ida sugiarti | Poltekkes Kemenkes Tasikmalaya (original) (raw)

Papers by ida sugiarti

Research paper thumbnail of Pengetahuan Perawat dalam Melaksanakan Pemberian Terapi Obat di Ruang Penyakit Dalam RSUD Kabupaten Sumedang Tahun 2012

Jurnal Persada Husada Indonesia, 2015

Peran perawat yang sering dilakukan dalam fungsi dependent adalah pemberian obat. Pemberian terap... more Peran perawat yang sering dilakukan dalam fungsi dependent adalah pemberian obat. Pemberian terapiobat beresiko dan perawat perlu tahu mengenai resiko dan cara pemberiannya untuk menghindari efek sampingobat. Hasil studi pendahuluan berdasarkan hasil observasi selama 2 minggu pada bulan Maret 2012, perawatsudah memberikan obat sesuai jadwal. Dalam memberikan obat, perawat tampak sudah terampil tetapi perawattidak memberikan Health Education berupa dampak, interaksi obat dengan makanan/minuman, faktor-faktoryang mempengaruhi kerja obat. Tujuan penelitian ini adalah untuk memberikan gambaran pengetahuan perawat(Conseptual Knowledge) tentang pemberian terapi obat yang sering diberikan di ruang penyakit dalam RSUDKabupaten Sumedang tahun 2012 berupa Antimikroba (Cephalosphorine/Cepotaxime, Ciproploxacin dan AntiTB), Histamine Antagonis (Ranitidine, Lansoprazole) dan Non Narkotik Analgesic Antipiretik (Paracetamol).Metode penelitian yang digunakan adalah penelitian deskriptif. Populasi dalam penelitian ini adalah perawat diruang penyakit dalam RSU BLUD Sumedang berjumlah 56 orang. Teknik pengambilan sampel menggunakantotal sampel. Alat ukur pengumpulan data berupa kuesioner. Variabel yang dibuat berasal dari soal-soalNCLEX-RN REVIEW 2000 dan NCLEX-RN 2003-2004 EDITION. Uji validitas dan reliabilitas menggunakanAna-Test. Hasil penelitian menunjukkan 3, 58 % memiliki pengetahuan cukup, dan 96, 42 % memilikipengetahuan kurang. Saran penelitian ini agar diadakannya nursing conference yang sistematis dan terjadwalmengenai obat-obatan dan peran perawat dalam pelaksanaan pemberian obat, dan memberikan kesempatankepada perawat untuk mengikuti pelatihan/seminar yang berhubungan dengan pemberian obat.Kata Kunci: pengetahuan perawat, terapi pemberian obat, antimikroba, histamine antagonis, nonnarkotic analgesic antipiretik

Research paper thumbnail of Pendampingan Pembuatan Clinical Pathway Dalam Peningkatan Mutu Pelayanan Kesehatan DI Rsud Dr. Soekardjo Kota Tasikmalaya

Jurnal Pengabdian Masyarakat (Jupemas)

Clinical pathways are used for quality and cost control in health services in hospitals. A clinic... more Clinical pathways are used for quality and cost control in health services in hospitals. A clinical pathway is the main requirement for quality control and cost control, especially in cases that have the potential to spend large resources. Research shows that the application of clinical pathways can reduce the length of stay and hospital costs. The existence of clinical pathways in hospitals is sought to refer to the National Guidelines for Medical Services (PNPK). The existence of clinical pathways at dr. Soekardjo does not all meet these criteria. Community service activities are carried out referring to the lecturer roadmap that has been made. The purpose of the activity is to the availability of clinical pathway forms that can be used in hospitals as needed and the preparation of clinical pathways according to PNPK criteria. The method of activity is in the form of FGD and Assistance in making clinical pathways. The activity was carried out well and agreed on a form that refers ...

Research paper thumbnail of Prosedur dan Jenis Permintaan Visum et Repertum di Rumah Sakit: Literature Review

Indonesian of Health Information Management Journal (INOHIM), 2021

AbstractVisum et repertum (VeR) is a medical certificate used for judicial needs in the form of a... more AbstractVisum et repertum (VeR) is a medical certificate used for judicial needs in the form of a written report made by a doctor containing the results of the examination. VeR is one of the five legal pieces of evidence in court. Making a VeR that is not following hospital procedures can lead to the submission of evidence in court proceedings. This study aims to determine the standard procedure for implementing medical information for VeR and the types of cases for which a VeR is requested. This type of research is a literature review using Google Scholar and Garuda databases with a boolean system strategy. The flow of the implementation of patient medical information for VeR begins with the police submitting a letter of request for VeR to the hospital administration by bringing the requirements of an official request letter from the director of the hospital. The visa request letter and the report are placed in the Medical Record Installation for further processing by the Medical R...

Research paper thumbnail of Legal Protection of Patient Rights to Completeness and Confidentiality in Management of Medical Record Documents

Various problems of the lawsuit exist because the health service is not optimal, complaints about... more Various problems of the lawsuit exist because the health service is not optimal, complaints about the quality of health services are also perceived. If the medical record document is filled with complete, it will be easy for health professionals to explain it if there is a lawsuit. The contents of the medical record contain medical secrets. Completeness and confidentiality are the rights of the patient and are protected by law. The purpose of this study was to understand the implementation of the arrangement of the patient's right for the confidentiality and completeness of medical record fulfillment filling and legal consequences of that. The method used a sociological juridical, the approach is analytical descriptive. The type of data is primary and secondary data. Collection of information through literature and interviews. Data analysis used a qualitative approach with thematic analysis and juridical analysis. The result is shown in the fulfillment of the right of patients f...

Research paper thumbnail of Qualitative Study About Inpatient Medical Records Document Management in Assembling Part of Medical Record Unit Dr. Soekardjo Hospital Tasikmalaya

Alur prosedur pengelolaan dokumen rekam medis di bagian assembling RSUD dr. Soekardjo Kota Tasikm... more Alur prosedur pengelolaan dokumen rekam medis di bagian assembling RSUD dr. Soekardjo Kota Tasikmalaya sesuai dengan SOP. Awalnya ada pengecekkan kelengkapan terlebih dahulu, kemudian dilakukan proses perakitan dokumen rekam medis. Tetapi kelengkapan yang diperiksa sebelum dilakukannya perakitan yaitu kelengkapan identitas, tanda tangan dokter dan diagnosa. Analisis kelengkapan kuantitatif dilaksanakan oleh petugas analisis. Tupoksinya dicantumkan untuk pengecekkan kelengkapan analisis kuantitatif dilakukan oleh petugas assembling . Petugas melakukan perakitan dokumen RM yaitu rata-rata 6,87 menit. Rumah Sakit ini belum memiliki standar waktu untuk assembling. Pengalaman petugas rekam medis terhadap pengelolaan dokumen rekam medis rawat inap di bagian assembling RSUD dr. Soekardjo Kota Tasikmalaya tidak sama, dikarenakan pendidikan dan masa kerja dari setiap informan juga berbeda. Hal tersebut tidak mempengaruhi pada perakitan dokumen rekam medis.

