Audit Rekam Medis dalam Upaya Peningkatan Kualitas Pengisian Rekam Medis di RSUD Sleman

A hospital is a health service institution that provides complete individual health services for inpatient, outpatient, and emergency care. Hospitals as health service providers are required to maintain medical records. The administration of medical records for each hospital refers to the Regulation of the Minister of Health of the Republic of Indonesia. A medical record audit is needed to determine the completeness of data in medical records both in quantity and quality. The purpose of this study was to determine the medical record audit at RSUD Sleman. The type of research used is analytic observational with a cross-sectional study design. This research was conducted at RSUD Sleman, Special Region of Yogyakarta. The research was done from April to October 2022, during a period of 7 months. Simple random sampling was used to collect data from 94 medical records. The audit of 94 samples of medical records resulted in the following findings: completeness, patient identity 100%, professional identity in providing care 99.01%, date and time 70.21%, initial assessment 90.42%, subjective examination 98.84%, objective examination 66.01%, management plan 91.49%, clinical pathology examination 58.51%, radiological examination 75.53%, primary diagnosis 100%, secondary diagnosis 100%, and general agreement 100%. The lowest percentage of 58.51% was obtained for incomplete data

Studi Kasus Pelayanan Rekam Medis pada Masa Pandemi Covid-19 Di Puskesmas Gondokusuman II Kota Yogyakarta

The Covid-19 outbreak has been declared as a public health emergency of international concern by the World Health Organization (WHO). The pandemic has also changed the process of health services provided to patients, including medical record services. This study aimed to examine the process of medical record services at the Gondokusuman II Primary Health Center (PHC) in Yogyakarta City during the Covid-19 pandemic. This qualitative research explored medical record services during pandemics. Three staff were recruited as respondents using the purposive sampling technique. Data were collected through observation and interviews. There were differences in patient registration services before and after the pandemic. Before registering, patients will be screened first. If they show Covid-19 symptoms, the patients are directed to the infectious clinic and the provision of medical records will be prioritized. To support the implementation of health protocols, the primary health center provides personnel protective equipment adequately. However, the reference for health protocols related to medical record services at the PHC level is not yet available. So, reference issued by the Ministry of Health is used respectively. Therefore, specific regulations need to be immediately compiled and disseminated to ensure that the prevention of Covid-19 transmission can be carried out more precisely

Penerapan Sistem Data Cleansing untuk Mencegah dan Menghilangkan Duplikasi Rekam Medis

Sistem Informasi Kesehatan adalah sistem yang mengintegrasikan pengumpulan, pengolahan, pelaporan data, dan penggunaan informasi yang diperlukan untuk  meningkatkan efektivitas dan efisiensi pelayanan kesehatan melalui pengelolaan yang lebih baik pada semua tingkat layanan kesehatan. Dinas Kesehatan Kulon Progo merupakan salah satu Dinas Kesehatan yang telah memanfaatkan Sistem Informasi Kesehatan dalam penyelenggaraan transaksi kesehatan. Namun, implementasi Sistem Informasi Kesehatan masih memiliki kekurangan, yaitu ditemukan data seorang pasien yang memiliki banyak nomor rekam medis atau sering disebut duplikasi data rekam medis. Kegiatan pengabdian kepada masyarakat ini dilaksanakan dengan memanfaatkan teknologi tepat guna di Dinas Kesehatan Kulon Progo. Kegiatan ini bertujuan untuk mengimplementasikan teknik data cleansing dengan framework “RESIK” untuk membantu dalam pencegahan dan mendeteksi duplikasi rekam medis serta memberikan pelatihan kepada tenaga perekam medis perihal penerapan sistem data cleansing. Pelatihan diikuti oleh 105 peserta yang masing-masing merupakan perwakilan pegawai puskesmas di wilayah Dinas Kesehatan Kulon Progo. Framework “RESIK” selanjutnya diujicobakan di Puskesmas Sentolo 2 sebagai lokasi implementasi sistem. Dalam kegiatan ini ditemukan data rekam medis yang duplikat di Puskesmas Sentolo 2. Pembersihan kemudian dilakukan. Pihak Dinas Kesehatan Kulon Progodisarankan untuk mengimplementasikan data cleansing dengan framework “RESIK” di seluruh puskesmas di wilayah Kulon Progo

