http://akademiperekammedis.ac.id/jurnal/index.php/medicordhif/issue/feed MEDICORDHIF Jurnal Rekam Medis 2019-04-15T11:03:10+07:00 APIKES Bhumi Husada jurnal@akademiperekammedis.ac.id Open Journal Systems <p><strong>MEDICORDHIF&nbsp;Jurnal Rekam Medis</strong> is a Scientific Electronic Journal of the Medical Recorder and Health Information Academy of Bhumi Husada Jakarta (APIKES BHJ) in order to accommodate the research results of APIKES BHJ lecturers and students as well as other authors outside the APIKES BHJ institutions, as one of the goals of higher education institutions in Indonesia.</p> <p>The Medicordhif e-journal provides the widest opportunity for lecturers, researchers and authors in the scientific fields of <strong>medical records</strong>, <strong>health information</strong>, <strong>public health</strong>, <strong>hospital management</strong> and also <strong>health management</strong> to join in as an author in our MEDICORDHIF e-journal.</p> http://akademiperekammedis.ac.id/jurnal/index.php/medicordhif/article/view/2 Pemanfaatan Metode Fishbone Pada Studi Kasus Keterlambatan Pengembalian Rekam Medis di Rumah Sakit Muhammadiyah Taman Puring 2019-04-15T11:02:57+07:00 Choirunisa Choirunisa apikesbhumihusada@yahoo.com Lily Widjaja lilywidjajaiwan@gmail.com <p><strong><em>ABSTRACT</em></strong></p> <p><em>The delay in returning inpatient medical records can show the quality of health services that are less than optimal. To achieve service goals optimally, it is necessary to have a good and supportive system in RM services in accordance with the procedures set out in the hospital. Delay in returning inpatient RM patients will affect and result in the processing and presentation of data starting from assembling activities, analysis, coding, indexing to reporting RM (RM). The purpose of this study was to find out the factors that influence the delay in returning the hospitalization RM to the RM unit at the Muhammadiyah Hospital in Taman Puring using the fishbone method. This type of research is descriptive, population of 253 RM in July 2018 obtained a sample of 155 RM. The technique of collecting data by observation and interviews, the instruments are in the form of interview guidelines, checklists, calculators and return expedition books. Analysis of the data with the percentage of the accuracy of the RM return time and with the Fishbone method get the factors that affect the delay in returning the RM. The results of the study and the discussion that the RM return from the appropriate treatment room was 65.16% and the late ones were 34.83%. The main factor in delaying the return of a patient's RM is a resume that has not been filled in, there is no special officer who returns the hospitalized RM to the RM unit.</em></p> <p><strong><em>Keyword: </em></strong><em>Delay, Return Medical Record, Fishbone.</em></p> <p>&nbsp;</p> 2018-12-21T00:00:00+07:00 Copyright (c) 2018 MEDICORDHIF Medical Record Journal http://akademiperekammedis.ac.id/jurnal/index.php/medicordhif/article/view/3 Tinjauan Kelengkapan Pengisian Medis Penyebab Kematian di Rumah Sakit Setia Mitra 2019-04-15T11:02:58+07:00 Septia Salsabila apikesbhumihusada@yahoo.com Indah Kristina indahbhj55@gmail.com Rury Agnesia ruryasmsp@gmail.com <p><strong><em>ABSTRACT</em></strong></p> <p><em>The cause of death is any illness, illness, or injury that causes or facilitates the death and accident or violence that causes the injury. Medical certificate of cause of death is a certificate used to cause of death. From the obstervations at Setia Mitra Hospital there was not a single medical certificate of death which was filled in completely. The purpose of this study was to determine the completeness of filling in the death certificate medical certificate at Setia Mitra Hospital. The type of research used is descriptive. The method used is observation and intercview. The study population was 6 medical certificates causeing death.