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"ABSTRAK Nama : Yosia Christian YustinProgram Studi : Magister Administrasi Rumah SakitJudul : Analisis Penyelenggaraan Rekam Medik Terdesentralisasi di RSUDCimacan Jawa Barat Tahun 2018Pembimbing : Prof. DR. dr. Adik Wibowo, MPHPenyelenggaraan Rekam Medik RSUD Cimacan menggunakan sistem desentralisasikarena beberapa alasan yaitu: perekam medik bukan dari kualifikasi D3 rekam medik,pola pembangunan yang horizontal, dan poliklinik yang tersebar di dalam 4 gedungRSUD Cimacan. Data Juni 2016 ndash; Oktober 2017 didapati kejadian duplikasi rekam mediksebanyak total 2.218 berkas. Penelitian kualitatif menggunakan metode observasi, telaahdokumen, dan wawancara mendalam dengan variabel-variabel SDM IRM, anggaran,alur, teknologi, kebijakan, dan sarana dan prasarana, serta lingkungan demografi,ekonomi, kebijakan nasional, dan kompetitor . Dilakukan Focus Group Discussion FGD untuk menentukan critical success factor CSF dari faktor internal dan faktoreksternal. Dengan mengunakan bantuan analisis SWOT, didapatkan strategi RSUDCimacan pada pilihan pengembangan pelayanan. Melalui teknik Concensus DecisionMaking Group CDMG didapatkan upaya - upaya perbaikan pada kualitas dan kuantitasSDM, evaluasi penyelenggaraan rekam medik, evaluasi dan melengkapi kebijakaninternal terkait penyelenggaraan rekam medik, penyediaan anggaran dengan lebih efisiendan maksimal, memaksimalkan teknologi yang sudah di implikasi agar lebih efektif danefisien.Kata kunci:Penyelenggaraan rekam medik terdesentralisasi, instalasi rekam medik, SWOT, rencanaaksi. ABSTRACT Name Yosia Christian YustinStudy Programe Magister Administrasi Rumah SakitTitle The Analysis of Decentralized Medical Records at RSUDCimacan West Java in 2017.Counsellor Prof. DR. dr. Adik Wibowo, MPHDecentralized system on medical record management was used by Cimacan RegionalHospital RH , West Java because the human resource from sufficient medical recordsdiploma is not adequate, horizontalized development pattern, and clinics were scatteredinto four buildings of Cimacan RH. From 2016, June until 2017, October, there were2.218 duplication incidents of medical records. Qualitative method research wasconducted through observation, document review, and in depth interview on factors ofmedical record management, human resources of Medical Records Department, budget,process flow, technology, internal policy, facilities, and environment demography,economy, national policies, and competitors . Focus Group Discussion FGD wasconducted to determine the critical success factor CSF from internal factors and externalfactors. Through SWOT analysis, it was obtained a strategy resulted on the servicedevelopment strategy. It was obtained efforts through Concensus Decision Making Group CDMG resulted in improving the quality and quantity of human resources, improvingthe evaluation of medical records management, evaluating and complementing internalpolicies related to the conduct of medical records management, providing budget to bemore efficient and maximal, maximizing technology that already implicated to gain aneffective and efficient process.Keywords Implementation of decentralized medical record, medical record department, SWOT,plan of action."

"Dalam usaha untuk meningkatkan kepuasan pelanggan, rumah sakit dituntut untuk selalu melakukan perbaikan dalam pemberian pelayanan bermutu dengan meningkatkan kualitas kerja untuk memenuhi harapan pelanggan. Pelayanan yang bermutu bukan hanya dilakukan pada pelayanan medis saja, tetapi juga pada pelayanan penunjang salah satunya yaitu penanganan rekam medis di rumah sakit yang menjadi salah satu indikator mutu rumah sakit yang dapat diketahui melalui kelengkapan pengisian rekam medis.Penelitian ini bertujuan untuk mengetahui faktor-faktor yang mempengaruhi kelengkapan pengisian berkas rekam medis pasien rawat inap RS Hermina Depok Tahun 2018. Jenis penelitian ini adalah kuantitatif dan kualitatif dengan metode telaah dokumen, telaah data dan wawancara mendalam.Hasil penelitian menunjukan bahwa dari 60 sampel penelitian, ditemukan bahwa 78,3 berkas rekam medis pasien rawat inap tersebut belum terisi dengan lengkap. Selanjutnya terlihat ada hubungan antara usia dokter, pendidikan dokter dan status kepegawaian dokter dengan kelengkapan pengisian berkas rekam medis pasien rawat inap. Namun tidak ditemukan keberpengaruhan sarana dan prasarana, SPO dan biaya dengan kelengkapan pengisian berkas rekam medis pasien rawat inap di RS Hermina Depok.

