Penerapan Manajemen Mutu Pelayanan di Unit Rekam Medis Rumah Sakit PKU Muhammadiyah Surakarta

The presence of medical records on a hospital is very important as a source of information derived from medical records. hence the need for good quality management in penggelolaan medical record as the basis for planning and assessing the performance of the medical service units. Medical record management problems still occur in PKU Muhammadiyah Hospital Surakarta the placement of medical records clerk kompetesinya not in accordance with, then relation to the facilities and infrastructure, especially its use is still not maximal capacity filling shelves. Then Standard Operating Procedure (SOP) in the management of existing medical records, but there are some that are not in accordance with the SOP. The purpose of this research is to know how the application of quality management services at the medical records of PKU Muhammadiyah Surakarta. This is a qualitative study using a case study approach (Case Study). Key informants were selected by the researchers comprises two coordinators managing medical records and informants Triangulation consists of Unit Manager Medical Record medical records staff. and hospital management includes planning unit, a team of hospital regulation and PPSDM. Data collection using structured interview techniques. The results showed PKU Muhammadiyah Hospital has conducted the planning of the recruitment of medical records personnel, facilities and infrastructure, SOP is done properly. Monitoring of the initial planning has been on a regular basis ie daily, monthly and yearly. Identification of the problems that arise are discipline, loyalty, rigor, which exceeds the shelf filing and SOP that is not run by baik.Tindakan and solutions that have been done is getting the warning letter (SP), cutting incentives, increase shelf filing. SOP socialization periodically

Pelaksanaan Sistem Informasi Kesehatan Ibu Hamil Di Puskesmas Mojogedang II Kabupaten Karanganyar

Mojogedang II sub-district health officer Karanganyar on the implementation of maternal health information system in the process of recording data pregnant women, pregnant women data processing and reporting of health data pregnant women frequent delays. The purpose of this study was to determine how the implementation of the Maternal Health Information System at Puskesmas Mojogedang II Karanganyar. This research is a qualitative descriptive study. Informants were selected researchers amounted to 7 people consisting of six village midwife and one person as triangulation. The data analysis of this study by using data reduction, data presentation, and conclusion. The results showed that the flow of data collection implementation of maternal health starts from Midwife Practice Mandiri, village midwives and health centers KIA officer. Input data with a computer. Processing of the data is still manual by writing in the register book and the book is still shaped data summary paper. Data Reporting PWS contains 13 indicators and report cases of obstetric emergencies. The problem is the human resources officer in the process of recording, processing and reporting

Perbedaan Kelengkapan Pengisian Rekam Medis Berdasarkan Status Akreditasi Pada Puskesmas Di Wilayah Dinas Kesehatan Kota Surakarta

The completeness of medical record document becomes an important component in the accreditation assessment of puskesmas. Accreditation has a close relationship with the quality of health service facility services, so accredited status can be said as an effort to maintain the quality of health services. The better the status of the accreditation value, the higher the quality of service, including the quality of medical records at the puskesmas. This study aims to determine the differences in the completeness of medical record recording based on accreditation status at Gilingan Community Health Center with plenary accreditation status, Puskesmas Sangkrah with main accreditation status, Gambirsari Public Health Center with accreditation status and Puskesmas Pucangsawit with basic accreditation status in Surakarta City. The type of this research is qualitative quantitative combination research (mix methodology) with cross sectional research design. The population in this study were all active medical records used for patient service during the first quarter of 2018 and taken 379 medical records at Gilingan, Sangkrah, Gambirsari and Pucangsawit Public Health Centers in Surakarta City as the study sample. Meanwhile, the respondents of this study were a medical recorder, doctors and nurses at each of these puskesmas. Data analysis using Kruskal-Wallis Test. The results showed that there was a significant difference in the completeness of medical record data (p-value = 0.001) between the completeness of medical record in Gilingan Community Health Center, Sangkrah, Gambirsari and Pucangsawit. Meanwhile, the completion of medical record with the highest average rating is in Sangkrah Public Health Center and the lowest average rating is in Gilingan Community Health Center (Puskesmas Gilingan). Factor of incomplete filling of medical record at Puskesmas Gilingan, Sangkrah, Gambirsari and Pucangsawit seen from side man that is the lack of staff accuracy, the age of the officers, the time to accelerate the service, the exhaustion of the officers in serving the many patients, and the lack of knowledge of the officers, from the material side of the medical record form is less supportive, from the side of the machine is the limitation and the use of the stamp of the doctor's name is less than the maximum and the absence of the form of deficiency sheet and from the side of the method that is not yet the existence of SOP regarding the assessment of medical record completeness, not yet the implementation of the assessment of medical record completeness in medical record staff jobdes, not yet the assessment of medical record completeness and less maximal audit of medical record done