Research paper thumbnail of Pengetahuan Perawat dalam Melaksanakan Pemberian Terapi Obat di Ruang Penyakit Dalam RSUD Kabupaten Sumedang Tahun 2012

Peran perawat yang sering dilakukan dalam fungsi dependent adalah pemberian obat. Pemberian terap... more Peran perawat yang sering dilakukan dalam fungsi dependent adalah pemberian obat. Pemberian terapiobat beresiko dan perawat perlu tahu mengenai resiko dan cara pemberiannya untuk menghindari efek sampingobat. Hasil studi pendahuluan berdasarkan hasil observasi selama 2 minggu pada bulan Maret 2012, perawatsudah memberikan obat sesuai jadwal. Dalam memberikan obat, perawat tampak sudah terampil tetapi perawattidak memberikan Health Education berupa dampak, interaksi obat dengan makanan/minuman, faktor-faktoryang mempengaruhi kerja obat. Tujuan penelitian ini adalah untuk memberikan gambaran pengetahuan perawat(Conseptual Knowledge) tentang pemberian terapi obat yang sering diberikan di ruang penyakit dalam RSUDKabupaten Sumedang tahun 2012 berupa Antimikroba (Cephalosphorine/Cepotaxime, Ciproploxacin dan AntiTB), Histamine Antagonis (Ranitidine, Lansoprazole) dan Non Narkotik Analgesic Antipiretik (Paracetamol).Metode penelitian yang digunakan adalah penelitian deskriptif. Populasi d...

Research paper thumbnail of Implementasi Pengisian Formulir Informed Consent Kasus Bedah Umum Sebagai Salah Satu Bukti Transaksi Terapeutik DI Rsud Dr. Soekardjo Kota Tasikmalaya Tahun 2017

According to the Ministry of Health Decree No. 129 of 2008 concerning Minimum Standards Services ... more According to the Ministry of Health Decree No. 129 of 2008 concerning Minimum Standards Services in Hospitals, filling Informed Consent (IC) forms must be 100%. Preliminary study addressing 15 IC form of general surgery case in January 2017 wasn’t filled complete. Purpose of the research is for knowing how the implementation filling of the IC form general surgery cases as evidence of therapeutic transactions in Dr. Soekardjo Tasikmalaya city hospital on 2017.The method of research is descriptive with mixed method approach, a total sample is 127 IC form, and the research participant is a general surgeon, chief medical record unit, nurse and patient.The result showed that the average percentage of completeness IC form of the general surgery cases in the first quarter of 2017 was 68.9%. Inhibitory factors are limited time, lack of human resources, priority on BPJS patient, lack of socialization, priority on high risk patients, no follow-up analysis, oral IC is considered easier, and de...

Research paper thumbnail of Evaluasi Sistem Surveilans Demam Berdarah Dengue di Kota Tasikmalaya

Dengue Hemorrhagic Fever (DHF) has spread across all districts/cities in Indonesia, including in ... more Dengue Hemorrhagic Fever (DHF) has spread across all districts/cities in Indonesia, including in Tasikmalaya City as an endemic area. We conducted a mixed-methods study to evaluate surveillance system for dengue hemorrhagic fever in Tasikmalaya City. Qualitative data collection with in-depth interviews and focus group discussions. This research was conducted in the Tasikmalaya City Health Office’s work area from April to November 2018. Surveillance data through the hospital’s early warning report to the Tasikmalaya City Health Office mostly reported more than 24 hours. Completeness of reporting from RSU Dr. Soekarjo was 65.96% and TMC Hospital was 92%. There was a significant relationship between the presence of larvae and dengue cases (p-value = 0.001). It can be concluded that the accuracy and completeness of the hospital’s early warning report to the Tasikmalaya City Health Office was still relatively low due to the implementation of information system have not been integrated, D...

Research paper thumbnail of Menelusuri Potensi Fraud dalam Jkn Melalui Rekam Medis di Rumah Sakit

Jurnal Kesehatan Vokasional, 2022

Latar Belakang: Akibat fraud, BPJS (Badan Penyelenggara Jaminan Sosial Kesehatan) harus membayar ... more Latar Belakang: Akibat fraud, BPJS (Badan Penyelenggara Jaminan Sosial Kesehatan) harus membayar klaim lebih besar, sehingga terjadi kerugian negara. Salah satu bentuk fraud yang ditemukan di kelompok provider adalah upcoding. Data koding dan rekaman pelayanan kesehatan dalam rekam medis dapat digunakan sebagai deteksi fraud.Tujuan: Menelusuri potensi fraud dalam rekam medis melalui telusur keakuratan kode diagnosis dan clinical pathway.Metode: Pendekatan kuantitatif kualitatif. Jenis penelitian case study, kasus thypoid. Subjek penelitian ditentukan dengan purposive sampling. Sampel penelitian kuantitatif menggunakan berkas rekam medis. Metode pengumpulan data menggunakan lembar observasi dan indept interview. Analisis data kuantitatif dengan analisis deskriptif dan Analisa data kualitatif dengan analisis konten.Hasil: Dari 87 dokumen, ketidaktepatan kode diagnosis 31,03%, dengan presentase ketidaksesuaian tarif klaim 26,44%. Terdapat berbagai penyebab upcoding diantaranya karena a...

Research paper thumbnail of Claim Procedure Analysis Health BPJS In Hospital

Indonesian Journal of Health Information Management, 2021

The membership administration procedure factor, the medical resume factor, the diagnosis codifica... more The membership administration procedure factor, the medical resume factor, the diagnosis codification factor and the action codification factor are still obstacles so that they are returned by the BPJS Health verifier. The purpose of the study was to determine the BPJS Health claim procedure at the hospital. Literature research or literature study and qualitative approach. Based on a review of 15 (fifteen) journals, it was found that there are still obstacles in the BPJS Health claim procedure so that the file is returned to the BPJS verifier. As in the case of membership administration procedures, medical resume factors, diagnosis codification factors, and action codification factors. which causes BPJS health files to be returned, namely the absence of Standard Operating Procedures which regulates the factors regarding the collection of documents for BPJS patient registration requirements. Components of author authentication and audit records are not appropriate because there is no...

