scholarly journals TINJAUAN PELAKSANAAN NILAI GUNA REKAM MEDIS BAGI PASIEN DI RUMAH SAKIT UMUM IMELDA PEKERJA INDONESIA (RSU IPI) MEDAN TAHUN 2018

2020 ◽  
Vol 5 (1) ◽  
pp. 80-84
Author(s):  
Johanna Christy ◽  
Afni Efani Putri S
Keyword(s):  
Health Care ◽  
Medical Care ◽  
General Hospital ◽  
Medical Record ◽  
Medical Records ◽  
Health Care Facilities ◽  
Use Value ◽  
Care Facilities ◽  
Conducting Research

ABSTRAK Rekam medis adalah berkas yang berisi catatan dan dokumen tentang identitas pasien, pemeriksaan, pengobatan, tindakan dan pelayanan lain kepada pasien pada sarana pelayanan kesehatan. Tujuan penelitian ini adalah untuk mengetahui bagaimana pelaksanan nilai guna rekam medis bagi pasien. Jenis penelitian ini adalah deskriptif bertujuan menggambarkan secara sistematis fakta dan karakteristik objek dan subjek secara tepat. Waktu penelitian ini dilakukan pada bulan Juli di Rumah Sakit Umum Pekerja Indonesia Medan (RSU IPI) Tahun 2018. Populasi dalam penelitian adalah 440 berkas rekam medis. Dalam melakukan penelitian, peneliti mengambil sampel sebanyak 81 berkas rekam medis. Berdasarkan hasil penelitian yang dilakukan di RSU IPI pelaksanaan nilai guna rekam medis sudah terlaksana dengan baik, dilihat dari tersedianya ringkasan masuk dan keluar, resume, lembar operasi, identifikasi bayi, lembar persetujuan tindakan, lembar kematian pada setiapberkas pasien pulang meninggal, asuhan keperawatan didalam berkas rekam medis. Tetapi dalam pengisian berkas rekam medis petugas rekam medis belum mengimplementasikan nilai guna rekam medis dengan baik. Kesimpulannya pelaksanaan nilai guna rekam medis sudah baik namun dalam pengisian berkas rekam medis lebih di perhatikan sesuai Permenkes 269 Tahun 2008 Tentang rekam Medis sehingga pelaksaaan nilai guna rekam medis dan pengisisan berkas rekam medis berjalan lebih baik.   Kata Kunci: Rekam Medis, Nilai Guna Rekam Medis, Berkas Rekam Medis                                             ABSTRACT   Medical record is a document that contains records and documents about patient identity, examination, treatment, care and other services for patients in health care facilities. The purpose of this study was to study how the implementation of the use of medical records for patients. This type of research is descriptive which addresses the systematic problem and the appropriate characteristics of objects and subjects. When this study was conducted in July at the Medan Indonesian Workers General Hospital (RSU IPI) in 2018. The population in this study was 440 medical record documents. In conducting research, researchers took 81 samples of medical records. Based on the results of research conducted at the IPI General Hospital, the implementation of the use value of medical records has been carried out well, seen from the availability of incoming and outgoing assessments, proceeding, surgery sheets, accessing infants, action approval sheets, consent sheets on each patient's return documents, medical care care. However, in applying medical records, medical record officers have not applied the use value of medical records properly. Conclusion the reclamation of the value of the medical record has been better in the reclamation of the medical record is better with the approval in accordance with Minister of Health Regulation 269 of 2008 About the Medical Record requires the implementation of the value of the medical record and the filling of the medical record better.

scholarly journals PENGELOLAAN DATA REKAM MEDIS MELALUI SISTEM PENOMORAN DAN PENYIMPANAN UNTUK MENINGKATKAN MUTU PELAYANAN KESEHATAN DI KLINIK GIGI DAN UMUM PURI MEDICAL

2019 ◽  
Vol 3 (2) ◽  
pp. 135
Author(s):  
Rahmi Septia Sari
Keyword(s):  
Health Care ◽  
Medical Record ◽  
Community Service ◽  
Storage System ◽  
Patient Data ◽  
Health Care Facilities ◽  
Medical Record Data ◽  
Care Facilities ◽  
Record Data ◽  
And Storage

