Upaya Meningkatkan Kepatuhan Profesional Pemberi Asuhan Pasien Dalam Dokumentasi Rekam Medis

Adanya tuntutan rumah sakit untuk menjamin kelengkapan rekam medis, perlu didukung dengan upaya rumah sakit melalui suatu regulasi dan edukasi kepada para PPA dalam proses pendokumentasian rekam medis. Lebih lanjut bahwa paradigma faktor manusia, dalam hal ini adalah PPA dalam menjaga kualitas rekam medis cukup berpengaruh langsung dalam keselamatan pasien. Tujuan dari penelitian ini adalah mengeksplorasi upaya rumah sakit dalam meningkatkan kepatuhan PPA pada dokumentasi rekam medis Penelitian ini merupakan penelitian deskriptif dengan pendekatan kualitatif. Rancangan penelitian menggunakan metode cross sectional. Penelitian ini dilaksanakan di RSUD Panembahan Senopati Bantul. Hasil penelitian menunjuukan RSUD Panembahan Senopati Bantul telah berupaya meningkatkan kepatuhan PPA dengan menetapkan regulasi berupa Pedoman Pelayanan Rekam Medis dan SPO Pengisian Rekam Medis. Upaya dari aspek material dilakukan dengan menyediakan formulir rekam medis berbahan kertas ukuran A4 berat 80 gram berbentuk persegi panjang dengan beberapa warna sesuai kebutuhan pengguna dan diberikan nomor formulir rekam medis. RSUD Panembahan Senopati Bantul telah melakukan penilaian kinerja setiap tahun sekali di akhir tahun, akan tetapi penilai kinerja berkaitan dengan kepatuhan PPA dalam dokumentasi rekam medis belum tertuang dalam SKP. Dalam upaya meningkatkan kepatuhan PPA dalam dokumentasi rekam medis, maka Tim KMKP menetapkan angka ketidaklengkapan assesmen awal medis dalam 24 jam pada pasien rawat inap melalui Instalasi Gawat Darurat (IGD) sebagai indikator mutu prioritas di RSUD Panembahan Senopati Bantul. Sebaiknya dalam upaya meningkatkan motivasi, budaya kerja dan kepatuhan PPA dalam dokumentasi medis, maka RSUD Panembahan Senopati Bantul dapat menerapkan reward dan punishment, sehingga tercapai kepuasan kerja karyawan

Perancangan Sistem Informasi Peminjaman dan Pengembalian Rekam Medis Rawat Jalan di Rumah Sakit Muhammadiyah Bandung

This research was conducted based on the problem of managing the borrowing and returning outpatient medical records at the Muhammadiyah Hospital Bandung which aims to find solutions to these problems to support the effectiveness of medical record services. The research method used in this research is a qualitative method with a descriptive approach. The data collection techniques used were interviews, observation, and study approach. In making the software design the writer uses the waterfall method and the supporting applications used are Microsoft Visual Studio 2010 and Microsoft Access 2013. From the results of the research conducted, the authors found several problems in the management of borrowing and returning outpatient medical records, namely: (1). There were no medical records found on the storage shelf; (2). Recording of borrowing and returning medical records still uses a manual system; (3). The absence of reports on borrowing and returning medical records. The suggestions that can be given by the author, namely : (1). It is better if the borrowing of medical records is determined by the due date so that there are no more medical records that are late to be returned to the storage room; (2). An information system is needed on borrowing and returning medical records to support activities in the hospital, especially in making reports on borrowing and returning medical records. The result of this research is an information system for borrowing and returning medical record files at Muhammadiyah Hospital Bandung.

Tinjauan Pelepasan Informasi Rekam Medis Kepada Pihak Ketiga Di RSU Imelda Pekerja Indonesia Medan