Research paper thumbnail of Pengembangan Sistem Informasi Posyandu Terintegrasi (Sipter) DI Wilayah Puskesmas Tawang Kecamatan Tawang Kota Tasikmalaya

Posyandu adalah salah satu bentuk upaya kesehatan berbasis masyarakat yang sudah menjadi milik ma... more Posyandu adalah salah satu bentuk upaya kesehatan berbasis masyarakat yang sudah menjadi milik masyarakat serta menyatu dalam kehidupan dan budaya masyarakat. Kegiatan-kegiatan pengembangan di Posyandu saat ini tidak hanya pada kegiatan Kesehatan Ibu dan Anak, Gizi, KB saja, tapi berkembang sesuai dengan kebutuhan masyarakat setempat misalnya: Bina Keluarga Balita (BKB), Pendidikan Anak Usia Dini (PAUD), Ekonomi Keluarga, Koperasi, Keagamaan, Penyuluhan pengendalian penyakit-penyakit menular, Perilaku Hidup Bersih dan Sehat (PHBS). Hasil kegiatannya dicatat dan dilaporkan dalam format tertentu. Pada penyelenggaraannya, kader posyandu telah melakukan penyelenggaraaan pencatatan dan pelaporan, pencatatan dilakukan oleh kader segera setelah kegiatan dilaksanakan. Pencatatan dilakukan dengan menggunakan format baku sesuai dengan program kesehatan, Sistem Informasi Posyandu (SIP), selama ini dilaksanakan secara manual. Penyelenggaraan pencatatan dan pelaporan SIP manual memberikan beb...

Research paper thumbnail of Upaya Peningkatan Kemandirian Masyarakat Melalui Pembentukan Tim Penggerak Desa Sehat Penyakit Tidak Menular DI Kota Tasikmalaya

Abdimas Galuh

ABSTRAK Penambahan jumlah kasus Covid-19 berlangsung cepat, terutama gejala muncul pada pasien de... more ABSTRAK Penambahan jumlah kasus Covid-19 berlangsung cepat, terutama gejala muncul pada pasien dengan comorbid yang mengakibatkan kematian. Salah satu comorbid yaitu Penyakit Tidak menular (PTM), diantaranya DM dan Hipertensi. Tingginya kasus PTM, membutuhkan perhatian dan identifikasi sedini mungkin serta penanganan segera agar tidak berakibat fatal. Pemerintah memiliki sumber daya yang terbatas dalam pengelolaan pelayanan kesehatan. Situasi pandemi Covid-19 juga membutuhkan perhatian khusus dan sumber daya yang tidak sedikit. Oleh karena itu, pentingnya melibatkan partisipasi masyarakat untuk terlibat terutama dalam pencegahan dan deteksi dini melalui pembentukan Tim Penggerak PTM. Metode yang digunakan berupa pelatihan dan pembentukan tim penggerak PTM yang didukung dengan aplikasi Lembur Sehat PTM. Hasil pengabdian kepada masyarakat terdapat peningkatan pengetahuan dari kader dan tim penggerak setelah pelatihan. Rata-rata nilai pre test pada tim penggerak wilayah Tawang yaitu 72,67; sedangkan rata-rata nilai post test yaitu 94,67. Rata-rata nilai pre test pada tim penggerak wilayah Cibeureum yaitu 63,64; sedangkan rata-rata nilai post test yaitu 90,36. Hasil monitoring dan observasi menunjukkan kader melakukan pendataan berupa pengukuran gula darah dan tensi serta mengisi data di aplikasi Lembur Sehat PTM. Jumlah kader yang mengikuti pelatihan sebanyak 60 kader dan karang taruna. Hasil observasi pada aplikasi tercatat 600 data masyarakat yang sudah dientry. Hasil pengukuran menjadi data bagi Puskesmas setempat dan akan ditindaklanjuti. Data juga dilaporkan ke Dinas Kesehatan Kota Tasikmalaya.

Research paper thumbnail of TINJAUAN PENYEDIAAN DOKUMEN REKAM MEDIS DI RSUD Dr. SOEKARDJO KOTA TASIKMALAYA

Jurnal Manajemen Informasi Kesehatan Indonesia, Dec 17, 2015

Fast and precise services are the desire of consumers. The speed of document provision of medical... more Fast and precise services are the desire of consumers. The speed of document provision of medical records to the clinic can be an indicator in measuring satisfaction. Based on preliminary studies in dr. Soekardjo Kota Tasikmalaya found that the provision of medical record documents less than the maximum and delayed. The aim of this research is to determine the implementation of the provision of documents in the old patient medical records outpatient services. This research type is a descriptive study. Data collection used observation sheets, stopwatch, and interview guidelines. Sample size is 99 medical record documents with accidental sampling technique. The amount of sample is 99 document medical records with accidental sampling technique. Data were analyzed using univariate analysis. The results shows 63.64% late provision of medical record documents with an average time of 12.36 minutes, it exceeds the minimum standard service that is d"10 minutes. The groove of the provision of documents in the old patient medical records outpatient is 100% not appropriate. This is due to the amount of time a patient visits increased, less officer, less storage rack capacity, system alignment sequence and the absence of tracer. The conclusion is the provision of document medical record of old patients is late and the groove of the provision of documents in the old patient medical records outpatient is not appropriate. To solve those problems, it would be better if the service quality is improved, especially in the speed of medical records document provision.

Research paper thumbnail of Gambaran Effisiensi Penggunaan Tempat Tidur Ruang Perawatan Kelas III DI Rumah Sakit Umum Daerah Tasikmalaya Tahun 2011 Dan 2012

Jurnal Manajemen Informasi Kesehatan Indonesia, Mar 11, 2014

The Integrated Emergency Response System (SPGDT) is a web-based system that provides information ... more The Integrated Emergency Response System (SPGDT) is a web-based system that provides information about the availability of beds in hospitals and health centers inpatient care in Kebumen District. During this time the operators that are medical record officers in each hospital or health center input data manually into SPGDT so that data is not always updated regularly and not realtime. This study aims to develop interoperability of SPGDT so that data synchronization can be done automatically from the Hospital Management Information System (SIMRS) and the Health Center Management Information System (SIMPUS). This type of research is research and development. Needs asessment was carried out with focus group discussions (FGD) involving representatives from hospitals, inpatient health centers, health offices, and the Kebumen District Communication and Information Agency. A web service infrastructure has been developed in the form of an Application Programming Interface (API) that can be used by hospitals and health centers to synchronize data from SIMRS and SIMPUS automatically.

Research paper thumbnail of Faktor-Faktor Keterlambatan Pengembalian Sensus Harian Rawat Inap DI Rsud Kab. Ciamis

Jurnal Manajemen Informasi Kesehatan Indonesia, Dec 17, 2015

The implementation of good medical records will support the implementation of health improvement ... more The implementation of good medical records will support the implementation of health improvement services in hospital, one of them is making report based on the daily census. The return of daily hospitalizazion census to the medical record unit in RSUD Kab. Ciamis is often delayed. This research aims to know the factors of delay returns daily census of hospitalizazion to medical record unit at RSUD Kab. Ciamis. The method used in this research is qualitative method with phenomenological approach. The data collecting used interview and observation techniques in 8 informants. Data analysis is done by the data reduction, data presentation and withdrawal data conclusion or verification. Based on this research, it is known that the daily census has been delayed for two weeks, it is incompatible with the standard operating procedures (SOP) in which the daily census should have sent to the Medical Records back at least at 09.00 am the next day. The cause of the delay returns daily census is the lack of responsibility of the officer and the mismatch workload which is resulting in low productivity of labour. It is necessary for the holding of related SOP socialization census data collection daily hospitalization for officers, especially for the nurses in the implementation mechanism census daily data.

