cover
Contact Name
Muhammad Yunus
Contact Email
m.yunus@polije.ac.id
Phone
+628123413933
Journal Mail Official
j-remi@polije.ac.id
Editorial Address
Program Studi Rekam Medik Politeknik Negeri Jember Jl. Mastrip PO Box 164, Jember, Jawa Timur
Location
Kab. jember,
Jawa timur
INDONESIA
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan
ISSN : -     EISSN : 2721866X     DOI : https://doi.org/10.25047/jremi
Core Subject : Health,
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan is a scientific journal that is managed and published by the Program Studi Rekam Medik, Jurusan Kesehatan, Politeknik Negeri Jember. J-REMI contains the publication of research results from students, lecturers and or other practitioners in the field of medical records and health information with coverage and focus on the fields of Health Information Management, Health Information Systems, Health Information Technology, Health Quality Information Management and Classification, Coding of Diseases and Problems. Health and Action.
Articles 103 Documents
Analisis Aspek Kompetensi Individu dalam Duplikasi Nomor Rekam Medis di Puskesmas Nurmawati, Ida; Arofah, Kurnia
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 1 (2019): December
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/jremi.v1i1.1928

Abstract

Duplication of medical record number is one of the problems in medical record section. Duplication that occurred in the Labruk Kidul Public Health Center was 10,3% consist of 7,6% duplicate one medical record number owned by some head of families, and 2,7% duplicated one head of family with some medical record numbers. The purpose of this research is to analyze the priority causes of duplication medical record of numbers in the Labruk Kidul Public Health Center Lumajang. It was a qualitative research and the data collection techniques used interviews,and observations. The subject of this research was registration officer, head of the medical record and head of the public health center. The results showed that the cause of duplication from individual competency factors was that the officer could not make KIUP, the officer did not write the. The solution is to socialize the system of numbering and additional time and labor in finding duplicate medical record number and merging files.
Inovasi Sistem Informasi Pendaftaran Pasien Dengan Scanner Kib Dan Mesin Antrian Elektronik Maulana, Moh.
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 1 (2019): December
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/jremi.v1i1.1930

Abstract

Registration system at the Banjarsengon Community Health Center is still done manually starting from calling the queue number to the making of the MNH. Such a system would cause the patient registration process to be ineffective in terms of time while in the manufacture of MNH using paper material, it would not be durable or could be said to be damaged so that the writing could not be read. In addition, in looking for data on old patient visits, officers must search individual patients' names in the thick registration book. The purpose of this study is that all of the problems previously described can be resolved. The technology used in making the KIB scanner and the queue number uses RFID and sevent segment which is controlled by an Arduino microcontroller. Making the patient registration information system application using Microsoft Visual Studio 17. The results of this study are the patient registration information system with the MNH scanner and electronic queuing machine that can facilitate the registration officer in serving patients.
Sistem Informasi Pelaporan Status Gizi Balita Berbasis Web di Puskesmas Banjarsengon Sholehah, Firdaus
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 1 (2019): December
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/jremi.v1i1.1931

Abstract

Recording and reporting nutritional status at the Banjarsengon Community Health Center is still manual and uses Excel. The report also includes the process of determining or calculating the nutritional status of children under five. The use of Excel has many limitations such as the absence of a password for toddlers data security, the process of rearranging the Excel sheet for printing and so on. The purpose of this study was to design and create a web-based nutritional status reporting information system for children under five in the Banjarsengon Health Center using the waterfall method. Data collection is done by interview, observation, and documentation. The results of this study are web-based nutritional status reporting information systems with several advantages, in addition to focusing on calculating the nutritional status of children under five, this information system can also make detailed nutritional status reports for toddlers. The detailed report in question is a toddler report which is grouped based on nutritional problems experienced by toddlers and their solutions. This information system is expected to make it easier for nutrition workers at the Banjarsengon Health Center to carry out their duties.
Analisis Kejadian Missfile Berkas Rekam Medis Rawat Jalan di Puskesmas Bangsalsari Wati, Try Ganjar; Nuraini, Novita
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 1 (2019): December
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/jremi.v1i1.1932

Abstract

Based on preliminary research at Bangsalsari Public Health Center were found that on December 2018 to March 2019 for 53 out of 200 medical record files were misplaced or misfiling. The misplaced file or misfiling could inhibit and led into delay on the patient service process. In addition, a new file would be created to replace the missing medical record file and affected the unsustainable medical record files. The aim of this research was to analyze, determine the priority causes and to fix the problem of misfiling incident using USG (Urgency, Seriousness, Growth) and brainstorming in Bangsalsari Public Health Center. This research is qualitative research and collecting the data using interview, observations, documentation, questionnaire, and brainstorming. The result of this research were the priority causes of mis filing incident coming from the broken folders and stacking files which had no folders. The improvement efforts for the problem are made by replacing the broken folders, duplicating medical record folders, gradually providing folders on medical record files, adding some filing cabinets to avoid stacking files, and separating inactive files.
Evaluasi Sistem Informasi Manajemen Rumah Sakit Dengan Metode Technology Acceptance Model (TAM) di Rumah Sakit X Putra, Dony Setiawan Hendyca; Kurniawati, Rizka
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 1 (2019): December
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/jremi.v1i1.1933