</em></p> <p><em>Based on the result of the quantitative analysis of the 6medical certificates that cause death, the results were completed in full by 76% and those that were not filled in were 24%. Of the four components of quantitative analysis, the most complete percentage analysis is found in the author authentication of 88,83% important report of 61,17%. Based on interviews conducted with medical record officers at Setia Mitra Hospital, there were several factors that caused incompleteness in filling out medical certificates for the cause of death, namely the absence of SPO (Standard Operating Procedures) which regulated the completeness of medical certificate of death cause and dthe implementation of quantitative analysis for medical causes. Death that has not yet been done.</em></p> <p><strong><em>Keyword: </em></strong><em>Medical </em><em>Certificat of Couse of Death</em></p> <p>&nbsp;</p> 2019-01-03T00:00:00+07:00 Copyright (c) 2018 MEDICORDHIF Medical Record Journal http://akademiperekammedis.ac.id/jurnal/index.php/medicordhif/article/view/4 Tinjauan Kelengkapan Pengisian Persetujuan Tindakan Kedokteran Pada Pasien Rawat Inap di Rumah Sakit Yadika Kebayoran Lama 2019-04-15T11:03:00+07:00 Redha Maulina apikesbhumihusada@yahoo.com Indah Kristina indahbhj55@gmail.com Rury Agnesia ruryasmsp@gmail.com <p><strong><em>ABSTRACT</em></strong></p> <p><em>From the results of observations at YadikaKebayoran Lama Hospital, none of the medical action approval forms were filled in completely. The purpose of this study was to obtain an overview of completing the approval form for medical treatment for inpatients at YadikaKebayoran Lama Hospital. The type of research used is descriptive. The method used is observation and interview. The study population was 128 medical action approval forms. Based on the results of a quantitative analysis of 128 approval forms of medical action, the results were filled in completely by 88.47% and those not filled in completely by 11.53%. of the 4 components of the quantitative analysis criteria the most complete percentage analysis is found in the patient's identity at 100% while the lowest percentage is in the good recording of 75%. Based on interviews conducted with the head of the medical record at YadikaKebayoran Lama Hospital there are several factors that cause incompleteness in filling out medical action approval forms, namely SPO (Standard Operating Procedures) used are still Informed Consent and lack of understanding of officers in the inpatient room when filling out medical action approval forms.</em></p> <p><em>So the author gives suggestions for revision of existing SPO (Standard Operating Procedures) and re-socialized to officers in the inpatient room to fill in the complete in the incomplete parts such as important reports, good authentication and recording. It is expected that officers in the inpatient room, either room doctors / nurses, are related to filling out approval forms for medical actions to fill in completely, especially on the authentication component and important reports on the information content section.</em></p> <p><strong><em>Keyword: </em></strong><em>Medical Action Approval Form</em></p> <p><strong><em>&nbsp;</em></strong></p> <p><strong>ABSTRAK</strong></p> <p>Dari hasil observasi di Rumah Sakit Yadika Kebayoran Lama tidak ada satu pun formulir persetujuan tindakan kedokteran yang diisi dengan lengkap. Tujuan dari penelitian ini adalah memperoleh gambaran kelengkapan pengisian formulir persetujuan tindakan kedokteran pasien rawat inap di Rumah Sakit Yadika Kebayoran Lama. Jenis penelitian yang digunakan adalah deskripstif. Metode yang digunakan adalah observasi dan wawancara. Populasi penelitian adalah 128 formulir persetujuan tindakan kedokteran. Berdasarkan hasil analisa kuantitatif terhadap 128 formulir persetujuan tindakan kedokteran di peroleh hasil yang diisi dengan lengkap sebesar 88.47% dan yang tidak diisi dengan lengkap sebesar 11.53%. dari 4 komponen analisa kuantitatif kriteria analisa jumlah persentase terlengkap terdapat pada identitas pasien sebesar 100% sedangkan persentase terendah terdapat pada pencatatan yang baik sebesar 75%. Berdasarkan wawancara yang dilakukan dengan kepala rekam medis di RumahSakit Yadika Kebayoran Lama terdapat beberapa faktor penyebab ketidaklengkapan pengisian formulir persetujuan tindakan kedokteran yaitu SPO (Standar Prosedur Operasional) yang digunakan masih <em>Informed Consent </em>dan kurang pahamnya petugas di ruang rawat inap dalam pengisian formulir persetujuan tindakan kedokteran.