EVALUASI MANAJEMEN DOKUMEN REKAM MEDIS DI FILING AKTIF RUMAH SAKIT SWASTA KABUPATEN SEMARANG

Missfile can inhibit medical services provided to patients without information about history. From the initial survey, it found 90 missile incidents (4.7%) from 2000 medical record documents, the second survey found 578 incidents from 7000 medical record documents with 9.0% missfile. This study aims to identify the medical records management in the outpatient filing section of The Private Hospital, Semarang Regency in 2019. This research is a mix methode study. Data collection by observation and interview methods with a cross-sectional approach. The research subjects were 3 filing officers. The research objects to the management of medical record documents in the outpatient filing section. The research instrument used in this research were interview and observation guidelines.The number of polyclinics at The Private Hospital in Semarang Regency is 20 polyclinics. There should be a submission terminal so staff will not be tired. The hospital management facilities were adequate but have not been properly utilized by the officers, the officers should use these facilities to facilitate document tracking. The Hospital should make a policy regarding the management of medical record documents and use colour codes on the documents so that the staff can understand and carry out their duties properly.Key Word : medical record management, storage systems, management standard

Analisis Prosedur Penyusutan Dokumen Rekam Medis di Puskesmas Rawat Inap di Kota

Public Health Center (PHC) is a central health development in its working area. The orientation of PHC is the patient safety, so medical records have to be kept safely in the appropriate order. Therefore, medical record documents can be traced easily and quickly. For maintaining medical records documents in a particular numbers in the spaces, it needs medical record documents retention to reduce the burden of storage and workload of file officer, that is associated with patient’s medical record documents tracking speed. There were some medical record documents missfile incidences due to stacking file.The research desain was a case study with cross sectional approach. Data was collected by  observation and interviews and analyzed by descriptive analysis. The result showed that the numbering system that applied on the patient’s family folder was Unit Numbering System (UNS). Generally, PHCs implemented Terminal Digit Filing (TDF) system, but Puskesmas Tlogosari Kulon still applied Straight Numerical Filing (SNF). The retention system was decentralization, while Tlogosari Kulon implemented centralized. The retention of medical record documents was not scheduled routinely and there was no documentation. Several PHCs did not perpetuate medical record documents as regulated on The Permenkes Nomor 269/Menkes/PER/III/2008. Medical record documents retention required the disease index, patient index, standard operating procedure, record retentions schedules and documentation. In addition, it needs to reform the medical record documents management to facilitate the implementation of retention system.Keywords: medical record document, retention, public health center (PHC

STANDAR PENYUSUTAN DOKUMEN REKAM MEDIS DI PUSKESMAS KEDUNGMUNDU KOTA SEMARANG TAHUN 2019

Public Health Center (PHC) is a central development in the working area. Its orientation is the safety of the patient. For it takes depreciation medical record documents to reduce the burden of storage and workload file clerk. Therefore, medical record documents more easily and quickly traceable.It is associated with patient’s medical record documentstracking speed. Result for The PHC obtained their medical record documents missfile accident due to stacking file. The research desain is a case study. Cross sectional approaching with observation and interviews as the method of collecting data. Processing data using collecting, editing, and tabulating. Then the data were analyzed descriptively. Generally, numbering system with applied to the patient’s family health centers folder is Unit Numbering System (UNS). PHC, in general, already implementing Terminal Digit Filing (TDF) alignment system, but in Puskesmas Kedungmundu still apply Straight Numerical Filing (SNF). The retention system is decentralization. While Puskesmas Kedungmundu peciathas implemented centralized. Depreciation medical record documents has not been routinely performed and without documentation. Several PHC even do not perpetuate medical record documents as regulated on The Permenkes Nomor 269/Menkes/PER/III/2008. Medical record documents depreciation required the disease index, patient index, standard operating procedure, record retentions schedules and documentation. In addition, need to reform the medical record documents management to facilitate the implementation of depreciation. Keywords : medical record document, depreciation, public health cente

ANALISIS DESAIN FORMULIR KARTU PENGOBATAN PENCEGAHAN TB (TB 01 P) UNTUK KELENGKAPAN DATA DI PUSKESMAS TAHUN 2019

Tuberculosis is an infectious disease which becomes a global problem. The increase in TB case is caused by inadequate monitoring of treatment, unavailability of standardized recording and reporting system. This research was conducted to evaluate the completeness TB form design in providing more complete information. This research was administered in the form of a case study. Interviews were done to 3 nurses and 1 doctor and TB Form (TB.01P) was observed at Miroto Health Center. The completeness of 33 TB form filling (TB.01P) at the Malmahera Health Center was also evaluated. The obtained data were descriptively analyzed. The results showed the completeness of identification review reached 96%, recording review of 90%, reporting review of 64%,and 0% for authentication review. Incomplete information led to inaccurate TB control information. This incompleteness was associated toimproper design of the form, especially the unavailability of form filling instructions, names and signatures of officersin the anatomic aspect. In the aspect of content, lack of clinical data was also found. Regarding to the results of this research, revision in the design of TB Treatment and Prevention Card is needed in order to accommodate the data completeness of TB patients. This research also proposed a better design of TB Treatment and Prevention Card Keywords : Quantitative Completeness, Tuberculosis, Form Design, TB Treatment Card (TB.01P)