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In an attempt to increase customer satisfaction, hospitals are required to always repair in provision pf service quality by improving the quality of work to meet the expectations of customers. Quality service do not only on medical section, but also on the supporting one of them is handling medical record in the hospital that was one of indicator of the quality hospital that can known through completeness filling medical record.

Research aims to understand factors affecting completes charging file record medical patient in patient Hermina Hospital Depok 2018. The kind of research is quantitive and qualitative with the methods review of documentation, review of data and in depth interviews.

The result of the study showed that from 60 sample, that found 78,3 file medical record inpation has yet fill with complete. There was a correlation between the ages of doctor, education of doctor and the doctors employement status completeness filling medical record inpatiens, but there was not found correlation of facilities and infrastructure, standard operating procedur and financing with completeness charging record file medical inpatient in Hermina Hospital Depok. "

"Latar belakang. Penerapan teknologi digital di bidang kesehatan membawa potensi untuk meningkatkan kualitas dan keamanan pelayanan kesehatan Penerapan RME ini dituangkan dalam Permenkes No.24 tahun 2022. Tujuan dari penelitian ini adalah untuk mengetahui kesiapan RSUD Dr. Alberth H Torey (RSUD AHT) dalam penerapan rekam medik elektronik.Metode. Studi analitik dengan mixmethode berupa analisis kualitatif dengan wawancara mendalam dan kuantitatif dengan kuesioner. Studi kualitatif menilai kesiapan penerapan RME melalui penilaian kesiapan sumberdaya manusia, anggaran, metode dan sarana prasarana. Penilaian perilaku penggunaan RME, dianalisis melalui kuesioner modified technology acceptance model (TAM-2) dan Unified Theory of Acceptance and Use of. Technology (UTAUT). Dilakukan pada November 2023 dengan total 71 responden dan 10 informan.Hasil. Belum tersosialisasi tentang penggunaan RME kepada seluruh unit. Mayoritas responden memperlihatkan hasil positif dalam kemauan penggunaan dan sikap dalam penggunaan baik dengan metode TAM-2 dan UTAUT. Proses penganggaran belum transparan. Belum ada SOP dalam pengelolaan dan evaluasi penggunaan RME. Terdapat keterbatasan jumlah perangkat keras yang tersedia di unit.Kesimpulan. RME memudahkan dalam penyelesaian pekerjaan. Rumah sakit dapat meningkatkan penerapan RME dengan membuat perencanaan sesuai perhitungan kebutuhan terhadap kesiapan sumberdaya manusia, pemenuhan perangkat keras, evaluasi berkala dan pengelolaan anggaran terkait RME.

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Background. The application of digital technology in the health sector brings the potential to improve the quality and safety of health services. The implementation of RME is outlined in Minister of Health Regulation No. 24 of 2022. The aim of this research is to determine the readiness of RSUD Dr. Alberth H Torey (RSUD AHT) in implementing electronic medical records.

Method. Analytical study with a mix method in the form of qualitative analysis with in-depth interviews and quantitative with questionnaires. Qualitative studies assess readiness to implement RME through assessing the readiness of human resources, budget, methods and infrastructure. Assessment of RME usage behavior, analyzed through the modified technology acceptance model (TAM-2) questionnaire and the Unified Theory of Acceptance and Use of. Technology (UTAUT). Conducted in November 2023 with a total of 71 respondents and 10 informants.

Results. The use of RME has not been socialized to all units. The majority of respondents showed positive results in willingness to use and attitudes towards using both the TAM-2 and UTAUT methods. The budgeting process is not yet transparent. There is no SOP for managing and evaluating the use of RME. There is a limited amount of hardware available in the unit.

