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Abstrak :
Skripsi ini membahas pengelolaan Rekam Medis rawat inap di RSUD Kota Bekasi pada tahun 2012. Proses pengelolaan rekam medis rawat inap yang terdiri dari yang terdiri dari pencatatan, pengelolaan data medis, penyimpana RM, dan pengembalian RM. Proses tersebut digunakan untuk menghasilkan informasi yang cepat dan lengkap. Penelitian ini dilakukan dengan menggunakan penelitian kualitatif dan kuantitatif (univariat). Sampel yang digunakan adalah 100 berkas rekam medis rawat inap. Adapun hasil data yang diperoleh waktu pengembalian berkas rekam medis periode Januari-Oktober 2012 dari ruangan perawatan adalah Tepat Waktu sebesar 20% (8961 RM) dan Tidak Tepat Waktu sebesar 80% (4892 RM). Sedangkan hasil evaluasi kelengkapan berkas rekam medis rawat inap periode Januari-Oktober 2012 adalah Lengkap sebesar 84% (84 RM) dan Tidak Lengkap 16% (16 RM). ......This thesis discusses the management of inpatient Medical Record Bekasi District Hospital in 2012. Process management of inpatient medical records consisting of consisting of records, medical records management, RM last save, and return RM. The process used to produce information quickly and completely. The research was conducted using qualitative and quantitative research (univariate). The samples used were 100 inpatient medical record file. The results of the data obtained medical record file payback period January to October 2012 from the treatment room is the Right Time by 20% (8961 Medical Record) and Not the Right Time by 80% (4892 Medical Record). While the results of the evaluation of the completeness of the medical record file hospitalization period January to October 2012 is a full 84% (84 Medical Record) and Incomplete 16% (16 Medical Record).

Abstrak :
[ABSTRAK
Tesis ini membahas analisis kelengkapan rekam medis rawat inap RSKO Jakarta tahun 2014. Penelitian ini adalah penelitian mixed method yaitu penelitian secara kuantitatif dan kualitatif. Penelitian kualitatif digunakan untunk mengetahui nilai kelengkapan rekam medis, dan penelitian kualitatif untuk menggali informasi terhadap input, proses, dan output. Hasil penelitian menunjukkan bahwa nilai kelengkapan rekam medis hanya 62,6% belum mencapai standard 100%. Pada penelitian kualitatif didapatkan hasil bahwa faktor input; sumber daya manusia, material, infrastruktur, dan prosedur, faktor proses; pengisian rekam medis dan monitoring evaluasi, dapat mempengaruhi kelengkapan rekam medis (faktor output). Rumah sakit harus membenahi faktor input dan proses agar neningkatkatkan nilai kelengkapan rekam medis sesuai standar sehingga dapat meningkatkan kualitas pelayanan kesehatan di RSKO Jakarta.

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ABSTRACT
This thesis describes completeness of inpatient medical records at RSKO Jakarta hospital on 2014. This research used mixed methods, consists of quantitative and qualitative research. Quantitative research is used to determine the completeness value of medical records, and then qualitative research is used to get information from the input, process, and output. The result showed that the completeness value of inpatient medical records only 62,6% and it didn?t reach the target of 100 % standard. On qualitative research showed that input factors consisted of human resources, materials, infrastructures, and procedures, Process factors consisted of medical records recording, monitoring and evaluation, are influences by completeness of medical records (output factors). Hospital must improve input factors and process factors in order to increase the good completeness value, to improve the quality of medical services at RSKO Jakarta.;This thesis describes completeness of inpatient medical records at RSKO Jakarta hospital on 2014. This research used mixed methods, consists of quantitative and qualitative research. Quantitative research is used to determine the completeness value of medical records, and then qualitative research is used to get information from the input, process, and output. The result showed that the completeness value of inpatient medical records only 62,6% and it didn?t reach the target of 100 % standard. On qualitative research showed that input factors consisted of human resources, materials, infrastructures, and procedures, Process factors consisted of medical records recording, monitoring and evaluation, are influences by completeness of medical records (output factors). Hospital must improve input factors and process factors in order to increase the good completeness value, to improve the quality of medical services at RSKO Jakarta., This thesis describes completeness of inpatient medical records at RSKO Jakarta hospital on 2014. This research used mixed methods, consists of quantitative and qualitative research. Quantitative research is used to determine the completeness value of medical records, and then qualitative research is used to get information from the input, process, and output. The result showed that the completeness value of inpatient medical records only 62,6% and it didn’t reach the target of 100 % standard. On qualitative research showed that input factors consisted of human resources, materials, infrastructures, and procedures, Process factors consisted of medical records recording, monitoring and evaluation, are influences by completeness of medical records (output factors). Hospital must improve input factors and process factors in order to increase the good completeness value, to improve the quality of medical services at RSKO Jakarta.]

