Category Archives: Jurnal Perekam dan Informasi Kesehatan

Jurnal Kesehatan Indonesia (Jurkessia)

Tinjauan Implementasi Persetujuan Tindakan Kedokteran di BLUD Rumah Sakit Dr. H. Moch. Ansari Saleh Banjarmasin Periode Mei-Juni Tahun 2012

Mislawaty1, Rizana Mirza2, Apit Widiarta2

Abstract
Informed Consent in the BLUD Dr. H. Moch. Ansari Saleh Hospital Banjarmasin, a doctor just run the informed consent in writing, while the informed consent in verbal there is not already running. Filling the completeness of informed consent is always filled in January and February, but in March there were nine incomplete the medical records. Purpose of the study to determine the implementation of informed consent in the BLUD Dr. H. Moch. Ansari Saleh Hospital Banjarmasin. The research method is descriptive research. Sampel in this study was all Doctor and nurse, patients / families who receive medical action, and informed consent forms that exist in the Kumala Room BLUD Dr. H. Moch. Ansari Saleh Hospital, with sampling techniqe was non probability and purposive sampling technique. Research is standard operating procedure informed consent especially about charging policy for approval are still in the process of revision. Approval of the implementation phase of informed consent is a doctor / nurse explain the procedure before and after surgery, diagnosis and procedure explanations of medical action, explanation of financial forecasts, the purpose of medical action is performed, risks and complications of medical action when given to patients is not performed. Completeness of informed consent the greatest percentage of incomplete evidence that self / identity card. For the month of May with a percentage of 46.7% and 40%. June with a percentage of 41,5% and 36,6%.

Keywords : Implementation of Informed Consent

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Jurnal Kesehatan Indonesia (Jurkessia)

Analisis Kelengkapan Pengisian Resume Medis Rawat Inap Periode April di Rumah Sakit Bhayangkara Banjarmasin Tahun 2011

Khairun Nisa Ginting1, Gussa Azizah2, Dion Angger Priyatama2

Abstract
Quantitative analysis is to assess the completeness and accuracy of health records (medical records) inpatient and outpatient facilities owned by the means service. Discharge summary is all about the care and treatment of patients as has been attemted by health workers and stakeholders. In a complete medical record, may obtain information that can be used for various purposes. The purpose of this study was to calculate the percentage of completeness of charging discharge summary. This research type used descriptive analytical records in April 2011. Sampling using simple random sampling of 171 pieces of discharge summary medical records. Instruments of research using observation, interviews, and sheet checklist. The result of the completeness the obtained rate is 62,02% of discharge summary where the results obtained from the average value identification of patients. The average reaches 39,38% completeness, the completeness of vital reports that the average of its research 56,14%, authentication of writing is average its rate is 63,7% completeness, and to note that both the completeness of its 88,87%. Human resources to analyzing existing 2people and they have never trained so that the knowledge obtained from socialization in the hospital and directly study the completeness of the SOP. Standard operating procedures andpolicies for the completeness of discharge summary follow a standard operating procedure completeness file medical records.

Keywords : quantitative analysis, completeness form discharge summary

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Jurnal Kesehatan Indonesia (Jurkessia)

Tinjauan Tata Kelola Sistem Filing Rekam Medis Rawat Jalan
di RSUD Datu Sanggul Rantau Tahun 2011

Indra Nur Asmayanti1, Apit Widiarta2*, Dion Angger Priyatama3

Abstract
Datu Sanggul Rantau Hospital used a straight numberical filing system, but has not been doing well. The filing system of the applied indeed facilitate the process of record keeping, but for the retrieval medical records of patient who want to get health care back takes longer time to found the medical records. Its happen because the number of the first group of the medical record is not sequence. This study used descriptive research through interviews and check list. From the research results of filing outpatient medical records systems at Datu Sanggul Rantau hospitals using a decentralized system, there is a separation between the inpatient medical and outpatient medical records filing room. filing system are applied in Datu Sanggul Rantau hospitals is the system uses the straight numberical system. Based on the results of the research of straight numberical system in Datu Sanggul Rantau hospitals has not been applied correctly. Where medical record number into three groups to the two already arranged correctly, but the numbers are still not in the first group sorted correctly. Thus the officials hard and long medical record in medical record retrieval. To improve the way the application of filing system with the straight numberical system of outpatient medical records officers need the training about medical records.