Conclusion. RME makes it easier to complete work. Hospitals can increase the implementation of RME by making plans according to calculating needs for human resource readiness, hardware fulfillment, periodic evaluations and budget management related to RME."

"Saat ini rumah sakit dan tenaga kesehatan rawan akan tuntutan-tuntutan yaitu tuntutan mutu pelayanan, tuntutan kesejahteraan karyawan, tuntutan hukum dari pasien dan banyak pesaing dalam bidang perumahsakitan. Atas dasar itu diperlukan upaya perbaikan mutu dan menjaga mutu.Penelitian Departemen Kesehatan tahun 1989 di rumah sakit kelas B, C, D pads enam provinsi rekam medis belum dapat digunakan sebagai alat ukur mutu pelayanan kesehatan dimana - pengisian rekam medis tak lengkap dan data-datanya disangsikan. Kejadian serupa terjadi di RSUD Tarakan Jakarta, dimana dari penelitian bulan Juni 2002 dan wawancara prapenelitian dengan kepala sub bagian rekam medis RSUD Tarakan Jakarta pada bulan Desember 2002, pengisian rekam medis tak lengkap dan pengembalian 100% terlambat.Untuk itu diperlukan penelitian kelengkapan dan ketepatan waktu pengembalian rekam medis rawat inap serta faktor-faktor apa yang berpengaruh terhadap kelengkapan dan ketepatan waktu pengembalian. Penelitian ini menggunakan metoda deskriptif kualitatif dan kuantitatif.Hasil penelitian pada rekam medis rawat inap bulan Oktober 2002 didapat rekam medis, yang lengkap hanya 4,7% dan tak lengkap 95,3% sedangkan tepat waktu pengembalian 18% dan tak tepat waktu 82%. Faktor-faktor yang berpengaruh terhadap kelengkapan adalah lingkungan kerja kurang menyenangkan, kompensasi belum memadai, ketidakdisiplin waktu kerja, monitoring (supervisi) tak berjalan, belum ada penghargaan yang memadai, peran dan fungsi panitia rekam medis tak berjalan, urgensi terhadap rekam medis masih rendah, sosialisasi buku pedoman pengelolaan rekam medis sangat kurang sedangkan faktor-faktor yang berpengaruh terhadap ketepatan pengembalian adalah resume medis belum diisi, pengetahuan dan pemahaman petugas administrasi ruang perawatan sangat kurang dan fungsi monitoring ( supervise) tak berjalan.Atas dasar temuan itu disarankan peningkatan kualitas sumber daya manusia dan pemberdayaan staff sub bagian rekam medis, peningkatan fungsi dan peran panitia rekam medis, peningkatan kompensasi, peningkatan disiplin waktu kerja, peningkatan sosialisasi buku pedoman pengelolaan rekam medis, peningkatan prasarana fisik dan sarana, dilaksanakan sistim pemberian penghargaan dan teguran terhadap petugas yang telah melaksanakan pengelolaan dengan baik dan tidak baik serta untuk masa akan datang digunakan sistim komputerisasi rekam medis dimana bila salah satu petugas tidak mengisi rekam medis maka secara otomatis jasa produksi tak keluar.Daftar Pustaka : 29 ( 1983-2003 )

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Recently, the hospital and health personnel are troubled by claims that are the claim of service quality, the claim of employee's welfare, criminal procedure by the patient and other competitors in hospitalization aspects. Base on those facts, so some effort of improving and maintaining the quality is needed.

The study by Department of Health on 1989 in the hospitals class B, C, D, in six provinces reveals that the medical record is can not be used yet as a measurement device to the quality of health services because the filling up of medical record is still incomplete and the data are doubted.

Similar things happen in RSUD Tarakan Jakarta; where from the study in June 2002 and the pre-study interview with the chief of medical record sub department in RSUD Tarakan Jakarta in the month of December 2002, the filling up of medical record was incomplete and the returns was 100% delayed.

Thus, there is a need to study about the completeness and accuracy of the medical record return in the hospitalized patient and those factors, which affect the completeness, and accuracy in returning time. This study was using the qualitative and quantitative descriptive method.