HUBUNGAN ANTARA PERSEPSI WANITA YANG MENIKAH DINI (< 20 TAHUN) TENTANG PERAN PETUGAS KESEHATAN DENGAN USIA MENIKAH WANITA DI DESA KEBUMEN KECAMATAN TERSONO KABUPATEN BATANG 2011

Pernikahan dini terjadi karena kurangnya pengetahuan tentang kesehatan reproduksi. Masalah di Desa Kebumen, Kecamatan Tersono adalah meningkatnya jumlah perempuan muda yangtelah menikah sebelum berusia 20 tahun. Pada tahun 2009, ada 8 wanita yang menikah sebelum usia 20 tahun. Tahun 2010 menjadi 19 orang dan tahun 2011 sebanyak 31 orang. Penelitian ini adalah untuk mengetahui hubungan antara persepsi wanita tentang peran petugas kesehatan dalam kesehatan reproduksi dengan usia pernikahan.Tujuan penelitian ini adalah penelitian Explanatory dengan metode Cross Sectional. Data diperoleh dengan mewawancarai 30 perempuan yang menikah sebelum 20. Uji Chi Square digunakan untuk menganalisis data.Hasil penelitian menunjukkan bahwa wanita memiliki persepsi negatif pada petugas kesehatan (60 %) dan berpikir bahwa petugas tidak berbagi informasi tentang konsekuensi biologis(50,0%), tidak pernah berbagi konsekuensi psikologis pernikahan dini (46,7%), tidak pernah memberikan informasi tentang dampak perilaku seksual jarang (46,7%), tidak pernahmemberikan dampak ekonomis karena pernikahan dini (56,7%), dan tidak pernah berbagi informasi tentang dampak pernikahan dini terhadap bayi (53,7%). Sebagian besar responden menikah pada usia dini (usia 13-18 tahun) sebanyak 76,7%. Tidak ada korelasi antara peran petugas kesehatan dengan usia perkawinan (p value 0.392 > 0,05 ).Dari hasil tersebut, disarankan agar petugas kesehatan memberikan informasi tentang kesehatan reproduksi bagi perempuan yang menikah sebelum usia 20 tahun sehingga para wanita akan memiliki informasi yang tepat tentang usia yang direkomendasikan untuk menikah dan punya anak.Kata kunci : Peran petugas kesehatan, usia pernikaha

PERAN PENANGGUNG JAWAB REKAM MEDIS (PJRM) UNTUK PENINGKATAN KETEPATAN KLAIM BPJS PASIEN RAWAT INAP DI RSUD KRMT WONGSONEGORO (RSWN) KOTA SEMARANG

Medical Record Document (MRD) guarantees patient safety. Besides, it related to claim accuracy to BPJS (Badan Penyelenggara Jaminan Sosial) as patient health insurance operator. In fact, from the survey conducted with 15 inpatients as the subjects, 10 MRD approved (approximately 66.67%) and the other 5 MRD or about 33.34% rejected. This happened as the consequences of whether supporting examination result which is not being submitted on 2 MRD (40%), 1 MRD or 20% hold incomplete BPJS document and other 40% caused by the inaccurate operation code in MRD. Hence, the aim of this study is to analyze the role of Person In Charge in Medical Record Department to improve MRD comprehensiveness to reach BPJS claim accuracy.The type of this study is qualitative with cross-sectional approach. Primary and secondary source observation and interview are used in collecting data. Purposive sampling with four interviewees from Person In Charge in Medical Record Department, and as the main interviewee is the head of Medical Record Department also one employee of BPJS Rumah Sakit Wongsonegoro as the triangulator.So, the main function of assembling employee is to ensure the quality of Medical Record Document (MRD), quantitatively and qualitatively. Whereas, RSWN already applied Person In Charge of Medical Record Department with concurrent analysis in controlling MRD comprehensiveness concept. According to observational result of 15 inpatients, found incomplete MRD, 13% occurs in identity section, also 13% each found both in recording and reporting. While, the authentication completes 100%. From consistency analyzing result discovered inconsistency recording about 13%. Main diagnose and inform consent recording reached 100% in consistency and 0% things that can cause loss.That is, the role of Person In Charge in Medical Record of inpatient unit needs yo be improved. The main and assembling function performs by PIC in Medical Record is both coding and indexing. Input standard, Standard Operational Procedures (SOP) and minimum services standard are already available and applied to control PIC in Medical Record performance quality. However, input, process and the output are not focus in controlling MRD comprehensiveness yet, especially in BPJS participant patient. So that, to control BPJS inpatient MRD quality, needs operational standard in methods and comprehensiveness control procedures, considered with PIC in Medical Record also performing ICD code and Medical Record Document quality requires coordination of all parties.The researchers suggest to add more points in controlling incomprehensiveness BPJS Medical Record Document procedures. Furthermore, enhance input in standard structure, operational job description in Standard Operational Procedure, also minimum services standard comprehensiveness which applied has to be reached 100% qualitatively and quantitatively.Keywords: PIC in Medical Record, BPJS claim, quantitative comprehensiveness, qualitative comprehensivenes