PENGEMBANGAN SISTEM INFORMASI SURVEILANS PROGRAM KESEHATAN IBU DAN ANAK BERBASIS DHIS2 (DISTRICT HEALTH INFORMATION SOFTWARE 2)

Indonesia masih menetapkan bahwa masalah kesehatan ibu dan anak (KIA) sebagai program prioritas yang harus diselesaikan karena angka kematian ibu (AKI) dan angka kematian bayi (AKB) belum memenuhi standar indikator. Sistem surveilans KIA belum terintegrasi sehingga data dan informasi yang dihasilkan juga belum bisa dimanfaatkan secara maksimal untuk mendukung pengambilan keputusan terhadap masalah KIA. Tujuan penelitian ini yaitu merancang dan mengembangkan sistem informasi surveilans program KIA berbasis DHIS 2. Jenis penelitian adalah action research dengan mengikuti langkah-langkah protoyping dalam mengembangkan sistem informasi surveilans program KIA berbasis DHIS 2 (District Health Information Software 2). Penelitian dilaksanakan pada bulan Agustus 2019 - Februari 2020 di Puskesmas Kabupaten Kulon Progo. Subjek penelitian ini yaitu Petugas KIA Puskesmas sebanyak 6 orang yang ditentukan berdasarkan purposive sampling. Objek penelitian ini adalah sistem informasi surveilans KIA. Prototipe sistem informasi surveilans program KIA berbasis DHIS 2 telah melalui tahap identifikasi kebutuhan, desain sistem, implementasi, dan pengujian. Hasil uji coba sistem membuktikan bahwa pengguna dapat menerima sistem tersebut dan sistem berjalan dengan baik. Sistem informasi surveilans program KIA berbasis DHIS 2 sudah berhasil dikembangkan dan diterima oleh pengguna. Oleh karena itu, pihak puskesmas disarankan agar mengimplementasikan sistem ini dalam kegiatan surveilans KIA

The Implementation of Spatial Weighted Regression on Detecting the Risk Factors of Malaria Incidences In Kulonprogo District

Malaria suffers a public health problem, caused by Plasmodium parasites. This disease is naturally transmitted through the bite of female Anopheles mosquitoes. Kulonprogo Regency is one of the malaria endemic areas that needs to be developed to combat malaria. This research aims to describe the distribution of malaria cases to determine vulnerable areas in Kulonprogo Regency. This research was an observational analytic with cross sectional design conducted between April and October 2018, based on a sampling of 62 malaria cases. Data analysis was performed using a Geographic Information System approach with overlay, buffer, cluster techniques, and spatial weighted regression. Based on the results of the partial analysis, it was found that 62 cases of malaria spread in 6 sub-districts namely: Kokap, Pengasih, Samigaluh, Kalibawang, Wates and Sentolo. The distribution of malaria cases clustered in Kokap Sub District, namely in Kalirejo Village (29 cases) and Hargorejo Village (9 cases). The overlay and buffer techniques found that the distribution of cases spread in Menoreh hills which have forest vegetation. Malaria-prone areas in Kulonprogo Regency were found in Kalirejo Village and Hargorejo Village through the results of spatial analysis using a Geographic Information System approach. Thus, malaria control efforts were focused on these vulnerable areas