The study result about the medical record of hospitalized patient in October 2002 revealing only 4,7% of complete medical record and the incomplete of 95,3%, where as the medical record with on time returning of 18% and not on time of 82%. The factors that affect completeness are inconvenient of working environment, insufficient compensation, indiscipline of working hours, stuck monitoring (supervision), insufficient reward, interference in the role and function of medical record committee, low urgency of medical record, the lack of medical record management guiding books socialization. Whereas the factors that affect returns are no filling up of resume of medical record, knowledge and understanding of the health care room administrative officer and the stuck in monitoring (supervision) function.

Based on those findings, it is suggested to improve the quality of human resources and make the staff of the medical record sub department to be efficient, enhance the function and role of the medical record committee, improve compensation, improve the discipline of working hours, enhance the socialization of the guiding book of medical record management, improve the physical utility and pre-utility, do the reward and punishment system for the officer who had done good and bad management respectively, and for the future, it will be used computerization system, where if there is an officer who does not fill up the medical record, then automatically there will be no production services."

"Rekam medis di Rumah Sakit Gading Pluit berupa manual rekam medis. Pengisian kelengkapan rekam medis di Unit Rawat Inap bulan Januari-Maret tahun 2016 di Rumah Sakit Gading Pluit masih ada yang dibawah indikator mutu kelengkapan rekam medis.Tujuan penelitian ini menganalisis pengisian kelengkapan rekam medis bulan Januari-Maret tahun 2016 di unit rawat inap RS Gading Pluit.Metode Penelitian analisis kualitatif dengan wawancara mendalam dengan studi kasus terhadap kelengkapan dokumen rekam medis bulan Januari- Maret tahun 2016.Hasil penelitian yaitu form resume medis, dimana tanda tangan dokter yang merawat lengkap sebesar 97,2%, tidak lengkap 2,8%. Form catatan pasien terintegrasi dimana nama dokter lengkap sebesar 35,5% tidak lengkap 64,5%, form informed consent dimana tanda tangan saksi lengkap hanya 37,91% tidak lengkap 62,09% dan nama saksi 16,80% lengkap, dan tidak lengkap 83,20%.Kesimpulan dari penelitian ini yaitu faktor-faktor yang memegang peranan dalam pengisian kelengkapan rekam medis rawat inap seperti pelatihan tentang rekam medis, standar operasional prosedur tentang rekam medis kurang disosialisasikan serta masih belum ada sanksi tegas bagi dokter yang sering tidak melengkapi rekam medis.

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Background : The medical records at Gading Pluit Hospital are still done manually. The completeness of medical records filling form at inpatient unit of Gading Pluit in January until March 2016 are still below the standard indicator quality.

Purpose : to analyze the charging form completeness of medical records in January until March 2016 at inpatient unit of Gading Pluit Hospital.

Methode: Qualitative anaylisis by in-depth interviews and case studi of medical records completeness in January until March 2016.

Results : Resume of medical records form, with signature of doctor who treat 97,2% completed, 2,8% incomplete. Integrated data patient form where there is a doctor name 35,5% completed, 64,5% incomplete. Informed consent form where there is a signature of witnesses 37,91% completed., 62,09% incomplete, and witnesses name 16,80% completed, 83,20% incomplete.

Conlusion : Factors that held an important role of the completeness of medical records filling form in inpatient unit are training about medical record, standar operating procedure about medical record which is still less socialized and still there is no sanction for the doctors who did not complete the filling of medical record."

"ABSTRACTProses pengembalian rekam medis pasien rawat jalan di RSUP Fatmawati masih belum optimal, ditunjukan dengan penyelenggaraan yang belum sesuai dengan peraturan, masih ada rekam medis yang terlambat, bahkan tidak kembali dari Instalasi Rawat Jalan IRJ ke Instalasi Rekam Medis dan Pusat Data Informasi IRMPDI pada hari dimana rekam medis digunakan. Penelitian ini dilakukan untuk mendapatkan hasil analisis proses pengembalian rekam medis pasien rawat jalan dari IRJ ke IRMPDI dengan pendekatan lean six sigma. Jenis penelitian ini adalah operational research, dengan desain penelitian kuantitatif dan kualitatif. Hasil penelitian digambarkan dengan value stream mapping yang memperlihatkan lead time proses pengembalian rekam medis pasien rawat jalan selama 183,09 menit dengan value added 41,55 menit 22,7 dan non value added 141,54 menit 77,3, proses paling lama terjadi pada langkah pengembalian rekam medis dari IRJ ke IRMPDI karena menunggu petugas IRMPDI mengambil rekam medis. Waste paling besar yaitu waste waiting sebesar 124,16 menit atau 87,72 dari total seluruh waste yang ditemukan. Berdasarkan analisis fishbone diagram diketahui bahwa akar penyebab masalah paling banyak berasal dari kategori man. Berdasarkan analisis tersebut diberikan usulan berupa pembuatan standarisasi kerja, penghitungan beban kerja, melakukan rapat koordinasi, membagi pekerjaan ke dalam periode waktu tertentu heijunka, dan meningkatkan pengawasan.

