expose by socialization of medical record to remember their responsibilty of their job description.Keywords : Completeness, medical record, Public Health Center

scholarly journals Aspek Hukum Rekam Medis atau Rekam Medis Elektronik sebagai Alat Bukti Dalam Transaksi Teurapetik

2017 ◽  
Vol 3 (2) ◽  
pp. 359-383 ◽  
Author(s):  
Sudjana Sudjana
Keyword(s):  
Medical Record ◽  
Electronic Medical Record ◽  
Medical Records ◽  
Health Workers ◽  
Legal Aspects ◽  
Literature Study ◽  
Descriptive Research ◽  
Positive Law ◽  
Approach Method ◽  
Administrative Sanctions

This study aims to obtain information on: first, the obligation to create and conceal Electronic Medical Record and its juridical consequences; Secondly, due to the law of absence or error in the manufacture of Electronic Medical Records and the position of Electronic Medical Record as a tool in the theoretical transactions.The research method used is normative juridical approach method, analytical descriptive research specification, research phase is done through literature study to examine primary law material, secondary law material, and tertiary law material. Data collection techniques are conducted through document studies, conducted by reviewing documents on positive law. Furthermore, the method of data analysis is done through normative qualitative.The results of the study indicate: Legal aspects of Medical Record or Electronic Medical Record   in Teurapetik Transactions related to: first, the obligation of health workers in coaching and health services to make Medical Record or Electronic Medical Record correctly and responsible for secrecy because it is the opening of Medical Record or Electronic Medical Record without With the permission of the patient having the consequences of criminal law. The absence or misuse of the Medical Record or Electronic Medical Record means that health workers may be subject to criminal, civil and administrative sanctions. Second, the position of  Medical Record or Electronic Medical Record is evidence in the form of a letter (if given outside the court), and expert information (if delivered in court).

scholarly journals THE UTILIZATION OF VISUAL BASIC.NET APPLICATION FOR DETERMINATION OF INDIVIDUAL DRUG DOSAGES IN DIABETIC PATIENTS OF CHRONIC RENAL DISORDER COMPLICATIONS

2018 ◽  
Vol 11 (13) ◽  
pp. 234
Author(s):  
Ari Usman ◽  
Nilsya Febrika Zebua
Keyword(s):  
Creatinine Clearance ◽  
Medical Records ◽  
Diabetes Complications ◽  
Diabetic Patients ◽  
Dose Calculations ◽  
Inclusion Criteria ◽  
Renal Disorder ◽  
Descriptive Research ◽  
Patients With Diabetes

  Objective: This research aims to apply the Visual Basic.Net (VB.NET) of individual dose calculations based on the formula of pharmacokinetics for diabetic patients of chronic renal disorder complication in Dr. Pirngadi Hospital because the dosage administered was not based on the patient’s creatinine clearance.Methods: This descriptive research was conducted using a simulated creatinine cleavage calculation using VB.NET programming language applications with variable patient data, the value of creatinine, the name of drug, and dosage.Results: This study obtained data about the use of drugs 40 patients who met the inclusion criteria of 320 medical records of diabetic patients, there are 6 types of drugs that are not in accordance with the dose based on the calculation of creatinine clearance are ceftriaxone(18 of 18 cases), furosemide (19 of 19 cases), ciprofloxacin (2 of 8 cases), ranitidine (4 of 24 cases), metformin (2 of 7 cases), and captopril (16 of 16 cases).Conclusions: This research aims to apply the VB.NET is it able to apply individual doses for patients with diabetes complications of renal failure have not been applied in accordance with creatinine clearance calculations at this hospitalwhere this work is difficult to do.

scholarly journals Review Of Returning Medical Records In Outpatient Medical Record

2021 ◽  
Vol 1 (1) ◽  
pp. 6-12
Author(s):  
Raden Minda Kusumah ◽  
Jessica Putri Meyliyan
Keyword(s):  
Data Collection ◽  
Health Center ◽  
Medical Record ◽  
Medical Records ◽  
Reporting System ◽  
Standard Operating Procedures ◽  
Literature Study ◽  
Standard Operating ◽  
Descriptive Approach

In returning the outpatient medical record file to thesection of the Medical Record Unit, Assembling there was a delay. This is because the return of medical record files has not been carried out according to Standard Operating Procedures, as a result, causing delays in the reporting system. The method used is qualitative using a descriptive approach. Data collection techniques by observation, interviews and literature study. This study aims to determine the return of former medical records of outpatients at Dayeuhkolot Health Center. The results of the study prove that the delay in returning outpatient medical record files at the Dayeuhkolot Health Center with presentations during the 1 week study amounted to 63 or 22% of 285 medical record files. Efforts have been made to disseminate information to all officers related to the efforts made by the person in charge of COVID-19 patients in returning medical record files on time.

scholarly journals Pengembangan Sistem Informasi Rekam Medis untuk Dinas Kabupaten Grobogan