Research paper thumbnail of Kelengkapan Pengisian Formulir Laporan Operasi Kasus Bedah Obgyn Sebagai Alat Bukti Hukum

Jurnal Manajemen Informasi Kesehatan Indonesia, Mar 4, 2019

According to the Ministry of Health Decree No. 129 of 2008 concerning Minimum Standards Services ... more According to the Ministry of Health Decree No. 129 of 2008 concerning Minimum Standards Services in Hospitals, filling medical record include surgery report forms must be 100% that can be used as legal evidence. Preliminary study addressing 10surgery report form of obgyn surgery cases in December 2017 wasn't filled complete. Knowing how the implementation filling of the surgery report formof obgyn surgery cases as a legal evidence in RSUD Ciamis District Ciamis in quarter IV 2017.Methods: Descriptive with mixed method approach, a total sample is 82 surgery report forms, and the research informant is a obgyn surgeon, coordinator of administration and medical record service, and surgical nurse.The average percentage of completeness surgery report forms of the general surgery cases in the IV quarter of 2017 was 63,78%. Inhibitory factors are limited time, patient quantity, delay in medical record control, too much items filled of form. Average percentage of surgery report form filling still below the Minimum Standards Services. Hospital shouldimprove the causal factors that inhibit the incompleteness of surgery report form.

Research paper thumbnail of Kelengkapan Pengisian Formulir Laporan Operasi Kasus Bedah Obgyn Sebagai Alat Bukti Hukum

Jurnal Manajemen Informasi Kesehatan Indonesia

According to the Ministry of Health Decree No. 129 of 2008 concerning Minimum Standards Services ... more According to the Ministry of Health Decree No. 129 of 2008 concerning Minimum Standards Services in Hospitals, filling medical record include surgery report forms must be 100% that can be used as legal evidence. Preliminary study addressing 10surgery report form of obgyn surgery cases in December 2017 wasn't filled complete. Knowing how the implementation filling of the surgery report formof obgyn surgery cases as a legal evidence in RSUD Ciamis District Ciamis in quarter IV 2017.Methods: Descriptive with mixed method approach, a total sample is 82 surgery report forms, and the research informant is a obgyn surgeon, coordinator of administration and medical record service, and surgical nurse.The average percentage of completeness surgery report forms of the general surgery cases in the IV quarter of 2017 was 63,78%. Inhibitory factors are limited time, patient quantity, delay in medical record control, too much items filled of form. Average percentage of surgery report form filling still below the Minimum Standards Services. Hospital shouldimprove the causal factors that inhibit the incompleteness of surgery report form.

Research paper thumbnail of Faktor-Faktor Keterlambatan Pengembalian Sensus Harian Rawat Inap DI Rsud Kab. Ciamis

Jurnal Manajemen Informasi Kesehatan Indonesia

The implementation of good medical records will support the implementation of health improvement ... more The implementation of good medical records will support the implementation of health improvement services in hospital, one of them is making report based on the daily census. The return of daily hospitalizazion census to the medical record unit in RSUD Kab. Ciamis is often delayed. This research aims to know the factors of delay returns daily census of hospitalizazion to medical record unit at RSUD Kab. Ciamis. The method used in this research is qualitative method with phenomenological approach. The data collecting used interview and observation techniques in 8 informants. Data analysis is done by the data reduction, data presentation and withdrawal data conclusion or verification. Based on this research, it is known that the daily census has been delayed for two weeks, it is incompatible with the standard operating procedures (SOP) in which the daily census should have sent to the Medical Records back at least at 09.00 am the next day. The cause of the delay returns daily census is the lack of responsibility of the officer and the mismatch workload which is resulting in low productivity of labour. It is necessary for the holding of related SOP socialization census data collection daily hospitalization for officers, especially for the nurses in the implementation mechanism census daily data.

Research paper thumbnail of Analisis Kelengkapan Pengisian Data Formulir Anamnesis Dan Pemeriksaan Fisik Kasus Bedah

Jurnal Manajemen Informasi Kesehatan Indonesia

Quantitative analysis has conducted in dr. Slamet Garut General hospital, but there are still ana... more Quantitative analysis has conducted in dr. Slamet Garut General hospital, but there are still anamnesis and physical examination forms are incomplete both clinical data and demographic data. Based on the highest preliminary survey of incompleteness on the register component is 83.34%. The aim of this research is to know the fulfilment procedure, completeness and incompleteness data fulfilment of anamnesis and physical examination forms. The method that used in this research is observation quantitative analysis, using instrument observation sheet. The population in this research are 1008 medical record documents on semester I in 2013. The magnitude of the sample uses Slovin formula is 90 documents. Slovin formula is used because it refers to large samples which are 90 documents. The result of research showed that complete form anamnesis and physical examination of the patient identification component is 20%, important report is 31.12%, authentication is 83.33% dan the register is 3.34%. refers to the minimum standard of completeness which is submitted by the department of health (2006), the completeness document must be 100%. It can be conclusion that the anamnesis and physical examination data fulfilment in dr.

Research paper thumbnail of TINJAUAN PENYEDIAAN DOKUMEN REKAM MEDIS DI RSUD Dr. SOEKARDJO KOTA TASIKMALAYA

Jurnal Manajemen Informasi Kesehatan Indonesia

Fast and precise services are the desire of consumers. The speed of document provision of medical... more Fast and precise services are the desire of consumers. The speed of document provision of medical records to the clinic can be an indicator in measuring satisfaction. Based on preliminary studies in dr. Soekardjo Kota Tasikmalaya found that the provision of medical record documents less than the maximum and delayed. The aim of this research is to determine the implementation of the provision of documents in the old patient medical records outpatient services. This research type is a descriptive study. Data collection used observation sheets, stopwatch, and interview guidelines. Sample size is 99 medical record documents with accidental sampling technique. The amount of sample is 99 document medical records with accidental sampling technique. Data were analyzed using univariate analysis. The results shows 63.64% late provision of medical record documents with an average time of 12.36 minutes, it exceeds the minimum standard service that is d"10 minutes. The groove of the provision of documents in the old patient medical records outpatient is 100% not appropriate. This is due to the amount of time a patient visits increased, less officer, less storage rack capacity, system alignment sequence and the absence of tracer. The conclusion is the provision of document medical record of old patients is late and the groove of the provision of documents in the old patient medical records outpatient is not appropriate. To solve those problems, it would be better if the service quality is improved, especially in the speed of medical records document provision.