</p> <p>Maka penulis memberikan saran untuk di revisi kembali SPO (Standar Prosedur Operasional) yang sudah ada dan disosialisasikan kembali kepada petugas di ruang rawat inap untuk mengisi dengan lengkap pada bagian yang masih belum lengkap seperti laporan penting, autentifikasi dan pencatatan yang baik. Diharapkan petugas di ruang rawat inap baik itu dokter ruangan/perawat terkait pengisian formulir persetujuan tindakan kedokteran untuk mengisi dengan lengkap khususnya pada komponen autentifikasi dan laporan penting pada bagian isi informasi.</p> <p><strong>Kata Kunci</strong>: Formulir Persetujuan Tindakan Kedokteran</p> 2019-01-03T00:00:00+07:00 Copyright (c) 2018 MEDICORDHIF Medical Record Journal http://akademiperekammedis.ac.id/jurnal/index.php/medicordhif/article/view/5 Tinjauan Pelaksanaan Pelepasan Informasi Medis Kepada Pihak Ketiga Untuk Klaim Asuransi di Rumah Sakit Muhammadiyah Taman Puring Jakarta Tahun 2018 2019-04-15T11:03:02+07:00 Sri Adinda apikesbhumihusada@yahoo.com Siswati 99 siswatiaries@yahoo.com Rury Agnesia ruryasmsp@gmail.com <p><strong><em>ABSTRACT</em></strong></p> <p><em>This study aims to determine the description of the process of release of medical information for insurance claims at Muhammadiyah Taman Puring Hospital. The research method used is a descriptive method of a survey conducted on a set of objects that usually aims to see a description of phenomena that occur within a particular population.</em></p> <p><em>On the implementation of medical information release and the existing Standar Operating </em><em>P</em><em>rocedure (SOP), regarding the policy for the release of medical information, namely in the form of 6,000 stamped power of attorney, photocopy of patient identity and third party identity, there were 41 requests for medical record documents from third parties, namely 34% who did not complete. SO</em><em>P</em><em> should be disseminated Information Release, especially to medical record officers and customer service who are in charge of handling the release of medical information by holding socialization as well as creating an x ​​banner containing requirements for the release of medical information placed in the lobby of the hospital or near the patient registration plac</em><em>e.</em><em> It is better to provide a special room to serve the request for the release of medical information so that the direct handling is the medical record officer not through customer service so there is no communication gap between the third party and the medical record officer.</em></p> <p><strong><em>Keyword: </em></strong><em>Release of Medical Information</em></p> <p><strong><em>&nbsp;</em></strong></p> <p><strong>&nbsp;</strong></p> <p>&nbsp;</p> 2018-12-21T00:00:00+07:00 Copyright (c) 2018 MEDICORDHIF Medical Record Journal http://akademiperekammedis.ac.id/jurnal/index.php/medicordhif/article/view/6 Tinjauan Waktu Pengembalian Rekam Medis Pasien Rawat Inap ke Unit Rekam Medis di Rumah Sakit X Jakarta Timur 2018 2019-04-15T11:03:03+07:00 Mutia Sari apikesbhumihusada@yahoo.com Ima Rusdiana ima.rusdiana@gmail.com <p><strong>ABSTRACT</strong></p> <p><em>At the East Jakarta Hospital X SOP the return of inpatient medical records in force is 2x24 in accordance with the theory of the 1991 Technical Guidelines for the Implementation of Medical Records and the Journal of Medicoeticolegal and Hospital Management in 2017 which states that the return time of inpatient medical records is 2x24 hours after the patient leaves treatment. The purpose of this study was to determine the policy and SOP regarding the return of medical records of inpatients in X Hospital in East Jakarta, calculate the payback time of medical records of patients who have been hospitalized, and identify the causes of inaccuracies in returning medical records of hospitalized patients. Obtained inaccuracies in return of inpatient medical records by 25% in April from a sample of 157 medical records of patients who left treatment. Lack of socialization regarding SOP in return of medical records of inpatients, lack of policies and job descriptions for returning inpatients' medical records and the length of time doctors complete patient medical records are factors that lead to inaccuracies in returning medical records of hospitalized patients.