Analisis Kelengkapan Pengisian Resume Medis Pasien Hyperplasia Of Prostate Pada Dokumen Rekam Medis Rawat Inap Di Rumah Sakit Mulia Hati Wonogiri Tahun 2013

Resume medis pasien merupakan formulir dalam suatu dokumen rekam medis yang harus diisi lengkap. Berdasarkan hasil survey di Rumah Sakit Mulia Hati Wonogiri terdapat ketidaklengkapan dalam pengisiannya. Tujuan Penelitian adalah menganalisis kelengkapan resume medis pasien hyperplasia of prostate pada dokumen rekam medis rawat inap di Rumah Sakit Mulia Hati Wonogiri tahun 2013. Jenis penelitian menggunakan deskriptif dengan rancangan penelitian retrospektif. Populasi penelitian ini adalah resume medis pada dokumen rekam medis pasien rawat inap di RS Mulia Hati sebanyak 83 dokumen. Teknik pengambilan sampel menggunakan sampling jenuh. Hasil penelitian menunjukkan kelengkapan terbanyak pada review identifikasi dokumen rekam medis yang diisi pada item nama sebesar 34 DRM (41%) dan umur sebesar 34 DRM (41%). Review pelaporan yang penting yang diisi pada item diagnosa masuk sebesar 58 DRM (70%), diagnosa akhir sebesar 58 DRM (70%), operasi sebesar 53 DRM (64%), dan ringkasan riwayat sebesar 35 DRM (42%). Review otentikasi nama dokter sebesar 47 DRM (57%). Review pendokumentasian yang benar pada pencatatan jelas dan terbaca sebesar 53 DRM ( 64%)

Penerapan Sistem Informasi Manajemen Puskesmas (Simpus) GizKIA Berbasis Komputer Di Puskesmas Karangdowo Klaten

Nutrition SIMPUS KIA (SIMPUS GizKIA) is one application module is intended to help manage the data of pregnant women and babies / toddlers so that the data obtained are valid and accurate. One of the constraints on the management of input data that have been saved can not be edited again thus increasing the workload of midwives. The purpose of this study to determine the Primary Health Care management information system (SIMPUS) GizKIA-based computer in the Primary Health Care Karangdowo Klaten. This type of research is qualitative descriptive study. The population in this study were 20 people from health professionals. The informants are 4 midwives and 4 informants as triangulation using purposive sampling technique. The data in this study is qualitative data in the form of direct interviews with informants. The results of research that flow from the data collection activities of midwives are recorded in advance in the cohort and also PWS KIA, then input by midwives using laptops equipped with offline applications SIMPUS GizKIA. Midwives coordination recapitulate data maternal and child health from 19 villages. Reports are sent to the District Health Office is the recapitulation of maternal and child health. The obstacles are there at the time of data entry, data processing and reporting of data

Manajemen Surveilans Epidemiologi Penyakit Potensi Kejadian Luar Biasa (KLB)Di Dinas Kesehatan Kabupaten Karanganyar Tahun 2014

Epidemiological surveillance is an activity analysis systematically and continuously against the diseases and conditions that affect the increase and spread of diseases or health problems. The accuracy and completeness of epidemiologic surveillance report delivery is an important factor related to the accuracy of the data. The purpose of this study was to determine the process of recording data, data processing, reporting and feed back reporting of epidemiological surveillance of disease outbreaks in DKK Karanganyar potential. This research is qualitative. The study population was a village midwife, health centers Surveillance Officer, Surveillance Officer and Head of Karanganyar DKK DKK P2PL Karanganyar. The results showed the recording and reporting of potential disease outbreaks epidemiological surveillance carried out every day, every week and every month reported by the village midwife Surveillance Officer Health Center reported to DKK Karanganyar then subsequently reported to the Provincial Health Office. Data processing carried out by a surveillance officer DKK Karanganyar. Feed back reporting to follow up depending on size of the problem, widespread problem, the number of cases, and the type of case. The conclusions of this study is the implementation of epidemiological surveillance management of potential disease outbreaks in DKK Karanganyar still experiencing delays in the collection of surveillance data

Pengaruh Beban Kerjacoder Dan Kelengkapan Informasi Penunjang Terhadap Keakuratan Code Rawat Inap Bpjs Di Rspau Dr.S Hardjolukito Yogyakarta