ANALISIS KESIAPAN PENERAPAN SISTEM INFORMASI SURVEILANS DEMAM BERDARAH DENGUE

Abstrak Demam Berdarah Dengue (DBD) merupakan penyakit menular akibat virus dengue yang ditularkan melalui gigitan nyamuk Aedes aegypti dan sering menimbulkan outbreak pada daerah beriklim tropis khususnya Indonesia. Keseriusan masalah ini bisa diatasi melalui sistem informasi surveilans dengan memanfaatkan teknologi informasi. Surveilans selama ini dilakukan secara manual (paper-based) yang menimbulkan permasalahan seperti keterlambatan pelaporan, data tidak up to date serta penyajian informasi yang kurang informatif dalam mendukung pengambilan keputusan. Langkah awal dalam menerapkan sistem informasi surveilans DBD yaitu menganalisis kesiapan pengguna agar implementasi sistem berjalan efektif dan efisien dan berdampak signifikan pada penurunan angka kejadian DBD. Penelitian ini bertujuan untuk menganalisis kesiapan penerapan sistem informasi surveilans DBD menggunakan instrument DOQ-IT (Doctor’s Office Quality – Information Technology). Jenis penelitian ini adalah kuantitatif dengan desain cross-sectional. Penelitian dilaksanakan pada bulan April – Oktober tahun 2020 di Puskesmas Gondokusuman II Kota Yogyakarta. Subjek penelitian sebanyak 6 orang yang terdiri dari petugas surveilans, programmer DBD dan kader kelurahan. Obyek penelitian yaitu sistem informasi surveilans DBD. Pengumpulan data menggunakan kuisoner, observasi dan studi dokumentasi. Hasil penelitian menemukan bahwa angka kesiapan penerapan sistem informasi surveilans DBD berada dalam kategori cukup siap dengan total nilai 47.75. Perolehan rata-rata skor dari masing-masing variabel yaitu variabel sumber daya manusia dengan skor 2.125, budaya organisasi dengan skor 1.87, tata kelola kepemimpinan dengan skor 1.86 dan infrastruktur dengan skor 1.38. Kesimpulan dari penelitian ini adalah Puskesmas Gondokusuman II berdasarkan hasil pengukuran dengan instrumen DOQ-IT (Doctor’s Office Quality – Information Technology) memiliki kemampuan yang baik pada komponen sumber daya manusia, namun juga terdapat beberapa kelemahan pada komponen budaya kerja organisasi, tata kelola kepemimpinan dan infrastruktur. Oleh karena itu, diperlukan identifikasi dan antisipasi lebih lanjut pada komponen yang lemah agar implementasi sistem informasi surveilans berjalan baik. Kata kunci: Analisis Kesiapan, Demam Berdarah Dengue (DBD), Sistem Informasi Surveilans  Abstract Dengue Hemorrhagic Fever (DHF) is a contagious disease caused by dengue virus and often causes outbreaks in tropical climates, especially Indonesia. This problem can be solved through surveillance using information technology. During this time, surveillance was doing manually (paper-based) which caused problems such as reporting delay, data not up to date and uninformative presentation for decision making. The first step in implementing DHF surveillance information system is analyze the user readiness so the system implementation runs effectively and efficiently and has significant impact on reducing incidence of DHF. This study aims to analyze the readiness to implement a dengue surveillance information system using the DOQ-IT (Doctor's Office Quality - Information Technology) instrument. This type of research is quantitative with a cross-sectional design. The research was conducted in April – October 2020 at Puskesmas Gondokusuman II, Yogyakarta. The research subjects were 6 people consisting of surveillance officers, DHF programmers, and village cadres. The research object is the DHF surveillance information system. Data collection techniques using questionnaires, observation, and documentation studies. The results of the study found that the readiness for the implementation of the DHF surveillance information system was in the ready category with a total score of 47.75. The average score obtained from each variable is the human resources variable with a score of 2.125, organizational culture with a score of 1.87, leadership governance with a score of 1.86, and infrastructure with a score of 1.38. This study concludes that Puskesmas Gondokusuman II based on the results of measurements with the DOQ-IT (Doctor's Office Quality – Information Technology) instrument has good capabilities in the human resource component, but there are also some weaknesses in the components of organizational work culture, leadership governance, and infrastructure. Therefore, further identification and anticipation of weak components are needed so that the implementation of the surveillance information system runs well. Keywords: Readiness Assessment, Dengue Hemorrhagic Fever, Surveillance Information System 