The Imelda Workers General Hospital of Indonesia does not yet have specific routines regarding the release of medical record information to third parties. however, they have used regular procedures for providing information and borrowing medical records in general, This study aims to determine the number of requests for medical record information. This type of research is descriptive, namely the research method carried out with the aim of making an objective state. The population was 4 people and the sample size was 4 people as the total sampling with the research methodology using quantitative methods. How to collect data by interview and observation. The results showed that the services of the Imelda Hospital for Indonesian Workers in Medan according to legalized death certificates amounted to 34 percent (0.56%), claims for raharja services amounted to 56 percent (0.92%), audits and insurance claims were 69 percent (1.14%) , research or education as much as 54 percent (0.89), post mortem as much as 28 percent (0.46%), BPJS as much as 5,790 percent (99.00%). Based on the results of the study, it is known that knowing the data on the number of requests for medical record information in January-June 2020 is 6,224 with a percentage (99.97%). As well as the absence of a special SPO on procedures and utilization of medical record information of deceased patients, however, they have used the permanent procedure of providing information and borrowing medical records in general. It is recommended that hospitals and medical record officers provide regular training or coaching to officers. And to health workers, especially medical records, in order to maintain the confidentiality of patient medical record information and carry out the established procedures properly.

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

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.

Analisis Pengimplementasian Pendistribusian Berkas Rekam Medis Pasien Rawat Jalan Di Rumah Sakit X Bandung

Medical records are an important part of the treatment of patient health, one form of service in each public health facilities is the distribution of medical record files. Based on research conducted at Hospital X Bandung, in the distribution of medical records the system used has not fully used electronic, the data entered into the application will then be searched manually by the officer for further medical record files distributed to each polyclinic concerned. The purpose of this study is to find out how the distribution of outpatient medical records at Hospital X Bandung using descriptive qualitative research methods that are research that aims to explain and describe the on distributing outpatient medical record documents with subjects in this study is an outpatient medical record document at Hospital X Bandung while the object in this study is the medical record officer in the distribution and filing. Thus, it can be concluded that the implementation of the distribution of medical record files has been quite effective and in accordance with the standard of time that has been set and Standard Operating Procedure that has been made despite some problems and constraints that always occur at the time of distribution of medical records, one of them is the application system used errors or buffering, the code on each polyclinic is sometimes confused with each other, but the officers can solve the problem.

Analisa Persepsi Verifikator Terhadap Kode Tindakan Medis Di RS Umum Citra Bunda Medical Center Padang

Based on the initial survey conducted by researchers, it was found that there were differences in perceptions between code verifiers and BPJS verifiers about medical action codes. In February, there were 15 disease codes with different perceptions, because the hospital had to follow the code based on the BPJS. The research objective was to analyze the perception of medical action codes by verifiers at Bunda Medical Center Hospital.This type of research is qualitative with a phenomonological approach. Research is conducted by in-depth interviews with 1 medical support person, 1 medical committee person, 1 code verifier, and 1 BPJS verifier, using a voice recorder and using interview guidelines. Data were analyzed using the Collaizzi method.The results showed that what hampered the implementation of the verification of medical action codes was that the doctor's writing was difficult to read by the verifier. There are differences in the perceptions of the verifier about the medical action code, where the verification of the medical action code is based on the number of resources used in the service, while the BPJS verifier thinks the medical action code is based on the level of severity or severity level. The conclusion in this study is that the educational qualifications between the BPJS verifier and the verification of medical action codes are not yet appropriate, then the BPJS verifier verifies the code based on the severity level it should be based on the most spent resources.

Analisis Trend Dan Grafik Barber Johnson Pada Efisiensi Tempat Tidur Di Rumah Sakit X Kota Bandung

Trend analysis is a statistical analysis method used for planning and evaluating efforts to minimize risk for the better. The purpose of this study was to analyze trends and barber johnson charts on the efficiency of bed use at X Hospital, Bandung City. This type of research is a qualitative method with a descriptive approach. Observations and interviews were carried out with data processing officers and medical record reporting officers, while secondary data was obtained from RL3 Year 2020 at Hospital X Bandung City. Data analysis using least square trend method and Barber Johnson chart. The results showed that the trend of BOR and BTO in Quarter I-IV of 2020 decreased. The trend of AvLOS and TOI in Quarter I and II increased, while in Quarter III and IV it decreased. Based on the results of the study, it can be analyzed that the use of beds at Hospital X Bandung City in 2020 has not been efficient, only reaching 20-60% while the standard value according to Barber Johnson is 75-85%, but it can be predicted that the TOI indicator will be more efficient, while the BOR indicator , AvLOS, and BTO are increasingly inefficient because their values ​​are getting further away from the predetermined standard values. To increase efficiency in the use of beds, the hospital should evaluate the beds and improve the quality of service.