Pemeliharaan dan pengambilan data rekam medis merupakan fungsi penting dalam pelayanan disetiap fasilitas asuhan kesehatan. Peningkatan tuntutan akan informasi kesehatan ini mengharuskan fasilitas untuk memelihara sistem informasi yang efektif dan efisien. Mengenai sistem penomoran, penyimpanan dan retensi dari manajemen rekam medis di Indonesia banyak jenisnya. Bentuk sistem penomoran dan penyimpanan yang baik merupakan tahap awal dalam pemberian pelayanan terhadap pasien. Pengambilan dan penyimpanan rekam medis yang tepat merupakan elemen penting dalam pemberian pelayanan. Perlu kehati-hatian dalam merencanakan sistem penomoran dan penyimpanan. Tujuan utama dalam melakukan pemberian penomoran adalah mengidentifikasi data pasien. Penulis berpendapat bahwa dengan menggunakan bentuk pemberian nomor metode apapun rahasia pasien dapat terjaga. Pemberian nomor ini dilakukan pada saat pasien mendaftar atau kontak dengan sarana pelayanan kesehatan. Hal tujuan utama dalam melakukan pemberian penomoran adalah mengidentifikasi data pasien. Pemberian nomor dilakukan pada saat pasien mendaftar atau kontak dengan sarana pelayanan kesehatan. Dalam kegiatan ini kami berusaha untuk mengoptimalkan sistem pelayanan kesehatan  di Klinik Puri Medical melalui penyuluhan tentang sistem penomoran dan penyimpanan data Rekam Medis  yang baik dan memudahkan petugas dalam pengambilan dan penyimpanan data Rekam Medis tersebut. Pelaksanaan Pengabdian kepada masyarakat ini kami menguraikan tentang pengelolaan data Rekam medis melalui tatacara sistem penomoran dan penyimpanan data Rekam Medis. Metode yang dilakukan dengan cara memberikan materi dan dipresentasikan serta didiskusikan dengan staf yang hadir dalam Pengabdian tersebut dengan beberapa tahap, antara lain dengan pemaparan materi tentang sistem penomoran dan penyimpanan yang disampaikan kepada staf/petugas bagian Rekam medik yang hadir dalam acara Pengabdian Kepada Masyarakat, setelah itu dilanjutkan dengan praktik lapangan, jika ada hal yang kurang dipahami dalam pelaksanaan maka akan dilanjutkan dengan tahap bimbingan dan konsultasi antara staf rekam medis dengan tim Pengabdian Kepada Masyarakat,tahap akhir dalam jangka beberapa minggu akan dilakukan monitoring dan evaluasi apakah ilmu yang di berikan telah teraplikasi dengan baik di klinik tersebut. Kata kunci: Rekam Medis, Penomoran, Pengarsipan, Klinik ABSTRACT Corresponding author: * [email protected]   Maintenance and retrieval of medical record data is an important function of service in every health care facility. This increasing demand for health information requires facilities to maintain effective and efficient information systems. Regarding the numbering, storage and retention systems of medical record management in Indonesia, there are many types. The form of a good numbering and storage system is the initial stage in providing services to patients. Proper collection and storage of medical records is an important element in the delivery of services. Care needs to be taken in planning the numbering and storage system. The main purpose in numbering is to identify patient data. The author believes that by using any method of giving numbers the patient's secret can be kept. Giving this number is done when the patient registers or contacts with health care facilities. The main goal in making numbering is to identify patient data. The number is given when the patient registers or contacts with health care facilities. In this activity we are trying to optimize the health service system at Puri Medical Clinic through counseling about the numbering system and storing good Medical Record data and facilitate the officers in retrieving and storing the Medical Record data. This Community Service Implementation describes the management of medical record data through the procedure for numbering and storing medical record data. The method is done by providing material and presented and discussed with the staff present at the Service with several stages, including the presentation of material about the numbering and storage system that was delivered to the staff / officers of the Medical Record section who attended the Community Service event, after it is continued with field practice, if there are things that are not understood in the implementation it will be continued with the guidance and consultation phase between the medical record staff and the Community Service Team, the final stage within a period of several weeks will be carried out monitoring and evaluation whether the knowledge provided has been applied well in the clinic. Keywords: Medical Record, Numbering, Archiving, Clinic

scholarly journals Perilaku Merokok Pengunjung dalam Mematuhi Peraturan Kawasan Tanpa Rokok (KTR) di Lingkungan RSUD S. K. Lerik Kota Kupang

2019 ◽  
Vol 1 (1) ◽  
pp. 8-14
Author(s):  
Imelda Fitryani Dam ◽  
Honey I. Ndoen ◽  
Indriati A. Tedjuhinga
Keyword(s):  
Health Care ◽  
General Hospital ◽  
Family Environment ◽  
Statistical Tests ◽  
Smoking Behavior ◽  
Health Care Facilities ◽  
Hospital Environment ◽  
Cross Sectional ◽  
Care Facilities ◽  
Level Of Knowledge