Tinjauan Pelaksanaan Penyusutan dan Pemusnahan Rekam Medis di RSUD Muntilan

Medical records are crucial documents in a hospital's patient care. Long-term use of paper-based or conventional medical records might result in issues including misfiles, disorganized shelves, and limited storage space. As a result, it's important to implement a procedure for the retention, elimination, and destruction of medical record files in order to eliminate useless files, decrease the growth in the number of files, and maintain the standard of medical record services. This study aims to evaluate the 5 M (Man, Money, Method, Material, and Machine) components of the process of eliminating and destroying medical record files at RSUD Muntilan. The object of research is medical record files, storage facilities, storage, implementation, and destruction of medical files. The method used in this study is a qualitative method through data collection by observation and interviews with medical record officers. The research was carried out at the Muntilan Hospital from June to July 2022.  Based on the research that has been done, the process of implementing and destroying medical records is in accordance with applicable procedures and the regulation of the Ministry of Health No. 269 of 2008.Medical records are crucial documents in a hospital's patient care. Long-term use of paper-based or conventional medical records might result in issues including misfiles, disorganized shelves, and limited storage space. As a result, it's important to implement a procedure for the retention, elimination, and destruction of medical record files in order to eliminate useless files, decrease the growth in the number of files, and maintain the standard of medical record services. This study aims to evaluate the 5 M (Man, Money, Method, Material, and Machine) components of the process of eliminating and destroying medical record files at RSUD Muntilan. The object of research is medical record files, storage facilities, storage, implementation, and destruction of medical files. The method used in this study is a qualitative method through data collection by observation and interviews with medical record officers. The research was carried out at the Muntilan Hospital from June to July 2022.  Based on the research that has been done, the process of implementing and destroying medical records is in accordance with applicable procedures and the regulation of the Ministry of Health No. 269 of 2008

ANALISIS SPASIAL DAN FAKTOR RISIKO KEJADIAN FILARIASIS DI KABUPATEN PASAMAN BARAT TAHUN 2012

Kelompok berisiko filariasis adalah orang yang berada atau tinggal di sekitar penderita filariasis. Hal ini berkaitan dengan kemampuan terbang nyamuk yang dapat menularkan cacing filaria dari penderita filariasis ke orang sehat. Berdasarkan penelitian Jontari (2008) mengenai analisis spasial faktor – faktor risko kejadian filariasis di Kabupaten Agam ditemukan bahwa faktor risiko terkuat yaitu keberadaan tempat tinggal dekat (< 500 m) dari lingkungan perkebunan kelapa sawit. Hal ini berarti bahwa secara spasial orang yang bertempat tinggal di sekitar perkebunan kelapa sawit lebih berpeluang terkena penyakit filarisis dibandingkan dengan orang yang tidak tinggal di sekitar perkebunan kelapa sawit.3, 19 Pemetaan sebaran penyakit secara epidemiologi penting dilakukan khususnya pemetaan persebaran penyakit menular dan penyakit infeksi. Dengan menggunakan anlisis spasial bukan hanya mengetahui pola distribusi penyakit, wilayah berisiko tinggi dan faktor risiko penyakit secara kewilayahan tetapi untuk penemuan penyebab atau sumber penularan penyakit sehingga upaya pengendalian dan pemutusan mata rantai penyakit dapat dilakukan dengan tepat. Namun sangat disayangkan penelitian analisis spasial khususnya filariasis belum banyak dilakukan khususnya di Indonesia. Di Kabupaten Pasaman Barat hingga tahun 2011 distribusi keberadaan lokasi pasti tempat tinggal penderita dan pola penyebaran filariasis di Kabupaten Pasaman Barat belum diketahui secara pasti, sehinggga berdasarkan latar belakang yang telah dipaparkan peneliti tertarik untuk meneliti lebih lanjut dengan menggunakan anlisis spasial (Sistem Informasi Geografis) faktor risiko kejadian filariasis di Kabupaten Pasaman Barat. Dengan harapan diketahui intervensi yang tepat untuk pengambilan keputusan, pemutusan mata rantai dan pengendalian penularan penyakit filariasis