2014 ◽  
Vol 2 (3) ◽  
pp. 203-208
Author(s):  
Purnaresa Yuliartanto ◽  
Adian Fatchur Rochim ◽  
Ike Pertiwi Windasari
Keyword(s):  
Health Center ◽  
Medical Record ◽  
Medical Records ◽  
Business Processes ◽  
Health Department ◽  
Health Centers ◽  
Process Data ◽  
Record Keeping ◽  
Storage And Retrieval ◽  
Number Of Patients

Abstract - Health services include the recording of the patient's medical record . Medical records were used to aid the treatment process. The number of medical records continues to grow proportional to the number of patients. Tens of thousands of sheets of paper used to record medical record requires effort , time and place great . The amount of effort will continue to grow each day. Search one sheet of medical records among a set of storage shelves requires considerable time and risk data is not found. The risk of error in the search and storing will increase every day. The development of technology allows the implementation of technology in the process of record-keeping. Changes in the form of digital medical records will reduce the need of a previous process. Labor, time and place required by the help of information systems will be reduced significantly . Storage process data stored in the cloud will provide more value for the system as a patient's medical records from a health center can be accessed from other health centers. The development of this system will reduce the risk of inappropriate storage and retrieval of medical records. Grobogan Health Department that oversees health center in Grobogan are office that are ready to migrate business processes into the digital age. Development of medical record information system for the health center expected to improve the quality of service of health centers , especially in health care.

scholarly journals Medical Record Storage System Analysis On The Effectiveness Of Patient Services

2021 ◽  
Vol 1 (1) ◽  
pp. 28-38
Author(s):  
Yoki Muchsam ◽  
Ilham Rizkiana Muharam
Keyword(s):  
Public Health ◽  
Health Center ◽  
Medical Record ◽  
Medical Records ◽  
System Analysis ◽  
Storage System ◽  
Health Care Facilities ◽  
Public Health Center ◽  
Additional Tool ◽  
Alignment System

This study aims to determine and analyze the medical record storage system on the effectiveness of patient care at the Cikole Public Health Center. The research method used is quantitative with inferential statistical analysis techniques. Data collection techniques by means of observation, interviews and questionnaires. Cikole Lembang Public Health Center is one of the first level health care facilities. Based on observations, the storage system used is a regional storage system in which each region starts from the first digit. There are 2 officers who work in the medical records section of the Cikole Public Health Center. With the storage system used, there are several shortcomings, namely the occurrence of misfiles and duplication. To find out whether there is an analysis of the medical record storage system on the effectiveness of the service, the author gives a questionnaire to the Cikole Public Health Center officers. The results of the questionnaire also show that the highest percentage level is found in item no.7, namely the decentralized storage system is in accordance with the target of 71%. Then the second is item no. 8, namely a decentralized storage system that allows the provision of medical record files on time by 61%. From the results of interviews with medical records officers, suggestions and input were given: (1). The storage system used was changed to centralization so that the alignment system was not duplicated; (2). The use of bindex as an additional tool to make storage neater and easier.

scholarly journals Aplikasi Filling Rekam Medis Menggunakan Metode Algoritma Turbo Boyer Moore

2020 ◽  
Vol 5 (2) ◽  
pp. 259
Author(s):  
Beni Harzani ◽  
Diana Diana
Keyword(s):  
Health Center ◽  
Medical Record ◽  
Medical Records ◽  
Community Health Centers ◽  
Processing System ◽  
Patient Data ◽  
Search Problem ◽  
Test Results ◽  
Medical Record Data ◽  
Record Data

Nagaswidak Health Center is one of the community health centers that is quite large and has complete facilities. But the problem that is often faced by officers in the puskesmas is the medical record data processing system which is still manual, causing the accumulation of patient medical record file data, in addition to patients who have been checked before and lost their medical records, it is very difficult for officers to find back, so the officer made a new medical record data. To overcome this problem, a Medical Records Filling Application was made at the Nagaswidak Health Center which includes the processing of medical records, patient data, drug data, action data, doctor data, and admin logins. So that the data search problem is not difficult, the turbo boyer moore algorithm method is applied which is expected to later be able to facilitate the search for patient data in the medical record filling application. Based on the test results Boyer Moore's Algorithm successfully applied to search for the beginning of a word, middle word, and final word. And the level of ease and usefulness of medical records application using Boyer Moore's algorithm obtained results that the level of ease is 80% and 100% usability rate.

scholarly journals REKAM MEDIS SEBAGAI ALAT BUKTI DALAM PENYELESAIAN SENGKETA LAYANAN MEDIS

Yurispruden ◽  
2020 ◽  
Vol 3 (1) ◽  
pp. 61
Author(s):  
Abdul Rokhim
Keyword(s):  
Medical Record ◽  
Expert Testimony ◽  
Medical Records ◽  
Criminal Procedure ◽  
Medical Services ◽  
Dual Function ◽  
Procedure Code ◽  
Written Form