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ABSTRACTThe process of returning outpatient medical records at RSUP Fatmawati is not optimal enough, indicated by the process is not in accordance with existing regulations, medical records are late, and not returned from Outpatient Installation IRJ to Installation of Medical Record and Information Data Center IRMPDI at the same day when it used. The aim of this research is to get analysis result of outpatient medical records return process from IRJ to IRMPDI using lean six sigma approach. This research is operational research type that use quantity and quality design. The results of this research were described with the value stream mapping that showed lead time of outpatient medical records return process for 183,09 minutes, with value added 41,55 minutes 22,7 and non value added 141,54 minutes 77,3, the longest process occurs on returning of medical record form IRJ to IRMPDI due to the waiting of IRMPDI officers to take medical records. The biggest waste is waiting for amount of 124,16 minutes 87,72 of the total waste. Based on fishbone diagram analysis it is known that the root cause of medical record problem mostly comes from man category. Based on that analysis, an improvement proposal will be given as the following development of work standarization, workload calculation, coordination meeting, devide the work into a certain period of time implementation of heijunka, and improvement of supervision. "

"A hospital is defined as a place where all people with health disorders are accommodate and being an inpatient to be care far. A hospital is also a place where every type of health and medicine expertise and experience are c ncentrated, as well as every medical instruments and appliances 0f modem health.Until now, Cimacan Hospital (CH) is still on aking a great effort to process the official approval from MOH of Inadonesia. as the-Letter of AnnoW1cement of Bupati Cianjur Number 42 of Year 2001 t at the claSsification of CH is not decided yet. The study is also produce a prototype on the Information System for Registration Installation with Medical Record-based that need a continuity on strong commitment from the director of the hospital and the entire medical record staffs, to be implemented and a persistence input for improvements."

"ABSTRAKPenelitian dilatarbelakangi sering ditemukan ketidaklengkapan berkas rekam medis diunit rawat inap RSUD Kota Bekasi. Bertujuan menentukan pengaruh serta besarannyaperilaku kepatuhan dan kompetensi dokter dalam mengelola rekam medis di unit rawat inapRSUD Kota Bekasi tahun 2013. Desain penelitian kuantitatif, cross-sectional, analisaStructural Equation Modeling-Partial Least Square. Uji chi-square variasi total jawabanvariabel perilaku dan variabel kompetensi terhadap karakteristik responden dengan tingkatsignifikansi α = 0,05 (CI 95%) menunjukkan P-values (asymp sign > 0,05). Hasil PLSpengaruh (rho) perilaku (69%) dan kompetensi dokter (38%) terhadap kinerja pengisianrekam medis. R-square 0,43 dan Q-square predictive 33%.

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ABSTRACTBacked by the research often found incomplete medical record file in unit inpatienthospitals city of Bekasi. Determining the magnitude and influence the behavior ofcompliance and competence in managing physician medical record unit inpatient hospitals inBekasi by 2013. Quantitative research design, cross-sectional, Structural Equation Modelinganalysis-Partial Least Square. Chi-square test variations total answer variable and variablebehavior competence with respect to the characteristics of the respondents with a level ofsignificance of α = 0.05 (CI 95%) shows P-values (asymp sign > 0.05). Results PLS influence(rho) behavior (69%) and competence of physicians (38%) against performance chargingmedical record. R-square value of 0.43 and Q-square predictive 33%."