</em></p> <p><strong><em>Keyword : Return of inpatient medical records</em></strong></p> 2018-12-22T00:00:00+07:00 Copyright (c) 2018 MEDICORDHIF Medical Record Journal http://akademiperekammedis.ac.id/jurnal/index.php/medicordhif/article/view/7 Tinjauan Ketidakpuasan Pasien Lama Terhadap Pelayanan Pendaftaran Rawat Jalan Di Rumah Sakit Menteng Mitra Afia 2019-04-15T11:03:04+07:00 Nur Endah Sari apikesbhumihusada@yahoo.com Gama Bagus Kuntoadi okudagama@gmail.com <p><strong><em>ABSTRACT</em></strong></p> <p><em>The hospital is one of the health service facilities chosen by the community in obtaining health services. Registration is the initial gate of a hospital service, this is where the important role of the registration officer, must be able to give a comfortable impression so that patients can feel the satisfaction of hospital services. Patient satisfaction consists of 5 dimensions namely tangible, responsiveness, reliability, assurance, and empathy. This research was conducted based on 5 dimensions of service quality, which was felt by old patients towards outpatient registration officers, namely the statement "satisfied" there was empathy dimension of 83.2%, the statement "dissatisfied" in the tangible dimension of 7.4%, and the statement "neutral" on the dimensions of reliability that is equal to 9.4%. Suggestion to the old patient outpatient registration officer is to conduct periodic refresher program on "excellent service" namely tangible, reliability, responsiveness, assurance, and empathy in entering the hospital program, especially the review of waiting room facilities in outpatient registration</em></p> <p><strong><em>Keywords :</em></strong><em>medical record, satisfaction, dissatisfaction, service quality dimension</em></p> 2018-12-22T00:00:00+07:00 Copyright (c) 2018 MEDICORDHIF Medical Record Journal http://akademiperekammedis.ac.id/jurnal/index.php/medicordhif/article/view/8 Analisis Kualitatif Kasus Gangren Pulpa Di Poliklinik Gigi Dalam Upaya Meningkatkan Kualitas Pelayanan Rumah Sakit Tk. IV Cijantung 2019-04-15T11:03:05+07:00 Gama Bagus Kuntoadi okudagama@gmail.com Rokiah Kusumapradja rorojkt4@yahoo.com <p><strong><em>ABSTRACT</em></strong></p> <p><em>“Rumah Sakit Tingkat IV Cijantung” is a type D hospital owned by Indonesian Armed Force (TNI-AD) which is located at 2<sup>nd</sup> Mahoni Street, Cijantung – Kesdam Jaya, East Jakarta, Indonesia. This hospital is equiped with 85 beds and also has several medical services unit such as an Emergency Unit, Polyclinic, Laboratory, Radiology, Pharmacy, and Operation Room. As a part of a Policlinic Unit, Dental Care Clinic have become a hospital frontline in interaction with their patients. By having a low medical services quality,&nbsp; it will affect on their patient satisfaction and then it will influence on their hospital revenue. There are so many ways to increase medical services quality, one of them is by doing a medical audit. As the result of this medical audit, the hospital manager will have an accurate data on certain level his medical unit services quality gained so far.&nbsp; Furthemore, this audit report will become a reference to determine their hospital policy to increasing hospital services quality. </em></p> <p><em>This research main purpose is to gain a medical quality services illustration on pulp gangrene case at hospital dental polyclinic. Research methodology which had been use is qualitative descriptive analysis by using checklist tool and then by interviewing all dental polyclinic staff at the hospital. The other result of this research is describing the existence of Medical Service Standard and Hospital Standard Operation Procedure (S.O.P) for pulp gangrene case, which will become their basic reference when treating their pulp gangrene patients. On the other hand, this research is also tried to