A limited number of officers coder with a high workload lead coder work less effective. Completeness Supporting Information is one of the important things for officers coder to determine the primary code and a secondary code. The purpose of this study was to determine the effect of workload coder and completeness of the information supporting the accuracy of code on a medical record file BPJS patient hospitalization. This type of research is observational. The study design approach time series (data series of the time). while the analysis of data using multiple linear regression. Object of this research is the Medical Record file. The collection of data by observation. Results of this study indicate In Partial there is significant influence between the workload for the accuracy of the code on the value of p = 0.001, partial no pengarauh significantly between the completeness of supporting information to keakuratn code with p = 0.466, no effect simultaneously between workload and completeness of the information supporting the accuracy of the code on the value of p = 0.001

Analisis Pecatatan Kesehatan Ibu Hamil pada Buku Kia dalam Memonitor Kehamilan di Fasilitas Kesehatan Wilayah Kerja Ibi Ranting Ngemplak Boyolali

Masih banyak ditemukan kesalahan dalam pencatatan kesehatan ibu hamil pada buku KIA yang berakibat terjadinya ketidaklengkapan pada buku KIA sehingga menyulitkan bidan dalam mengambil keputusan yang tepat dalam memonitor kesehatan ibu hamil. Tujuan penelitian adalah menganalisis pencatatan kesehatan ibu hamil pada buku KIA dalam memonitor kehamilan difasilitas kesehatan wilayah kerja IBI ranting ngemplak boyolali. Metode penelitian ini menggunakan rancangan penelitian deskriptif kualitatif. Populasi dalam penelitian ini terdiri dari 2 populasi, Populasi objek adalah buku KIA dan populasi Subjek terdiri dari semua anggota IBI Ranting Ngemplak Boyolali dan ibu hamil/pasien. Pengambilan sampel dilakukan secara purposive sampling. Uji validitas dilakukan dengan triangulasi. Hasil penelitian menunjukkan pencatatan kesehatan ibu hamil dibedakan berdasarkan dari status pasien baru dan pasien lama. Ketidaklengkapan pada catatan kesehatan ibu hamil buku KIA ada 2 faktor yaitu dari bidan dan dari ibu hamil/ pasien. Informasi yang terdapat pada catatan kesehatan ibu hamil pada buku KIA digunakan untuk proses tindakan selanjutnya, seperti perencanaan, penyuluhan, pengawasan dan pemantauan, selain itu merupakan dokumen resmi yang berifat hukum yang dapat digunakan dalam administrasi, rujukan, pendidikan dan penelitia

Hubungan Kelengkapan Informasi Dengan Persetujuan Klaim Bpjs Di RSUD Kabupaten Sukoharjo Tahun 2016

Completeness of medical record documents is very important. Medical record serves as proof of valid owned by each patient and legally defensible. Therefore, a complete medical record must be filled out completely and clearly about all the services provided to patients. Incomplete diagnosis codes / actions which contains the medical records of patients will affect the process of determining the claims BPJS. Preliminary studies indicate that they found a 5-7 document medical records have failed to claim every day although already qualified to the verifier, but still there is the possibility of having failed to claim support for attachment file is not complete. This study aimed to analyze the relationship between the completeness of the information in the medical record documents with the consent of claims BPJS in Sukoharjo District Hospital. The study was observational with cross sectional approach. The population in this study is a document medical records of patients hospitalized nonsurgical april dependents BPJS in Sukoharjo District Hospital. The research sample as many as 138 documents specified by consecutive sampling technique. The research instrument is a checklist sheet. Research data analysis using Chi Square. The results showed a significant relationship completeness of the information with the consent of the patient claims BPJS in Sukoharjo District Hospital with a value of p = 0.001

Analisis Pelaksanaan Pendokumentasian Data Pemantauan Status Gizi Balita di Posyandu Sedap Malam Wilayah Kerja Puskesmas Colomadu I Tahun 2013

Pemantauan status gizi balita dilakukan dengan melihat catatan Kartu Menuju Sehat dan catatan register anak balita. Tujuan penelitian adalah menganalisis pelaksanaan pendokumentasian status gizi balita di Posyandu Sedap Malam. Metode penelitian ini menggunakan rancangan penelitian deskriptif kualitatif. Populasi dalam penelitian ini terdiri dari 2 populasi, yaitu populasi objek dan populasi subjek. Populasi objek nya adalah data pemantau status gizi balita yang terdapat di Posyandu Sedap Malam. Populasi Subjek terdiri dari 3 bidan dan 9 kader yang bertugas di Posyandu Sedap Malam. Pengambilan sampel dilakukan secara purposive sampling yang terdiri dari 3 bidan dan 3 kader Posyandu Sedap Malam. Uji validitas dilakukan dengan triangulasi. Hasil penelitian menunjukkan bahwa proses pengisian data pemantau status gizi balita masih kurang lengkap. Ketidaklengkapan merupakan kekeliruan petugas yang menganggap beberapa item data pemantau status gizi balita hanya dijadikan informasi data penunjan