Abstract

Hospital has implemented hospital information management system (HIMS) since 2016. one of the factors that currently plays an important role in the successful application and use of information technology is the user factor. The level of readiness of users to receive information technology has a major influence in determining the success and failure of the application of the technology. The purpose of this research is to evaluate user perception of SIMRS based on dimension Technology Acceptance Model (perceived ease of use, perceived usefulness, attitude toward using, behavioral intention, actual usage). The method of this research is quantitative descriptive research. The object of this research is SIMRS user in all unit of hospital and research subjects are all SIMRS users. The results showed that the percentage of group calculation from PEOU 0.602 dimension (60.2%), PU 0.595 (59.5%) and ATU 0.594 (59.4%) were moderate category, dimensions of BI 0.777 (77.7%) and AU 0.694 (69.4%) are in good category. It states that the user perception of SIMRS has been running well and needs to be maintained, but there are still some shortcomings that need to socialize the officers who are less supportive of the SIMRS that is the need for motivation and assistance to users who have difficulty. Because remembering one of the benefits of SIMRS the SIM will accelerate and improve the accuracy of the transaction because everything is recorded and communicated between various units.
Analisis Risiko Kerja Petugas Filling Rawat Inap Dengan Menggunakan Severity Assessment di RSUP Dr. Hasan Sadikin Bandung De Crystal, Inggil; Tri Ardianto, Efri; Farlinda, Sustin
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 3 (2020): June
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/jremi.v1i3.1960

Abstract

Risk is the possibilities of an unwanted, or unexpected, adverse loss in an activity. Risk can occur as a form of thepossibility of something bad happening in the future which can not be predicted when it comes. These risks can beresulted as negative impacts for the existing officers in several activities. We have observed the examples of risks thatoccur in the filling room of Dr. Hasan Sadikin General Hospital, Bandung. There are several risks of occupationalaccidents experienced by officers such as fingers affected by stapler attached to the medical record files, officers feelaches and pain in their hands and back when retrieving files, and the possibility of officers being hit by files. Thisresearch was aimed to analyze the risks that occur in filling inpatients. This risk assessment uses severity assessmentand a hierarchy of risk control to overcome the risks that occur. The type of research uses qualitative research with 4respondents. The results of this study produced 7 risks with 4 high injury risks and 3 moderate injury risks. Handling inrisk prevention is needed by making work safety SOPs, mandatory of Personal Protective Equipment (PPE) usage, theuse of tools to lift heavy loads, the use of chairs and stairs with strong materials, giving warning signs, paying attentionto ventilation to regulate proper lighting, and installing thermometers in inpatient filling rooms.
DETERMINAN KEAMANAN DAN KERAHASIAAN DOKUMEN REKAM MEDIS DI RUANG FILING RS X Alfiansyah, Gamasiano; Wijayanti, Rossalina Adi; Nuraini, Novita; Swari, Selvia Juwita; Wafiroh, Siti
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 2 (2020): March
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/jremi.v1i2.1961

Abstract

Rumah Sakit X menerapkan pengelolaan rekam medis sebagai penunjang medis. Dokumen rekam medis belum terjaga keamanan dan kerahasiaannya, dimana banyak petugas medis lain keluar masuk ruang filing, terdapat petugas makan dan minum diruang filing, penyimpanan masih di rak terbuka, dan petugas atau mahasiswa penelitian membocorkan isi rekam medis pasien.  Tujuan dari penelitian ini adalah mengetahui determinan keamanan dan kerahasiaan dokumen rekam medis di Rumah Sakit X. Jenis penelitian yang digunakan dalam penelitian ini adalah penelitian kualitatif menggunakan metode brainstorming dengan teknik wawancara, observasi dan dokumentasi. Hasil yang didapatkan dalam penelitian ini adalah faktor karakteristik petugas terdiri dari tingkat pendidikan terakhir petugas SMA, umur petugas 32-38 tahun, dan jenis kelamin laki-laki. Faktor psikologi meliputi attitude seperti petugas masih makan dan minum, petugas medis lain keluar masuk, membuka dokumen rekam medis tanpa izin dan terdapat pembocoran isi dokumen rekam medis. Faktor motivasi meliputi petugas merasa puas dan kompetitif dalam bekerja. Faktor organisasi meliputi penghargaan berupa pujian dan kepemimpinan belum dilakukan pemberian petunjuk pergantian dokumen rekam medis yang hilang. Hasil brainstorming yang menjadi penyebab utama yaitu tingkat pendidikan petugas yang masih rendah yaitu SMA. Saran yang diberikan meliputi pendidikan lanjutan atau pelatihan, memberi evaluasi secara rutin dan piagam kepada petugas. Kata kunci : keamanan, kerahasiaan, penyimpanan
Evaluasi Kariadi Information System pada Petugas Koding Rawat Jalan di RSUP dr. Kariadi Semarang Nissa', Nabilah Khoirun; Erawantini, Feby; Roziqin, Mochammad Choirur
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 3 (2020): June
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/jremi.v1i3.1973