Research paper thumbnail of Pengetahuan Perawat dalam Melaksanakan Pemberian Terapi Obat di Ruang Penyakit Dalam RSUD Kabupaten Sumedang Tahun 2012

Jurnal Persada Husada Indonesia, 2015

Peran perawat yang sering dilakukan dalam fungsi dependent adalah pemberian obat. Pemberian terap... more Peran perawat yang sering dilakukan dalam fungsi dependent adalah pemberian obat. Pemberian terapiobat beresiko dan perawat perlu tahu mengenai resiko dan cara pemberiannya untuk menghindari efek sampingobat. Hasil studi pendahuluan berdasarkan hasil observasi selama 2 minggu pada bulan Maret 2012, perawatsudah memberikan obat sesuai jadwal. Dalam memberikan obat, perawat tampak sudah terampil tetapi perawattidak memberikan Health Education berupa dampak, interaksi obat dengan makanan/minuman, faktor-faktoryang mempengaruhi kerja obat. Tujuan penelitian ini adalah untuk memberikan gambaran pengetahuan perawat(Conseptual Knowledge) tentang pemberian terapi obat yang sering diberikan di ruang penyakit dalam RSUDKabupaten Sumedang tahun 2012 berupa Antimikroba (Cephalosphorine/Cepotaxime, Ciproploxacin dan AntiTB), Histamine Antagonis (Ranitidine, Lansoprazole) dan Non Narkotik Analgesic Antipiretik (Paracetamol).Metode penelitian yang digunakan adalah penelitian deskriptif. Populasi dalam penelitian ini adalah perawat diruang penyakit dalam RSU BLUD Sumedang berjumlah 56 orang. Teknik pengambilan sampel menggunakantotal sampel. Alat ukur pengumpulan data berupa kuesioner. Variabel yang dibuat berasal dari soal-soalNCLEX-RN REVIEW 2000 dan NCLEX-RN 2003-2004 EDITION. Uji validitas dan reliabilitas menggunakanAna-Test. Hasil penelitian menunjukkan 3, 58 % memiliki pengetahuan cukup, dan 96, 42 % memilikipengetahuan kurang. Saran penelitian ini agar diadakannya nursing conference yang sistematis dan terjadwalmengenai obat-obatan dan peran perawat dalam pelaksanaan pemberian obat, dan memberikan kesempatankepada perawat untuk mengikuti pelatihan/seminar yang berhubungan dengan pemberian obat.Kata Kunci: pengetahuan perawat, terapi pemberian obat, antimikroba, histamine antagonis, nonnarkotic analgesic antipiretik

Research paper thumbnail of Pendampingan Pembuatan Clinical Pathway Dalam Peningkatan Mutu Pelayanan Kesehatan DI Rsud Dr. Soekardjo Kota Tasikmalaya

Jurnal Pengabdian Masyarakat (Jupemas)

Clinical pathways are used for quality and cost control in health services in hospitals. A clinic... more Clinical pathways are used for quality and cost control in health services in hospitals. A clinical pathway is the main requirement for quality control and cost control, especially in cases that have the potential to spend large resources. Research shows that the application of clinical pathways can reduce the length of stay and hospital costs. The existence of clinical pathways in hospitals is sought to refer to the National Guidelines for Medical Services (PNPK). The existence of clinical pathways at dr. Soekardjo does not all meet these criteria. Community service activities are carried out referring to the lecturer roadmap that has been made. The purpose of the activity is to the availability of clinical pathway forms that can be used in hospitals as needed and the preparation of clinical pathways according to PNPK criteria. The method of activity is in the form of FGD and Assistance in making clinical pathways. The activity was carried out well and agreed on a form that refers ...

Research paper thumbnail of Prosedur dan Jenis Permintaan Visum et Repertum di Rumah Sakit: Literature Review

Indonesian of Health Information Management Journal (INOHIM), 2021

AbstractVisum et repertum (VeR) is a medical certificate used for judicial needs in the form of a... more AbstractVisum et repertum (VeR) is a medical certificate used for judicial needs in the form of a written report made by a doctor containing the results of the examination. VeR is one of the five legal pieces of evidence in court. Making a VeR that is not following hospital procedures can lead to the submission of evidence in court proceedings. This study aims to determine the standard procedure for implementing medical information for VeR and the types of cases for which a VeR is requested. This type of research is a literature review using Google Scholar and Garuda databases with a boolean system strategy. The flow of the implementation of patient medical information for VeR begins with the police submitting a letter of request for VeR to the hospital administration by bringing the requirements of an official request letter from the director of the hospital. The visa request letter and the report are placed in the Medical Record Installation for further processing by the Medical R...

Research paper thumbnail of Legal Protection of Patient Rights to Completeness and Confidentiality in Management of Medical Record Documents

Various problems of the lawsuit exist because the health service is not optimal, complaints about... more Various problems of the lawsuit exist because the health service is not optimal, complaints about the quality of health services are also perceived. If the medical record document is filled with complete, it will be easy for health professionals to explain it if there is a lawsuit. The contents of the medical record contain medical secrets. Completeness and confidentiality are the rights of the patient and are protected by law. The purpose of this study was to understand the implementation of the arrangement of the patient's right for the confidentiality and completeness of medical record fulfillment filling and legal consequences of that. The method used a sociological juridical, the approach is analytical descriptive. The type of data is primary and secondary data. Collection of information through literature and interviews. Data analysis used a qualitative approach with thematic analysis and juridical analysis. The result is shown in the fulfillment of the right of patients f...

Research paper thumbnail of Qualitative Study About Inpatient Medical Records Document Management in Assembling Part of Medical Record Unit Dr. Soekardjo Hospital Tasikmalaya

Alur prosedur pengelolaan dokumen rekam medis di bagian assembling RSUD dr. Soekardjo Kota Tasikm... more Alur prosedur pengelolaan dokumen rekam medis di bagian assembling RSUD dr. Soekardjo Kota Tasikmalaya sesuai dengan SOP. Awalnya ada pengecekkan kelengkapan terlebih dahulu, kemudian dilakukan proses perakitan dokumen rekam medis. Tetapi kelengkapan yang diperiksa sebelum dilakukannya perakitan yaitu kelengkapan identitas, tanda tangan dokter dan diagnosa. Analisis kelengkapan kuantitatif dilaksanakan oleh petugas analisis. Tupoksinya dicantumkan untuk pengecekkan kelengkapan analisis kuantitatif dilakukan oleh petugas assembling . Petugas melakukan perakitan dokumen RM yaitu rata-rata 6,87 menit. Rumah Sakit ini belum memiliki standar waktu untuk assembling. Pengalaman petugas rekam medis terhadap pengelolaan dokumen rekam medis rawat inap di bagian assembling RSUD dr. Soekardjo Kota Tasikmalaya tidak sama, dikarenakan pendidikan dan masa kerja dari setiap informan juga berbeda. Hal tersebut tidak mempengaruhi pada perakitan dokumen rekam medis.