Non-smoking area is a room or area that is otherwise prohibited to activities of production, sales, advertising, promotion and use of cigarettes. Regional regulation Kupang City No. 3A year 2014 about non-smoking area explain that health care facilities, including hospitals is a place or non-smoking area. S. K. Lerik Municipality General Hopital is government owned health care facilities in Kupang and non-smoking area but still a lot of casual visitors who smoke in the hospital environment. The purpose of this research was to determine the relationship between the level of knowledge, education and family environment with the behavior of visitor to comply with regulation of non-smoking area at S. K. Lerik Kupang Municipality General Hospital 2016. The method of this research was analytical surveys using the cross-sectional design. The population in this research were all those at S. K. Lerik Kupang Municipality General Hospital environment with a total sample of 384 respondents. Statistical tests were used for data analysis in this research is Chi-Square with a degree of confidence α= 0.05. The results showed that there was correlation between the level of knowledge and education with smoking behavior of the visitor at S. K. Lerik Kupang Municipality General Hospital. There was no correlation between family environment with smoking behavior of the visitors at S. K. Lerik Kupang Municipality General Hospital.

scholarly journals PENINGKATAN PENGETAHUN MASYARAKAT TERKAIT PENTINGNYA REKAM MEDIS BAGI PASIEN DI FASILITAS PELAYANAN KESEHATAN

2021 ◽  
Vol 5 (1) ◽  
pp. 163
Author(s):  
Romaden Marbun ◽  
Rea Ariyanti ◽  
Vincensia Dea
Keyword(s):  
Health Care ◽  
Health Service ◽  
Medical Record ◽  
Medical Records ◽  
Health Workers ◽  
Personal Information ◽  
Care Facility ◽  
Health Care Facilities ◽  
Public Knowledge ◽  
Maximum Point

ABSTRAKRekam medis merupakan bagian dari arsip yang menggambarkan segala aktivitas sebuah fasilitas pelayanan kesehatan dalam kurun waktu tertentu. Rekam Medis ialah berkas yang berisikan catatan dan dokumen tentang identitas pasien, pemeriksaan, pengobatan, tindakan, dan pelayanan lain yang telah diberikan kepada pasien. Rekam medis ini memiliki fungsi penting bagi pasien dan juga dokter. Oleh karena itu pengisian rekam medis ini harus lengkap dan tidak boleh ditunda pengisiannya baik bagi pasien ataupun tenaga kesehatan. Namun, banyak masyarakat yang belum mengetahui fungsi penting dari melengkapi rekam medis dan keterbukaan informasi pribadinya yang harus diberikan kepada fasilitas pelayanan kesehatan bahkan tenaga kesehatan yang merawatnya dalam menunjang mutu informasi pada rekam medis tersebut. Tujuan kegiatan ini adalah meningkatkan pengetahuan masyarakat khususnya RT 09 Kelurahan Bandulan Kota Malang tentang pentingnya rekam medis bagi masyarakat yang berobat di fasilitas pelayanan kesehatan. Metode penyuluhan dilakukan secara tidak langsung atau dalam jaringan (daring) dengan berkoordinasi via online grup whatsapp selama 3 kali pertemuan serta dikirimkan materi presentasi serta video pembelajaran. Masyarakat yang terlibat sebanyak 34 orang. Tahap evaluasi dilakukan melalui google form. Hasil kegiatan diperoleh peningkatan pengetahuan masyarakat dari rata-rata 37,53 menjadi 79,06 dengan point maksimal 100. Kegiatan berjalan dengan baik dan perlu adanya monitoring lebih lanjut. Kata kunci: pengetahuan; masyarakat; rekam medis; fasilitas pelayanan kesehatan. ABSTRACTThe medical record is part of the archive that describes all the activities of a health care facility within a certain period of time. Medical Record is a file that contains records and documents about the patient's identity, examination, treatment, action, and other services that have been provided to the patient. This medical record has an important function for patients as well as doctors. Therefore, the filling of this medical record must be complete and the filling should not be delayed either for the patient or the health worker. However, many people do not know the important function of completing medical records and the disclosure of personal information that must be provided to health care facilities and even health workers who take care of them in supporting the quality of information in the medical record. The purpose of this activity is to increase public knowledge, especially RT 09 RW 05 Kelurahan Bandulan Malang City about the importance of medical records for people who seek treatment at health service facilities. The counseling method is carried out indirectly or online by coordinating via online WhatsApp groups for 3 meetings and sending presentation materials and learning videos. There were 34 people involved. The evaluation stage is carried out through a google form. The results of the activity obtained an increase in public knowledge from an average of 37.53 to 79.06 with a maximum point of 100. The activity went well and needed further monitoring. Keywords: knowledge; public; medical records; health service facilities.