describing dental polyclinic staff obstacles in providing pulp gangrene medical services to their patients. </em></p> <p><strong><em>Keywords</em></strong><em> : medical record, medical audit, service quality, pulp gangrene</em></p> 2018-12-22T00:00:00+07:00 Copyright (c) 2018 MEDICORDHIF Medical Record Journal http://akademiperekammedis.ac.id/jurnal/index.php/medicordhif/article/view/9 Gambaran Capaian Persiapan Akreditasi Versi 2017 Bagian Kompetensi dan Kewenangan Staf (KKS) Standar 6 di Sub Bagian Kepegawaian Rumah Sakit Umum Kabupaten Tangerang Dengan Perbandingan Hasil Akreditasi Versi 2012 2019-04-15T11:03:07+07:00 Susi Shorayasari Zuhron susishorayasari@gmail.com Boy S. Sabarguna sabar014guna@yahoo.co.id Salwa Fadhila salwafadhila16@gmail.com <p><em><strong>ABSTRACT</strong></em></p> <p><em>Background: Hospital Accreditation is the recognition of the hospitals provided by an accredited institution of independent organizers stipulated by the minister of health. The research method used is search checklist document, interview and observation with approach of cuantatif with 1 informant 453 document of ownership of civil servant. Result of research description of hospital preparation achievement in facing accreditation of 2017 version that is 32%. Qualification is not fulfilled 1 (1%), fulfilled part 363 (80,1%) and fulfilled complete 89 (19,6%) with result score 0 job description that is not fulfilled 90 (19,9%), partially fulfilled 0 (0%) and complete fulfillment of 363 (80,1%) with result of score 10. Recruitment</em></p> <p><em>process that is not fulfilled 453 (100%), partially fulfilled 0 (0%) and fulfilled 0 (0%) with result score 0 the job is not fulfilled 215 (47,7%), fulfilled part 0 (0%) and fulfilled 238 (52,5%) with score result 5. Performance appraisal that is not fulfilled 59 (13%), fulfilled part 376 (83% ) and fulfilled 18 (4%) with score of 0. Copy of Certificate that is not fulfilled 143 (31,6%), partially fulfilled 0 (0%) and fulfilled 310 (68,4%) with result score 5. File update not fulfilled 0 (0%), fulfilled part of 453 (100%) and fulfilled 0 (0%) with result of score 0 Total unmet conclusion is 30,4%, fulfilled part 37,6% and complete complete 32%. From the data it can be concluded that RSU Kab. Tangerang has not fulfilled the graduation requirement of the standard of graduation ≥80%.</em></p> <p><em><strong>Keywords</strong>: Hospital Accreditation of 2017 version, Preparation Picture, Tangerang District Hospital</em></p> 2019-01-03T00:00:00+07:00 Copyright (c) 2019 Susi Shorayasari Zuhron http://akademiperekammedis.ac.id/jurnal/index.php/medicordhif/article/view/10 Faktor-Faktor Yang Berhubungan Dengan Kepatuhan Perawat Dalam Melaksanakan Standar Prosedur Operasional Pelayanan Klinik di Instalasi Rawat Jalan Rumah Sakit Umum Kabupaten Tangerang Tahun 2018 2019-04-15T11:03:08+07:00 Happy Novriyanti Purwadi happypurwadi@gmail.com Resna A. Soerawidjaja happypurwadi@gmail.com Yunita Anggraeni happypurwadi@gmail.com <p><strong><em>ABSTRACT</em></strong></p> <p><em>Introduction Compliance is part of the individual's behavior to obey something, so the nurse's compliance in implementing the standard operational procedure (SPO). There are several factors related to the compliance of nurses in implementing SPO among others age, length of work, education, gender, and employment status, the reward system, rewards, availability of facilities and infrastructure, and training. The research method is cross-sectional by observation and fill out the questionnaire using total sampling with the amount of 42 respondents. Result of the obedient 76.2% compliance of nurses compliance, while 23.8% were noncompliant. Ratio prevalence factors characteristic age of age comparison ≥30 years : age &lt;30 years = 1: 1. Comparison of working length &gt;5 years with a working period ≤5 years = 1: 1. Comparison of education, further education: initial education = 1: 1. Comparison of sex, male : female = 1: 1. Comparison of employment status, civil servant: non-civil = 1: 2. The factor of reward system, reward, availability of facilities and infrastructure, proved no significant relation with nursing nurses. Value of Pvalue&gt; value of α= 0,05. The conclusion that there is no relationship to nurse compliance. Suggestion, it is expected that the nurse can increase the awareness and nurse in the compliance of the nurse in implementing the SPO.