Research paper thumbnail of Pengetahuan Perawat dalam Melaksanakan Pemberian Terapi Obat di Ruang Penyakit Dalam RSUD Kabupaten Sumedang Tahun 2012

Peran perawat yang sering dilakukan dalam fungsi dependent adalah pemberian obat. Pemberian terap... more Peran perawat yang sering dilakukan dalam fungsi dependent adalah pemberian obat. Pemberian terapiobat beresiko dan perawat perlu tahu mengenai resiko dan cara pemberiannya untuk menghindari efek sampingobat. Hasil studi pendahuluan berdasarkan hasil observasi selama 2 minggu pada bulan Maret 2012, perawatsudah memberikan obat sesuai jadwal. Dalam memberikan obat, perawat tampak sudah terampil tetapi perawattidak memberikan Health Education berupa dampak, interaksi obat dengan makanan/minuman, faktor-faktoryang mempengaruhi kerja obat. Tujuan penelitian ini adalah untuk memberikan gambaran pengetahuan perawat(Conseptual Knowledge) tentang pemberian terapi obat yang sering diberikan di ruang penyakit dalam RSUDKabupaten Sumedang tahun 2012 berupa Antimikroba (Cephalosphorine/Cepotaxime, Ciproploxacin dan AntiTB), Histamine Antagonis (Ranitidine, Lansoprazole) dan Non Narkotik Analgesic Antipiretik (Paracetamol).Metode penelitian yang digunakan adalah penelitian deskriptif. Populasi d...

Research paper thumbnail of Implementasi Pengisian Formulir Informed Consent Kasus Bedah Umum Sebagai Salah Satu Bukti Transaksi Terapeutik DI Rsud Dr. Soekardjo Kota Tasikmalaya Tahun 2017

According to the Ministry of Health Decree No. 129 of 2008 concerning Minimum Standards Services ... more According to the Ministry of Health Decree No. 129 of 2008 concerning Minimum Standards Services in Hospitals, filling Informed Consent (IC) forms must be 100%. Preliminary study addressing 15 IC form of general surgery case in January 2017 wasn’t filled complete. Purpose of the research is for knowing how the implementation filling of the IC form general surgery cases as evidence of therapeutic transactions in Dr. Soekardjo Tasikmalaya city hospital on 2017.The method of research is descriptive with mixed method approach, a total sample is 127 IC form, and the research participant is a general surgeon, chief medical record unit, nurse and patient.The result showed that the average percentage of completeness IC form of the general surgery cases in the first quarter of 2017 was 68.9%. Inhibitory factors are limited time, lack of human resources, priority on BPJS patient, lack of socialization, priority on high risk patients, no follow-up analysis, oral IC is considered easier, and de...

Research paper thumbnail of Evaluasi Sistem Surveilans Demam Berdarah Dengue di Kota Tasikmalaya

Dengue Hemorrhagic Fever (DHF) has spread across all districts/cities in Indonesia, including in ... more Dengue Hemorrhagic Fever (DHF) has spread across all districts/cities in Indonesia, including in Tasikmalaya City as an endemic area. We conducted a mixed-methods study to evaluate surveillance system for dengue hemorrhagic fever in Tasikmalaya City. Qualitative data collection with in-depth interviews and focus group discussions. This research was conducted in the Tasikmalaya City Health Office’s work area from April to November 2018. Surveillance data through the hospital’s early warning report to the Tasikmalaya City Health Office mostly reported more than 24 hours. Completeness of reporting from RSU Dr. Soekarjo was 65.96% and TMC Hospital was 92%. There was a significant relationship between the presence of larvae and dengue cases (p-value = 0.001). It can be concluded that the accuracy and completeness of the hospital’s early warning report to the Tasikmalaya City Health Office was still relatively low due to the implementation of information system have not been integrated, D...

Research paper thumbnail of Menelusuri Potensi Fraud dalam Jkn Melalui Rekam Medis di Rumah Sakit

Jurnal Kesehatan Vokasional, 2022

Latar Belakang: Akibat fraud, BPJS (Badan Penyelenggara Jaminan Sosial Kesehatan) harus membayar ... more Latar Belakang: Akibat fraud, BPJS (Badan Penyelenggara Jaminan Sosial Kesehatan) harus membayar klaim lebih besar, sehingga terjadi kerugian negara. Salah satu bentuk fraud yang ditemukan di kelompok provider adalah upcoding. Data koding dan rekaman pelayanan kesehatan dalam rekam medis dapat digunakan sebagai deteksi fraud.Tujuan: Menelusuri potensi fraud dalam rekam medis melalui telusur keakuratan kode diagnosis dan clinical pathway.Metode: Pendekatan kuantitatif kualitatif. Jenis penelitian case study, kasus thypoid. Subjek penelitian ditentukan dengan purposive sampling. Sampel penelitian kuantitatif menggunakan berkas rekam medis. Metode pengumpulan data menggunakan lembar observasi dan indept interview. Analisis data kuantitatif dengan analisis deskriptif dan Analisa data kualitatif dengan analisis konten.Hasil: Dari 87 dokumen, ketidaktepatan kode diagnosis 31,03%, dengan presentase ketidaksesuaian tarif klaim 26,44%. Terdapat berbagai penyebab upcoding diantaranya karena a...

Research paper thumbnail of Claim Procedure Analysis Health BPJS In Hospital

Indonesian Journal of Health Information Management, 2021

The membership administration procedure factor, the medical resume factor, the diagnosis codifica... more The membership administration procedure factor, the medical resume factor, the diagnosis codification factor and the action codification factor are still obstacles so that they are returned by the BPJS Health verifier. The purpose of the study was to determine the BPJS Health claim procedure at the hospital. Literature research or literature study and qualitative approach. Based on a review of 15 (fifteen) journals, it was found that there are still obstacles in the BPJS Health claim procedure so that the file is returned to the BPJS verifier. As in the case of membership administration procedures, medical resume factors, diagnosis codification factors, and action codification factors. which causes BPJS health files to be returned, namely the absence of Standard Operating Procedures which regulates the factors regarding the collection of documents for BPJS patient registration requirements. Components of author authentication and audit records are not appropriate because there is no...