Abstract

Based on a preliminary survey that I had done during the Field Work Practice at RSUP Dr. Kariadi Semarang.The output that was there produced the KIS system on the RME menu that was not yet in accordance with thewishes of the outpatient coding officer. In the KIS system, the SIMRS menu entry grouping encoding externalcauses or external causes only have 3 digits of 4 characters. The use of the KIS menu RME systemsometimes occurs errors that are not equipped with guidelines or guidelines if an error occurs. This studyaims to evaluate KIS (Kariadi Information System) users in outpatient coding officers. Use the methoddiscussed, namely the EUCS method to measure the level of satisfaction from using a system. The resultsthat have been obtained from this research in terms of the content (content) of the information obtained isquite helpful for coding officers. The lack of entry grouping coding on the external cause, if complete willbenefit the patient. In terms of accuracy (accuracy) still requires an accuracy process, for example, if the inputerror registers, the data that appears will be different and occasional errors also occur. In terms of format(display) the interface is quite attractive based on user needs. In terms of timeliness, the system is able toprovide up to date information. In terms of ease of use (ease of use) the system is easy to learn only the lackof guidance if there has been an error. This research resulted in several recommendations that IT staff officerscan receive input related to the constraints of the use of the coder officer system, the head of the medicalrecord conducts further evaluation and supervision of the use of the system.
Analisis Faktor Penyebab Ketidaktepatan Kode Diagnosis Penyakit Diabetes Mellitus di Rumah Sakit Umum Haji Surabaya Loren, Errica Rostia; Wijayanti, Rossalina Adi; Nikmatun, Nikmatun
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 1 No 3 (2020): June
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/jremi.v1i3.1974

Abstract

The accuracy of determining the disease diagnosis code is one of the important things that must beconsidered in carrying out the coding process of the patient's disease diagnosis made by the coder. Theaccuracy and inaccuracy of providing disease diagnosis codes will affect data and information in the healthservice process and reduce the quality of services in hospitals. Besides, in the era of National HealthInsurance (JKN), the accuracy of the diagnosis code was also very influential in financing at hospitals. Thisresearch was aimed to analyze the factors which cause the diagnosis code inaccuracy in Diabetes Mellitus inSurabaya Hajj General Hospital in 2019. This research used qualitative methods with data collectiontechniques such as interviews, observation, and literature studies. The number of samples used in the studywas 21 medical records of Diabetes Mellitus patients and 2 informants. The results of research on the medicalrecord documents of patients with Diabetes Mellitus found that the documents have an incorrect code of 13medical record documents (62%) and documents that have an exact code of 8 medical record documents(38%). The results of the analysis found were several factors that influence the inaccuracy of the code such ascoder's competency, coder's knowledge, as well as the experience of coder and medical record document,both the completeness of the filling and the documentation. The solution that can be proposed by theresearcher is to included the coder and medical personnel in training and outreach related to thedetermination of diagnosis code, especially Diabetes Mellitus.
Tinjauan Pelaksanaan Pemeliharaan Dokumen Rekam Medis di Ruang Filling RSUP Dr. Sardjito Ayuningrum, Tias Agustin; Alfiansyah, Gamasiano; Sugeng, Sugeng; Farlinda, Sustin
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 2 No 1 (2020): December
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/jremi.v2i1.1983

Abstract

The implementation of maintenance medical record documents in RSUP Dr. Sardjito is not optimal. This statement was proven by the damage of medical record documents about 35,05%. The purpose of this research is to review the implementation of maintenance medical record documents uses management elements 5M (man, money, material, machine, and method). The research type is qualitative and the data collection techniques use interviews, observations, and documentations. The subjects of this research are filling officers. The result from man factor shown that filling officers have not received maintenance medical record documents training, meanwhile money factor shown that filling officers did not know about the budget management of maintenance medical record documents. The result from material factor show that the materials for medical records forms and folders have been provided optimally, meanwhile machine factor shown that the type of rack from combination of iron and wood was less suitable because it can made medical record documents were damage. The result from method factor show that standard operational procedure about implementation of maintenance medical record documents was not available. The solutions are giving socialization about implementation of maintenance medical record documents to filling officers, providing standard operational procedure about implementation of maintenance medical record documents, coating around the sharp part of rack using rubber tires that can prevent the damage of medical record folder.

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