Abstrak :
Penelitian ini membahas kelengkapan rekam medis rawat inap di Rumah Sakit Umum Pusat Fatmawati Bulan Desember 2015. Tujuan penelitian ini untuk menganalisis kelengkapan isi rekam medis pasien Instalasi Rawat Inap serta faktor-faktor yang berkaitan dengan pengisian rekam medis. Jenis penelitian ini adalah kuantitatif dan kualitatif dengan metode observasi dan wawancara mendalam. Hasil penelitian didapatkan rata-rata rekam medis pasien rawat inap adalah 57,8%. Tidak adanya pelatihan pengisian rekam medis merupakan salah satu hambatan dalam pengisian rekam medis secara lengkap. ......This study discusses the completeness of inpatient medical records at Fatmawati Fatmawati in December 2015. The purpose of this study was to analyze the completeness of the contents of the medical records of patients Inpatient as well as the factors relating to the charging of medical records. This research is a quantitative and qualitative methods of observation and in-depth interviews. The results, the average medical records of inpatient patients are 57.8%. The lack of filling medical record training is one of obstacles in filling the completely.

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ABSTRACT
Skripsi ini membahas tentang faktor-faktor yang mempengaruhi kelengkapan dokumen rekam medis rawat inap di Rumah Sakit Dr.Hafiz RSDH Cianjur berdasarkan empat variabel masukan yaitu man, material, machine, dan methode. Penelitian ini menggunakan metode deskriptif observasional, yaitu penelitian kuantitatif menggunakan data sekunder dengan observasi dan kualitatif untuk pendalaman dari penelitian kuantitatif dengan teknik wawancara mendalam. Hasil penelitian kuantitatif didapatkan bahwa rata-rata kelengkapan dokumen rekam medis rawat inap adalah 92,18, dan dari nilai tersebut 79,52 lengkap terisi sedangkan 20,48 tidak lengkap, 7,82 yang tidak ada atau tidak didokumentasikan. Gambaran kelengkapan dokumen rekam medis rawat inap di Rumah Sakit Dr.Hafiz RSDH Cianjur secara kuantitas sudah bagus namun secara kualitas masih buruk karena ada beberapa variabel penting seperti pengisian diagnosa dan tandatangan tenaga kesehatan dokter nilainya masih di bawah 50. Adapun faktor yang paling mempengaruhi kelengkapan dokumen rekam medis rawat inap adalah metode Standar Prosedur Operasional/SPO tentang Kelengkapan dokumen rekam medis rawat inap yang masih belum dipatuhi oleh tenaga kesehatan di Rumah Sakit Dr. Hafiz RSDH Cianjur, perlu adanya induksi Standar Prosedur Operasional/SPO tentang kelengkapan pengisisan dokumen rekam medis rawat inap dan prosedur safety secara berkala kepada pegawai baru maupun lama sehingga selalu terpapar dan dapat bekerja sesuai dengan prosedur yang ada.

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ABSTRACT
This study discusses the Factors Affecting the Completeness of Inpatient Medical Record Documents at Dr.Hafiz RSDH Hospital Cianjur based on four input variables namely man, material, machine, and method. This research uses descriptive observational method, that is quantitative research using secondary data with observation and qualitative for deepening of quantitative research with in depth interview technique. The result of quantitative research shows that the average of in patient medical record document is 92,18, and from 79,52 complete value is filled while 20,48 is incomplete, 7.82 is missing or not documented. The description of the completeness of the in patient medical record document at Dr.Hafiz Hospital RSDH Cianjur in quantity is good but the quality is still bad because there are some important variables such as filling diagnosis and signature of health personnel doctor the value is still below 50 . The factors that most affect the completeness of inpatient medical record document is the method Standard Operating Procedure SOP about the completeness of inpatient medical record document which still has not been obeyed by the health workers at Dr. Hafiz Hospital RSDH Cianjur, it is necessary to have induction of Standard Operating Procedure SOP on completeness of document medical record in patient medical record and safety procedures periodically to new and old employees so that always exposed and can work in accordance with existing procedures.