Keywords : governance medical record filing system, outpatient

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Jurnal Kesehatan Indonesia (Jurkessia)

Hubungan Antara Kelelahan Kerja dengan Produktivitas Kerja Petugas Rekam Medis di RS ”X”

Aris Antoni

Abstrak

Jumlah kunjungan pasien rawat jalan dan rawat inap yang tinggi di Siloam Hospitals Kebun Jeruk dan tidak diimbangi dengan jumlah tenaga yang cukup mengakibatkan beban kerja yang tinggi. Kondisi ini sering menimbulkan kesalahan dalam memberikan pelayanan rekam medis. Produktivitas kerja yang ditampilkan petugas rekam medis menjadi kurang memenuhi harapan. Penelitian ini bertujuan untuk mengetahui hubungan antara kelelahan kerja dengan produktivitas kerja petugas rekam medis di Unit Rekam Medis Rumah Sakit “X” Kebun Jeruk. Jenis penelitian bersifat kuantitatif dengan desain cross sectional menggunakan metode deskriptif analitik. Populasi dan sampel dalam penelitian ini adalah petugas rekam medis di Rumah Sakit “X” Kebun Jeruk berjumlah 18 orang yang melakukan jenis kerja fisik yaitu bagian admission, filing & retrieval, distribusi rekam medis, koding rawat jalan dan rawat inap, serta assembling dan analisis rawat inap. Skor produktivitas kerja diukur dari jumlah rekam medis yang selesai dikerjakan per jam. Skor kelelahan kerja dihitung berdasarkan angka CVL ( Cardiovascular Load) dengan mengukur denyut nadi kerja, denyut nadi istirahat, denyut nadi maksimal dan denyut nadi maksimal 8 jam.Data yang dihasilkan dianalisis dengan analisis univariat dan bivariat. Uji analisis data menggunakan Pearson Product Moment. Berdasarkan hasil penelitian menunjukkan sebagian besar petugas rekam medis berumur antara 25-34 tahun, jenis kelamin paling banyak laki-laki dan masa kerja antara 1-5 tahun, berpendidikan terbanyak DIII dan berstatus sebagian besar pegawai tetap. Rata-rata skor kelelahan kerja sebesar 38.33 (SD = 10.35) dan produktivitas kerja sebesar 50.22 (SD = 9.24). Uji statistik menunjukkan korelasi yang negatif namun tidak bermakna (r = -0.219 ; p = 0.384 > 0.05). Disimpulkan bahwa kelelahan kerja akan berdampak negatif terhadap produktivitas kerja dan akan merugikan perusahaan. Upaya-upaya untuk meningkatkan produktivitas kerja harus selalu dilakukan.

Kata Kunci: Rekam Medis, Kelelahan Kerja, Produktivitas Kerja

(Jurkessia, Vol. I, No. 1 hal 40 – 46)

Jurnal Kesehatan Indonesia (Jurkessia)

ASPEK REKAM MEDIS DALAM PERLINDUNGAN HUKUM PASIEN, DOKTER DAN INSTANSI PELAYANAN

Deasy Rosmala Dewi

Abstrak

Pola hubungan dokter – pasien yang semula paternalistik menjadi pola partnership menuntut adanya peningkatan mutu pelayanan kesehatan. Karena pada pola yang baru ini memperkenalkan beberapa hal yang saat ini sedang dalam proses penerimaan masyarakat, diantaranya tentang hak pasien. Tidak sempurnanya pelaksanaan hak pasien ini sering dijadikan alasan pasien untuk menggugat, mengadukan bahkan menuntut dokter maupun tenaga kesehatan lainnya dalam masalah malpraktek. Rekam Medis yang berisi  catatan  dan dokumen tentang identitas pasien, anamnesa, riwayat penyakit, hasil pemeriksaan laboratorium, diagnosis, persetujuan tindakan medis, tindakan pengobatan, catatan perawat, catatan observasi klinis dan hasil pengobatan, resume akhir dan evaluasi pengobatan harus dijaga dan dipelihara dengan baik kelengkapannya karena akan memberi kedudukan kuat sebagai bukti pertanggungjawaban hukum.

Kata kunci:  Rekam Medis, Pasien, Permenkes, malpraktek

(Jurkessia, Vol. I, No. 1 hal 33 – 39)