Research paper thumbnail of Pengembangan Sistem Informasi Posyandu Terintegrasi (Sipter) DI Wilayah Puskesmas Tawang Kecamatan Tawang Kota Tasikmalaya

Posyandu adalah salah satu bentuk upaya kesehatan berbasis masyarakat yang sudah menjadi milik ma... more Posyandu adalah salah satu bentuk upaya kesehatan berbasis masyarakat yang sudah menjadi milik masyarakat serta menyatu dalam kehidupan dan budaya masyarakat. Kegiatan-kegiatan pengembangan di Posyandu saat ini tidak hanya pada kegiatan Kesehatan Ibu dan Anak, Gizi, KB saja, tapi berkembang sesuai dengan kebutuhan masyarakat setempat misalnya: Bina Keluarga Balita (BKB), Pendidikan Anak Usia Dini (PAUD), Ekonomi Keluarga, Koperasi, Keagamaan, Penyuluhan pengendalian penyakit-penyakit menular, Perilaku Hidup Bersih dan Sehat (PHBS). Hasil kegiatannya dicatat dan dilaporkan dalam format tertentu. Pada penyelenggaraannya, kader posyandu telah melakukan penyelenggaraaan pencatatan dan pelaporan, pencatatan dilakukan oleh kader segera setelah kegiatan dilaksanakan. Pencatatan dilakukan dengan menggunakan format baku sesuai dengan program kesehatan, Sistem Informasi Posyandu (SIP), selama ini dilaksanakan secara manual. Penyelenggaraan pencatatan dan pelaporan SIP manual memberikan beb...

Research paper thumbnail of Upaya Peningkatan Kemandirian Masyarakat Melalui Pembentukan Tim Penggerak Desa Sehat Penyakit Tidak Menular DI Kota Tasikmalaya

Abdimas Galuh

ABSTRAK Penambahan jumlah kasus Covid-19 berlangsung cepat, terutama gejala muncul pada pasien de... more ABSTRAK Penambahan jumlah kasus Covid-19 berlangsung cepat, terutama gejala muncul pada pasien dengan comorbid yang mengakibatkan kematian. Salah satu comorbid yaitu Penyakit Tidak menular (PTM), diantaranya DM dan Hipertensi. Tingginya kasus PTM, membutuhkan perhatian dan identifikasi sedini mungkin serta penanganan segera agar tidak berakibat fatal. Pemerintah memiliki sumber daya yang terbatas dalam pengelolaan pelayanan kesehatan. Situasi pandemi Covid-19 juga membutuhkan perhatian khusus dan sumber daya yang tidak sedikit. Oleh karena itu, pentingnya melibatkan partisipasi masyarakat untuk terlibat terutama dalam pencegahan dan deteksi dini melalui pembentukan Tim Penggerak PTM. Metode yang digunakan berupa pelatihan dan pembentukan tim penggerak PTM yang didukung dengan aplikasi Lembur Sehat PTM. Hasil pengabdian kepada masyarakat terdapat peningkatan pengetahuan dari kader dan tim penggerak setelah pelatihan. Rata-rata nilai pre test pada tim penggerak wilayah Tawang yaitu 72,67; sedangkan rata-rata nilai post test yaitu 94,67. Rata-rata nilai pre test pada tim penggerak wilayah Cibeureum yaitu 63,64; sedangkan rata-rata nilai post test yaitu 90,36. Hasil monitoring dan observasi menunjukkan kader melakukan pendataan berupa pengukuran gula darah dan tensi serta mengisi data di aplikasi Lembur Sehat PTM. Jumlah kader yang mengikuti pelatihan sebanyak 60 kader dan karang taruna. Hasil observasi pada aplikasi tercatat 600 data masyarakat yang sudah dientry. Hasil pengukuran menjadi data bagi Puskesmas setempat dan akan ditindaklanjuti. Data juga dilaporkan ke Dinas Kesehatan Kota Tasikmalaya.

Research paper thumbnail of TINJAUAN PENYEDIAAN DOKUMEN REKAM MEDIS DI RSUD Dr. SOEKARDJO KOTA TASIKMALAYA

Jurnal Manajemen Informasi Kesehatan Indonesia, Dec 17, 2015

Fast and precise services are the desire of consumers. The speed of document provision of medical... more Fast and precise services are the desire of consumers. The speed of document provision of medical records to the clinic can be an indicator in measuring satisfaction. Based on preliminary studies in dr. Soekardjo Kota Tasikmalaya found that the provision of medical record documents less than the maximum and delayed. The aim of this research is to determine the implementation of the provision of documents in the old patient medical records outpatient services. This research type is a descriptive study. Data collection used observation sheets, stopwatch, and interview guidelines. Sample size is 99 medical record documents with accidental sampling technique. The amount of sample is 99 document medical records with accidental sampling technique. Data were analyzed using univariate analysis. The results shows 63.64% late provision of medical record documents with an average time of 12.36 minutes, it exceeds the minimum standard service that is d"10 minutes. The groove of the provision of documents in the old patient medical records outpatient is 100% not appropriate. This is due to the amount of time a patient visits increased, less officer, less storage rack capacity, system alignment sequence and the absence of tracer. The conclusion is the provision of document medical record of old patients is late and the groove of the provision of documents in the old patient medical records outpatient is not appropriate. To solve those problems, it would be better if the service quality is improved, especially in the speed of medical records document provision.

Research paper thumbnail of Gambaran Effisiensi Penggunaan Tempat Tidur Ruang Perawatan Kelas III DI Rumah Sakit Umum Daerah Tasikmalaya Tahun 2011 Dan 2012

Jurnal Manajemen Informasi Kesehatan Indonesia, Mar 11, 2014

The Integrated Emergency Response System (SPGDT) is a web-based system that provides information ... more The Integrated Emergency Response System (SPGDT) is a web-based system that provides information about the availability of beds in hospitals and health centers inpatient care in Kebumen District. During this time the operators that are medical record officers in each hospital or health center input data manually into SPGDT so that data is not always updated regularly and not realtime. This study aims to develop interoperability of SPGDT so that data synchronization can be done automatically from the Hospital Management Information System (SIMRS) and the Health Center Management Information System (SIMPUS). This type of research is research and development. Needs asessment was carried out with focus group discussions (FGD) involving representatives from hospitals, inpatient health centers, health offices, and the Kebumen District Communication and Information Agency. A web service infrastructure has been developed in the form of an Application Programming Interface (API) that can be used by hospitals and health centers to synchronize data from SIMRS and SIMPUS automatically.

Research paper thumbnail of Faktor-Faktor Keterlambatan Pengembalian Sensus Harian Rawat Inap DI Rsud Kab. Ciamis

Jurnal Manajemen Informasi Kesehatan Indonesia, Dec 17, 2015

The implementation of good medical records will support the implementation of health improvement ... more The implementation of good medical records will support the implementation of health improvement services in hospital, one of them is making report based on the daily census. The return of daily hospitalizazion census to the medical record unit in RSUD Kab. Ciamis is often delayed. This research aims to know the factors of delay returns daily census of hospitalizazion to medical record unit at RSUD Kab. Ciamis. The method used in this research is qualitative method with phenomenological approach. The data collecting used interview and observation techniques in 8 informants. Data analysis is done by the data reduction, data presentation and withdrawal data conclusion or verification. Based on this research, it is known that the daily census has been delayed for two weeks, it is incompatible with the standard operating procedures (SOP) in which the daily census should have sent to the Medical Records back at least at 09.00 am the next day. The cause of the delay returns daily census is the lack of responsibility of the officer and the mismatch workload which is resulting in low productivity of labour. It is necessary for the holding of related SOP socialization census data collection daily hospitalization for officers, especially for the nurses in the implementation mechanism census daily data.