Abstrak :
Pelayanan rekam medis rawat inap merupakan salah satu aspek penilaian mutu yang tercermin dalam kualitas dokumen rekam medis  dan pengelolaannya di bagian unit rekam medis. Terdapat empat indikator sasaran mutu rekam medis yang harus dipenuhi dalam pelayanan yaitu kelengkapan, keakuratan, ketepatan waktu pengembalian, dan pemenuhan persyaratan hukum. Hasil evaluasi bulanan URM RS Muhammadiyah Taman Puring (RSMTP) menunjukan persentase kelengkapan resume medis pada Bulan November 2021 yang masih rendah (32,10%). Tujuan penelitian ini adalah mengetahui faktor-faktor yang berhubungan dengan mutu rekam medis pasien rawat inap di RSMTP Jakarta Selatan. Penelitian ini menggunakan studi deskriptif observasional dengan pendekatan kualitatif dan kuantitatif yang menggunakan kerangka analisis sistem input-process-output. Subjek penelitian ini merupakan profesional pemberi asuhan dan pihak yang terlibat dalam fungsi pengelolaan dan pengawasan rekam medis, sedangkan objek penelitian adalah rekam medis rawat inap Bulan Mei 2022 sebanyak 103 sampel. Hasil penelitian menunjukan output berupa persentase rekam medis yang bermutu baik adalah sebesar 33%. Terkait dengan hasil tersebut, terdapat beberapa kendala pada komponen input dan process seperti kurangnya ketersediaan SDM rekam medis yang sesuai kompetensinya, belum tersosialisasinya SOP dan kebijakan terkait pengisian rekam medis, alur pendaftaran pasien yang belum tersedia, hingga fungsi pemantauan dan evaluasi yang belum berjalan dengan baik. ......Inpatient medical record service is one aspect of quality assessment which is reflected in the quality of medical record documents and their management in the medical record unit. There are four indicators of the quality of medical records, cosist of completeness, accuracy, timeliness of returns, and fulfillment of legal requirements. The results of the monthly MRU evaluation of the Muhammadiyah Taman Puring Hospital (RSMTP) show the percentage of complete medical resumes in November 2021 are still low (32.10%). The purpose of this study was to determine the factors associated with the quality of medical records of inpatients at RSMTP South Jakarta. This study uses a descriptive observational study with qualitative and quantitative approaches that use a system analysis framework. The subjects of this study were professional care provider and parties involved in the function of managing and supervising medical records, while the object of research was inpatient medical records in May 2022 with 103 samples. The results showed that the output in the form of the percentage of good quality medical records was 33%. Related to these results, there are several obstacles in the input and process components such as the lack of availability of medical record human resources according to their competence, the lack of socialization of SOPs and policies related to filling out medical records, the patient registration flow that is not yet available, to the monitoring and evaluation function that still need improvement.

Abstrak :
Latar Belakang: Informasi yang tidak efektif disebabkan oleh adanya keterlambatan pengembalian dan ketidaklengkapan pengisian data rekam medis. Kepmenkes Nomor 129 Tahun 2008 tentang Standar Pelayanan Minimal Rumah Sakit menetapkan waktu pengembalian dokumen rekam medis yaitu 1x24 jam dan kelengkapan dokumen rekam medis harus 100%. Di RSUP Fatmawati Jakarta terdapat peningkatan prosentase keterlambatan pengembalian dan ketidaklengkapan dokumen rekam medis rawat inap. Tujuan: Penelitian ini bertujuan untuk mengetahui dan mengidentifikasi alur, kebutuhan sistem informasi yang akan dikembangkan, serta merancang sistem informasi monitoring dokumen rekam medis rawat inap di RSUP Fatmawati. Metode: Penelitian ini menggunakan metode kualitatif dan dilakukan secara bertahap sesuai tahapan SDLC, serta menggunakan pendekatan metode prototype. Hasil: Adanya masalah-masalah pada sistem informasi rumah sakit saat ini yang membuat petugas masih harus melaksanakan pekerjaannya secara manual. Sistem informasi monitoring dokumen rekam medis rawat inap dirancang melalui penyusunan alur sistem, perancangan basis data, tampilan antarmuka (userinterface), SPO, dan manualbook. Kesimpulan dan Saran: Sistem informasi yang baru dapat mengatasi permasalahan yang terjadi, mempercepat dan mempermudah pekerjaan petugas, serta menghasilkan laporan yang bermutu. Sehingga capaian SPM rumah sakit dan indikator mutu IRMIK meningkat. Sebaiknya ada dukungan penyediaan sarana dan prasarana dari rumah sakit untuk pengembangan sistem informasi monitoring dokumen rekam medis rawat inap, perlu adanya sosialisasi SPO dan manualbook, proses uji coba sistem kepada user, serta sebaiknya dilakukan upaya perawatan basis data secara berkala.

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Background: In the hospital, ineffective information is caused by late referral and incomplete medical records. Decree of the Minister of Health No. 129/2008 of Hospital Minimum Service Standards explained this case. The standard said that medical record documents must be returned in 1x24hours and its completeness must be 100%. Nevertheless, Fatmawati Jakarta Hospital underwent an increase of late returns and incomplete inpatient medical record documents percentages. Objectives: Aims of this study are determining and identifying flow and needs of the development of an information system. Also, this study aims to design an information system for monitoring inpatient medical record documents. Methods: This study used a qualitative method, SDLC stages, and a prototype method approach. Results: There are problems in the current hospital information system. Also, it makes employees still need to do their works manually. Therefore, an inpatient medical record document monitoring information system was designed through some stages. Those are the system flow, database, user interface, OPS, and manualbook formings. Conclusions and Recommendations: The new information system provides some improvements in the hospital. Those are particularly in achievement and enhancement of quality indicators and standards. This is because it can overcome problems and produce quality reports. Also, it makes employees do their works efficiently. For recommendations, the hospital should support this development by facilities and infrastructure provision. They also need to socialize the operational procedure standard and manualbook. Then, they should do the process of testing the system to users and database maintenance efforts regularly.