AbstrakRekam medis adalah berkas yang berisi catatan dan dokumen tentang identitas pasien, pemeriksaan, pengobatan, tindakan dan pelayanan lain yang telah diberikan kepada pasien. Secara formil, rekam medis sebagai alat bukti dalam penyelesaian sengketa layanan medis mempunyai fungsi ganda, yaitu sebagai alat bukti keterangan ahli dalam bentuk tertulis berdasarkan pasal 186 dan 187 Undang-undang Nomor 8 Tahun 1981 tentang Acara Pidana (KUHAP), dan sebagai alat bukti surat berdasarkan pasal 187 KUHAP. Secara materiil, kedudukan rekam medis sebagai alat bukti keterangan ahli maupun sebagai alat bukti surat merupakan alat bukti bebas, artinya hakim tidak terikat untuk meyakini kebenaran isi rekam medis, ia bisa meyakini dan menggunakan alat bukti itu atau tidak, sepenuhnya bergantung pada penilaian bebas dari hakim.Kata Kunci: Rekam Medis; Alat Bukti; Layanan Medis AbstractMedical record is a file that contains records and documents about the patient's identity, examination, treatment, actions and other services that have been provided to patients. Formally, medical records as evidence in resolving disputes in medical services have a dual function, namely as evidence of expert testimony in written form pursuant to articles 186 and 187 of Law Number 8 of 1981 concerning Criminal Procedure (KUHAP), and as evidence of letters based on article 187 of the Criminal Procedure Code. Materially, the position of the medical record as evidence of expert statements and as evidence of letters is free evidence, meaning that the judge is not bound to believe the truth of the contents of the medical record, he can believe and use the evidence or not, entirely dependent on the free assessment of the judge.Keywords: Medical Record; Evidence; Medical Services

scholarly journals Tinjauan Pelaksanaan Sistem Penyimpanan Rekam Medis Berdasarkan Standar Akreditasi Di UPTD Puskesmas Kotanopan Mandailing Natal

2021 ◽  
Vol 6 (1) ◽  
pp. 14-22
Author(s):  
Zulham Andi Ritonga ◽  
Hasran Ependi Lubis
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Storage System ◽  
Patient Medical Record ◽  
Biological Damage ◽  
Descriptive Research ◽  
Accreditation Standards ◽  
File Storage ◽  
Speed Up ◽  
Storage Racks

Storage of medical records is one of the assessments in puskesmas accreditation standards. The medical record file storage system is very important to do in health care institutions, because the storage system can make it easier for medical record files to be stored in storage racks, speed up the recovery or retrieval of medical record files stored on storage racks, easy to return, and protect record files. from theft, physical, chemical and biological damage. The purpose of this study was to determine how the implementation of a medical record storage system based on puskesmas accreditation standards, which was carried out in August 2020. The research method used was descriptive research with a qualitative approach. The number of research informants was 4 people. Storage of medical records had not used tracers and expedition book as a means of replacing medical record files and notes in and out of borrowed medical record files. Meanwhile, tracer and expedition books can assist officers in searching for missing / out of place medical record files. This can hamper the provision of patient medical record files that are needed. It is hoped that the UPTD Puskesmas Kotanopan will provide regular training or debriefing to medical record officers

scholarly journals Pelaksanaan Penyimpanan Rekam Medis Berdasarkan Unsur Manjemen 5M di Puskesmas Medan Johor

2021 ◽  
Vol 6 (2) ◽  
pp. 152-160
Author(s):  
Valentina ◽  
Winda Andryani Sinaga
Keyword(s):  
Health Center ◽  
Medical Record ◽  
Medical Records ◽  
Good Health ◽  
Phenomenological Approach ◽  
Check List ◽  
Machine Element ◽  
Interview Guide ◽  
Material Element ◽  
Audio Recorder

The implementation of medical records carried out at the puskesmas requires management in managing all existing activities with the aim of creating good health services, in accordance with procedures and guidelines. To achieve the goal of processing medical records, 5 elements of management are needed, namely man, money, material, machine, and method. The purpose of this study was to determine the management elements of man, money, material, machine, and method in the implementation of medical records carried out at the Medan Johor Health Center. This type of research uses qualitative research methods with a phenomenological approach. The study was conducted from May to July 2020. The population was all medical record officers at the Medan Johor Health Center. The research sample amounted to 5 people who were taken by saturated sampling. The research instrument is an interview guide and recorded using an audio recorder and a check list sheet for observation. The results showed that the man element was 5 people and none of them had a medical record background and had never received training, the money element was the funding obtained from JKN and APBD, the material element was that a family folder was used to store all patient forms, while the use of tracers and register books has not been used to control the borrowed files out of the storage rack, and the filling cabinet is used as a tool to store medical record files, the machine element is a primary care application to register patients, the SIMPUS application is used for reporting, the method element is Not all SOPs in medical records exist. The advice given is to provide training to medical record officers so that their officers better understand the importance of medical records.

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