Research paper thumbnail of Kelengkapan Pengisian Formulir Laporan Operasi Kasus Bedah Obgyn Sebagai Alat Bukti Hukum

Jurnal Manajemen Informasi Kesehatan Indonesia, Mar 4, 2019

According to the Ministry of Health Decree No. 129 of 2008 concerning Minimum Standards Services ... more According to the Ministry of Health Decree No. 129 of 2008 concerning Minimum Standards Services in Hospitals, filling medical record include surgery report forms must be 100% that can be used as legal evidence. Preliminary study addressing 10surgery report form of obgyn surgery cases in December 2017 wasn't filled complete. Knowing how the implementation filling of the surgery report formof obgyn surgery cases as a legal evidence in RSUD Ciamis District Ciamis in quarter IV 2017.Methods: Descriptive with mixed method approach, a total sample is 82 surgery report forms, and the research informant is a obgyn surgeon, coordinator of administration and medical record service, and surgical nurse.The average percentage of completeness surgery report forms of the general surgery cases in the IV quarter of 2017 was 63,78%. Inhibitory factors are limited time, patient quantity, delay in medical record control, too much items filled of form. Average percentage of surgery report form filling still below the Minimum Standards Services. Hospital shouldimprove the causal factors that inhibit the incompleteness of surgery report form.

Research paper thumbnail of Kelengkapan Pengisian Formulir Laporan Operasi Kasus Bedah Obgyn Sebagai Alat Bukti Hukum

Jurnal Manajemen Informasi Kesehatan Indonesia

According to the Ministry of Health Decree No. 129 of 2008 concerning Minimum Standards Services ... more According to the Ministry of Health Decree No. 129 of 2008 concerning Minimum Standards Services in Hospitals, filling medical record include surgery report forms must be 100% that can be used as legal evidence. Preliminary study addressing 10surgery report form of obgyn surgery cases in December 2017 wasn't filled complete. Knowing how the implementation filling of the surgery report formof obgyn surgery cases as a legal evidence in RSUD Ciamis District Ciamis in quarter IV 2017.Methods: Descriptive with mixed method approach, a total sample is 82 surgery report forms, and the research informant is a obgyn surgeon, coordinator of administration and medical record service, and surgical nurse.The average percentage of completeness surgery report forms of the general surgery cases in the IV quarter of 2017 was 63,78%. Inhibitory factors are limited time, patient quantity, delay in medical record control, too much items filled of form. Average percentage of surgery report form filling still below the Minimum Standards Services. Hospital shouldimprove the causal factors that inhibit the incompleteness of surgery report form.

Research paper thumbnail of Faktor-Faktor Keterlambatan Pengembalian Sensus Harian Rawat Inap DI Rsud Kab. Ciamis

Jurnal Manajemen Informasi Kesehatan Indonesia

The implementation of good medical records will support the implementation of health improvement ... more The implementation of good medical records will support the implementation of health improvement services in hospital, one of them is making report based on the daily census. The return of daily hospitalizazion census to the medical record unit in RSUD Kab. Ciamis is often delayed. This research aims to know the factors of delay returns daily census of hospitalizazion to medical record unit at RSUD Kab. Ciamis. The method used in this research is qualitative method with phenomenological approach. The data collecting used interview and observation techniques in 8 informants. Data analysis is done by the data reduction, data presentation and withdrawal data conclusion or verification. Based on this research, it is known that the daily census has been delayed for two weeks, it is incompatible with the standard operating procedures (SOP) in which the daily census should have sent to the Medical Records back at least at 09.00 am the next day. The cause of the delay returns daily census is the lack of responsibility of the officer and the mismatch workload which is resulting in low productivity of labour. It is necessary for the holding of related SOP socialization census data collection daily hospitalization for officers, especially for the nurses in the implementation mechanism census daily data.

Research paper thumbnail of Analisis Kelengkapan Pengisian Data Formulir Anamnesis Dan Pemeriksaan Fisik Kasus Bedah

Jurnal Manajemen Informasi Kesehatan Indonesia

Quantitative analysis has conducted in dr. Slamet Garut General hospital, but there are still ana... more Quantitative analysis has conducted in dr. Slamet Garut General hospital, but there are still anamnesis and physical examination forms are incomplete both clinical data and demographic data. Based on the highest preliminary survey of incompleteness on the register component is 83.34%. The aim of this research is to know the fulfilment procedure, completeness and incompleteness data fulfilment of anamnesis and physical examination forms. The method that used in this research is observation quantitative analysis, using instrument observation sheet. The population in this research are 1008 medical record documents on semester I in 2013. The magnitude of the sample uses Slovin formula is 90 documents. Slovin formula is used because it refers to large samples which are 90 documents. The result of research showed that complete form anamnesis and physical examination of the patient identification component is 20%, important report is 31.12%, authentication is 83.33% dan the register is 3.34%. refers to the minimum standard of completeness which is submitted by the department of health (2006), the completeness document must be 100%. It can be conclusion that the anamnesis and physical examination data fulfilment in dr.

Research paper thumbnail of TINJAUAN PENYEDIAAN DOKUMEN REKAM MEDIS DI RSUD Dr. SOEKARDJO KOTA TASIKMALAYA

Jurnal Manajemen Informasi Kesehatan Indonesia

Fast and precise services are the desire of consumers. The speed of document provision of medical... more Fast and precise services are the desire of consumers. The speed of document provision of medical records to the clinic can be an indicator in measuring satisfaction. Based on preliminary studies in dr. Soekardjo Kota Tasikmalaya found that the provision of medical record documents less than the maximum and delayed. The aim of this research is to determine the implementation of the provision of documents in the old patient medical records outpatient services. This research type is a descriptive study. Data collection used observation sheets, stopwatch, and interview guidelines. Sample size is 99 medical record documents with accidental sampling technique. The amount of sample is 99 document medical records with accidental sampling technique. Data were analyzed using univariate analysis. The results shows 63.64% late provision of medical record documents with an average time of 12.36 minutes, it exceeds the minimum standard service that is d"10 minutes. The groove of the provision of documents in the old patient medical records outpatient is 100% not appropriate. This is due to the amount of time a patient visits increased, less officer, less storage rack capacity, system alignment sequence and the absence of tracer. The conclusion is the provision of document medical record of old patients is late and the groove of the provision of documents in the old patient medical records outpatient is not appropriate. To solve those problems, it would be better if the service quality is improved, especially in the speed of medical records document provision.