Tinjauan Sistem Penyelenggaraan Rekam Medis Menurut Standart Akreditasi Puskesmas di Puskesmas Pangakalan Berandan Tahun 2020

Puskesmas are required to maintain medical records containing data and information on patient care. Implementation according to accreditation standards, namely criteria 3.2 Registration Process and 3.8 Administration of medical records which are divided into 3.8.1 Coding, 3.8.2 Medical Record Access Rights 3.8.3 Clinical Information Filling and 3.8.4 Storage. The purpose of the study was to find out the implementation of the medical record management system according to the Puskesmas accreditation standards at the Pangkalan Berandan Health Center in 2020. This type of research was qualitative with a Phenomenology approach. The place of research was conducted at the Pangkalan Berandan Health Center. Time of study in July 2020. Research population is all medical record officers at the Pangkalan Berandan Health Center. The research sample is 5 officers. The research instrument was interview guide and check list sheet for observation. The results of the study revealed that the outpatient registration process had been carried out according to criteria 3.2 but there was no inpatient numbering of medical records. Coding was not carried out according to criteria 3.8.1, namely the absence of coding SOPs carried out by doctors using ICD 10, Medical Record Access Rights were carried out according to criteria 3.8. 2 but the implementation is not fully carried out in accordance with the SOP, the lending process is not recorded in the expedition book, Assembling is in accordance with criteria 3.8.3 but recording corrections are carried out using stip-ex and the storage process has been carried out according to criteria 3.8.4 but retention is not carried out according to the guidelines legislation. It is recommended for registration to give medical record numbers to inpatients, coding to make SOPs and given coding training, access rights to medical records to record loans in expedition books, assembling to be given socialization in terms of correcting recording of medical record files and storing tracers as well as in the retention process. given socialization about the implementation of retention.

Pengaruh Pemberian Kode Warna Wilayah Pada Folder Terhadap Ketepatan Penyimpanan Berkas Rekam Medis Di Puskesmas Wadaslintang 1

A Medical records are files containing notes and documents regarding the patient's identity, examination, treatment, actions and other services that have been provided to patients. So that a medical file is strictly protected so that it is not damaged or lost.Based on observations, it was found that there were several files of medical records that were interchanged or not in the normal filling rack. Medical record files can be exchanged due to the large number of regional shelf columns so that alternatives and innovations are needed to increase the accuracy of returning and retrieving medical record files correctly.Troubleshooting efforts are being made, namely by providing a regional color code in the medical record file folder so that errors in taking and returning medical record files can be minimized.Based on the results of observations made by the author, it was found that there was an effect before and after color coding the region in the medical record file folder.

Pengaruh Faktor Predisposisi, Faktor Pendorong Dan Faktor Pendukung Terhadap Pencatatan Rekam Medis di RSUD Dr. RM Djoelham Binjai

Law of the Republic of Indonesia number: 29 of 2004 concerning Medical Practice, which includes the obligation of doctors and dentists to make medical records. The results of the evaluation of the completeness of medical records in RSUD Dr. RM Djoelham Binjai still found incomplete medical record files. This study aims to determine the effect of predisposing factors (knowledge, attitudes), driving factors (support from other officers) and supporting factors (facilities and facilities, regulations) on the behavior of doctors in recording medical records. The research design used in this study was a descriptive analytic survey with a cross sectional design, a sample of 29 doctors and quantitative data analysis with univariate, bivariate and multivariate analysis. Based on the results of the chi square test, it was obtained that Knowledge variable p = 0.001, Attitude power p = 0.002, other support staff p = 0.000, facilities and facilities p = 0.002 and settings p = 0.007 multivariate test showed that of the 5 variables tested multiple logistic regression showed variable which has a p-value > 0.05. Based on the results of the multiple logistic regression test, the significant value of the model together was obtained at 0.002 < 0.05, which means that the four variables used as models have a significant influence on Medical Record Recording, the factor that has the greatest influence on Medical Record Recording is the Support Personnel variable. Others are indicated by an OR value of 0.062. The conclusion in this study is that there is an influence, Knowledge, Attitude, Support of Other Personnel, Facilities and Facilities, and Regulations on the Completeness of Medical Record Recording. It is hoped that doctors do not delay in recording complete medical records.