Sistem Pendukung Keputusan Penyesuaian Nutrisi Makanan Berdasar Rekam Medis Pasien Berbasis Forward Chaining

Fulfilling nutrition for patients certainly does not only pay attention to the last illness they suffered, but nutritionists also need to pay attention to the patient's medical history. Providing certain foods to support the body's recovery after treatment for certain diseases may not necessarily be in accordance with the history of previous illnesses. Fulfilling nutritional intake according to certain disease conditions is not easy, especially if the patient has a medical history with a variety of diseases, so nutritionists need to be more selective in providing nutritional intake from a number of alternative foods that will be provided. A management decision system based on artificial intelligence is able to choose a food balance that is balanced with the various complaints experienced by patients. The method used in the food management information system for medical records uses the forward chaining method, namely by determining forward, in this case, food nutritional information that is suitable for the patient, by reading the facts that have been arranged as a representation to produce a conclusion. The accuracy value resulting from comparing manual nutrient selection and using forward chaining was 86

PENERAPAN METODE PROFILE MATCHING UNTUK MANAJEMEN EVALUASI TUMBUH KEMBANG ANAK

Evaluasi tumbuh kembang pada anak penting dilakukan agar apabila terjadi penyimpangan pertumbuhan dapat segera dilakukan intervensi sejak awal sehingga dapat meminimalisir kelainan yang mungkin terjadi. Pada anak usia dini perlu dilakukan evaluasi setiap bulan yaitu untuk anak usia 12-72 bulan dan enam bulan sekali untuk anak usia 12-72 bulan. Dalam pelayanan kesehatan berfungsi untuk mengevaluasi tingkat kesehatan anak, namun untuk evaluasi anak di sekolah berguna untuk mengetahui kekuatan dan kelemahan komponen tumbuh kembang aspek kognitif, afektif, psikomotorik. Beberapa cara yang digunakan untuk mengevaluasi adalah dengan tes, pengukuran dan penilaian. Pengukuran sering digunakan untuk menilai jenis nilai sikap (afektif), misalnya kesediaan untuk berbagi dengan sesama teman. Evaluasi dalam bentuk tes digunakan untuk tipe kognitif dan penilaiannya lebih pada evaluasi tipe psikomotorik. Metode yang digunakan adalah profile matchin

Management of Medical Record Unit Services for Covid-19 Patients in Type C Hospitals: A Study of Legal Aspects.

Background:&nbsp;The impact of the pandemic on medical record health service procedures has induced significant changes. The duplication of Covid-19 patient numbers in the patient medical record unit is an important concern. This study aims to analyze the legal aspects of managing medical record services during the Covid-19 pandemic in hospitals. Methods:&nbsp;This type of research is descriptive and quantitative with a cross-sectional approach. The key informants are 15 registration and medical record unit officers, using online interview techniques, employed in three hospitals in Semarang with a focus on group discussions. The object of research includes the management of medical records and service standards for Covid-19 patients as regulations in the medical record unit of the Semarang city general hospital. Results:&nbsp;Policies and standards for medical record services for Covid-19 patients, have not been adjusted to the provisions based on Circular Letter Number HM.01.01/001/III/2020 concerning procedures for work in situations of the Covid-19 outbreak. The medical record service for Covid-19 patients still applies paper-based or semi-electronic medical records so that errors can occur. This can cause legal problems for hospitals; therefore, medical record service standards must meet legal aspects as legal evidence that can protect the interests of various parties. Conclusions:&nbsp;It is necessary to manage a medical resume form design that is better, complete, electronical, and in accordance with legal aspects