</em></p> <p><strong><em>Keywords: </em></strong><em>n</em><em>urse compliance, standard operational procedures</em></p> 2019-01-03T00:00:00+07:00 Copyright (c) 2019 Happy Novriyanti Purwadi http://akademiperekammedis.ac.id/jurnal/index.php/medicordhif/article/view/11 Status Resiko 4 Terlalu (4T) Pada Ibu Hamil Dilihat Dari Pengetahuan dan Sikapnya di Puskesmas Kecamatan Pondok Aren Tahun 2016 2019-04-15T11:03:09+07:00 Siti Dariyani sitidariyani82@gmail.com Restu Octasila restuoctasila@gmail.com <p><strong><em>ABSTRACT</em></strong></p> <p>Introduction, One of the indirect causes of maternal death is too long a mother, too young, too old, too close and too often. Often complications are triggered by this 4T risk. Research Methodology, research design is analytical. The number of research samples is 144 respondents, the sampling technique was accidental sampling. Data analysis using chi-square. Research Results, the presentation of respondents who were at risk of 4T risk status was still 42.3%, the level of knowledge was good 87.5%, the percentage of positive attitudes was 83.3%. The results of chi-square analysis of knowledge and attitudes with 4T risk status obtained p value 0.339 and 1,000 Conclusions, there was no significant relationship between knowledge and attitudes of pregnant women on the 4T risk status. before pregnancy occurs.</p> <p><strong><em>Keyword</em></strong><em>: </em>Knowledge, attitude, risk status 4T</p> 2019-01-03T00:00:00+07:00 Copyright (c) 2019 Siti Dariyani http://akademiperekammedis.ac.id/jurnal/index.php/medicordhif/article/view/12 Tinjauan Ketidaklengkapan Pengisian Resume Medis Pasien Rawat Inap di RS Setia Mitra Tahun 2018 2019-04-15T11:03:10+07:00 Diaz Maulana apikesbhumihusada@yahoo.com Hudiyati Agustini kaktini77@yahoo.com <p><strong>ABSTRAK</strong></p> <p><em>Based on preliminary observations carried out the medical records of the Setia Mitra Hospital in March 2018 of the 10 medical resumes observed were incomplete results with an average proportion of 14%. The purpose of this study was to find out the description of the incompleteness of filling out medical resumes of hospitalized patients at Setia Mitra Hospital. Specific Objectives, namely (1) identifying Standard Operating Procedures (SOP) filling in medical resumes of hospitalized patients. (2) identify the contents of the inpatient medical resume form. (3) calculate the number of incompleteness in filling out medical resumes of inpatients.</em></p> <p><em>The method used is descriptive method. Based on the results of research on 169 medical resume forms conducted at Setia Mitra Hospital, the authors can draw conclusions that the Setia Mitra Hospital has Standard Operating Procedures (SOP). There is a difference in the application of the part of the medical resume form in Setia Mitra Hospital, the application of which differs from the Standard Operating Procedure (SOP) that is established and also according to the provisions of the Komisi Akreditasi Rumah Sakit (KARS). The results of calculations according to quantitative analysis with a sample of 169 medical resumes from 293 medical resumes as a result of completing the medical resume form of incomplete inpatients 100% only reached the completeness value of 12% with an incomplete value of 88%. The author's suggestion is to evaluate the medical resume form so that it is in accordance with the provisions of the Komisi Akreditasi Rumah Sakit (KARS) so that the parts that must be filled are simpler, easier to fill and can be completed. Need to be re-socialized to medical personnel to fill out completely. If there is a section that cannot be completed, it is filled with the phrase "none" or with a sign "-" (stripe).</em></p> <p><strong><em>Keyword: </em></strong><em>Incompleteness in filling out medical resumes of hospitalized patients</em></p> 2018-12-22T00:00:00+07:00 Copyright (c) 2018 MEDICORDHIF Medical Record Journal