scholarly journals SISTEM INFORMASI REKAM MEDIS PASIEN RAWAT JALAN DI UPTD PUSKESMAS KUNINGAN BERBASIS WEB

2019 ◽  
Vol 13 (2) ◽  
pp. 19
Author(s):  
Tatang Saputra ◽  
Erik Kurniadi
Keyword(s):  
Health Care ◽  
Information System ◽  
Health Services ◽  
Medical Record ◽  
Medical Records ◽  
Record System ◽  
Web Based ◽  
Medical Record System ◽  
Health And Illness ◽  
Conducting Research

Puskesmas is a level 1 health facility. More than 40% of Indonesia's population uses health services at the Puskesmas. It is interesting that the Puskesmas is the health care provider that is closest to the community. Recording medical records of patients at the Kuningan Health Center is still done manually. Data search has time constraints. This happens because the same data is often found. Ineffective management of medical records will become a major problem in health services at the Puskesmas. This problem must be overcome so that the puskesmas has good data and information. One way to overcome this problem is to build a computerized medical record information system. Medical Record is a compilation of facts about the health and illness of a patient. Medical Records become a very important thing in the delivery of health services. Because the importance of a medical record, the author is interested in conducting research with the title "Information Systems for Outpatient Medical Records in UPTD Puskesmas Kuningan Web-Based". The medical record information system is expected to help improve the function of the Puskesmas as a place of health care. With the existence of a medical record system, each patient visit can be taken in a database making it easier for officers in the process of finding medical record data when needed. With the database, the compilation of patients forgetting to bring a treatment card can be done by searching the patient's data by the electronic officer. Making a report will be easier because it retrieves data that is done through the request system so as to facilitate the process and minimize errors in data management.Keywords: php, mysql, medical record, outpatient

Time and Distance: The Journey for Medical Care

1973 ◽  
Vol 3 (2) ◽  
pp. 237-244 ◽  
Author(s):  
G. W. Shannon ◽  
J. L. Skinner ◽  
R. L. Bashshur
Keyword(s):  
Health Care ◽  
Regression Analysis ◽  
Medical Care ◽  
Medical Service ◽  
Health Care Facilities ◽  
Travel Patterns ◽  
Correlation And Regression Analysis ◽  
Linear Distance ◽  
Care Facilities ◽  
Relative Accessibility

Time and distance, the two common measures of travel, are examined as they relate to the use of various types of medical service facilities, using correlation and regression analysis. Different conclusions about the relative accessibility of health care facilities for selected sub-population groups result from the use of each measure separately. Differences in travel patterns to hospitals and those to physicians and dentists are observed when measured by time alone or by linear distance alone. Methodologic and health care implications are discussed.

scholarly journals The capability of early detection of eye diseases in the community by primary health facility worker

2020 ◽  
Vol 3 (3) ◽  
pp. 203
Author(s):  
Doni Widyandana ◽  
Muhammad Eko Prayogo ◽  
Suhardjo Suhardjo
Keyword(s):  
Health Care ◽  
Primary Health Care ◽  
Early Detection ◽  
Health Care Workers ◽  
Medical Records ◽  
Health Care Facilities ◽  
Primary Health ◽  
Care Workers ◽  
Care Facilities ◽  
Primary Health Care Facilities

Cataract is one of the biggest causes of blindness in the world. As many as 2.4 million people suffered from cataracts in Indonesia in 2013. Therefore, early detection needs to be done to prevent further complications. However, health workers' limited ability in primary health care facilities has resulted in high cataract diagnosis rates. The purpose of this study was to determine the ability of early detection of eye diseases, especially cataracts by primary health care workers. This study was conducted using a quantitative descriptive method analyzing 158 medical records as a result of early detection of primary health care facilities in Sleman Regency, which were sent to the ophthalmologist team of the Department of Eye Health FKKMK UGM to be re-examined. The re-examination results by a team of ophthalmologists received 141 medical records that fulfilled the inclusion criteria, consisting of 61 patients confirmed by cataract diagnosis (43.3%) and 80 patients with a diagnosis of not cataract (56.7%). According to the study, primary health care workers' ability towards early detection of cataracts in Sleman Regency needed to be enhanced (4.3%).

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