"ABSTRAKMenjelang diterapkannya Sistem Jaminan Sosial Nasional tahun 2014,rumah sakit wajib menyelenggarakan administrasi rekam medis yang tertib yakni rekam medis lengkap,dan akurat sesuai dengan pelayanan yang telah diberikan. Selain itu, ketidaklengkapan dalam pengisian rekam medis akan sangat mempengaruhi mutu rekam medis dan mencerminkan mutu pelayanan di suatu rumah sakit (Depkes,2006). Dari hasil pengamatan pendahuluan, masih ada keluhan dari pasien,perawat dan dokter terhadap sistem rekam medis rawat jalan di unit RSU Bhakti Yudha Depok. Penelitian ini bertujuan untuk menganalisis sistem rekam medis rawat jalan (input, process, output, feedback, dan control) di Unit Rekam Medik RSU Bhakti Yudha Depok tahun 2013. Penelitian ini merupakan penelitian Mix Methods dengan pendekatan studi kasus. Cara pengumpulan data melalui observasi partisipatif moderat, wawancara mendalam, dan dokumentasi. Hasil: sistem rekam medis rawat jalan belum berjalan secara optimal sehingga berpengaruh pada output yakni rekam medis rawat jalan tidak akurat,tidak lengkap dan tidak aman secara fisik. Ini disebabkan oleh tidak dilakukannya analisis kelengkapan rekam medis rawat jalan, serta proses pengiriman rekam medis yang tidak aman. Saran : supervisor rekam medis menunjuk seorang petugas rekam medis yang khusus menangani penaataan berkas rekam medis rawat jalan, sekaligus melakukan analisis kelengkapan rekam medis dan kepada manajemen rumah sakit agar mempertimbangkan metode alternatif untuk mengirimkan rekam medis.

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ABSTRACTTowards the implementation of the National Social Security System (SJSN) in 2014, hospital must conduct an orderly administration of the medical record namely medical records complete, accurate and in accordance with the service provided. Moreover, the incompleteness of the charging medical records will greatly affect the quality of medical records and reflect the quality of care in a hospital (Depkes, 2006). From preliminary observations, there were still complaints from patients, nurses and doctors about the outpatient medical record systems in Bhakti Yudha Hospital. This study aims to analyze the outpatient medical record system (input, process, output, feedback, and control) at the Medical Records Unit of Bhakti Yudha Hospital in 2013. The method used was Mix Methods with a case study approach. The data collected through participant observation moderate, in-depth interviews, and documentation. Result : The outpatient medical record system was not running optimally, so that the effect on the output of the outpatient medical record are inaccurate, incomplete and not secure. This is due to the completeness analysis of outpatient medical records was never had been assessed, as well as the delivery method of medical records that is not safe. Advice for the Medical Record Supervisor is appoint a medical record officer who specializes in assembling the outpatient medical record, as well as to analyze the completeness of the medical records and suggest to hospital management to consider alternative methods to delivery the medical records.Key words : system analysis, medical record, outpatient."

"ABSTRAKPenelitian ini menganalisis pelayanan rekam medis rawat jalan di RSUD GunungJati Kota Cirebon. Tujuan dilakukannya penelitian ini adalah untuk mengetahuilama waktu yang dibutuhkan dalam proses pelayanan rekam medis rawat jalanserta mengidentifikasi hambatan. Jenis penelitian yang digunakan adalahpenelitian kualitatif. Hasil penelitian menunjukkan bahwa rata-rata lama waktuyang dibutuhkan adalah 151 menit. Proses terlama terdapat di tahap pencarianrekam medis rawat jalan. Waktu yang dibutuhkan untuk proses pelayanan rekammedis rawat jalan yaitu > 10 menit, dipengaruhi oleh minimnya pelatihan tentangpenyimpanan, serta belum optimalnya lemari penyimpanan rekam medis dibagianpenyimpanan

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ABSTRACTThis research analyzed the outpatient medical record services at RSUD GunungJati Cirebon. The purposes of this study were to determine the length of time ittakes in a series of processes of outpatient medical record services and to identifyobstacles. The type of research employed was qualitative research. The resultsshowed that the average length of was 151 minutes. The longest process occurredin the search stage of outpatient medical records. The time required in the processof outpatient medical record services was still within the old category, i.e. >10minutes, which was affected by the lack of training on storage, and the nonoptimumuse of medical record storage cabinets in the storage section"