Aplikasi Monitoring dan Evaluasi Analisis Kuantitatif Pada Formulir Resume Medis Digital Di SMC RS Telogorejo Semarang tahun 2022
DOI:
https://doi.org/10.25047/j-remi.v5i4.4918Keywords:
Qualitative Analysis, Quantitative Analysis, Digital Forms, Quality Assurance, EMRAbstract
Hospital accreditation standards require periodic reviews of medical records as part of performance improvement efforts, with review results being regularly reported to the Hospital Director. A preliminary survey in the Inpatient Department (IRNAP) at Telogorejo General Hospital, Semarang City, conducted from January to February 2022, showed that the implementation of electronic medical records (EMR) for inpatient services began on October 26, 2021. It was found that certain sections, especially in the discharge summary form, were not fully completed by doctors. This study aims to design and develop an application for monitoring and evaluating the quantitative analysis of digital medical discharge forms at SMC Telogorejo Hospital Semarang in 2022. The research employs a descriptive method, analyzing quantitative variables in the EMR. The study population consists of 1,826 inpatient medical records from 2021, with a sample of 183 records selected using purposive sampling. The result of this study is the SIKUMIS application. The development of the SIKUMIS application is crucial in supporting the assurance of medical record service quality, particularly in the analysis of inpatient discharge summaries. This application is expected to strengthen the integrity and completeness of medical record data, as well as improve efficiency and accuracy in healthcare services.
References
R. Amran, A. Apriyani, and N. P. Dewi, “Peran Penting Kelengkapan Rekam Medik di Rumah Sakit,” Baiturrahmah Med. J., vol. 1, no. 1, pp. 69–76, 2021, [Online]. Available: https://jurnal.unbrah.ac.id/index.php/brmj/article/view/1061
S. N. F. Sukma, S. Sudiro, and E. Y. Fatmasari, “Analisis Perencanaan Quality Assurance Ditinjau Dari Aspek Input Pelayanan Keperawatan Rawat Inap Pasca Akreditasi Paripurna RS Swasta X Kota Semarang,” JKM J. Kesehat. Masy., vol. 5, no. 4, pp. 127–136, 2017, doi: https://doi.org/10.14710/jkm.v5i4.18326.
F. Agiwahyuanto, E. Widianawati, W. R. Wulan, and C. K. Komara, “Analisis Quality Assurance Penerapan Kebijakan Reward and Punishment Berdasarkan Assesment Tingkat Kepatuhan,” J. Manaj. Inf. Kesehat. Indones., vol. 8, no. 1, pp. 37–43, Mar. 2020, doi: 10.33560/jmiki.v8i1.263.
A. M. Ningtyas and I. K. Lubis, “Literatur Review Permasalahan Privasi Pada Rekam Medis Elektronik,” Pseudocode, vol. 5, no. 2, pp. 12–17, Nov. 2018, doi: 10.33369/pseudocode.5.2.12-17.
D. Wani and M. Malhotra, “Does the meaningful use of electronic health records improve patient outcomes?,” J. Oper. Manag., vol. 60, no. 1, pp. 1–18, May 2018, doi: 10.1016/j.jom.2018.06.003.
F. Kamalia and L. Indawati, “Tinjauan Ketepatan Kode Diagnosis pada Kasus Neoplasma di RSIJ Cempaka Putih,” J. Ilm. Wahana Pendidik., vol. 10, no. 7, pp. 454–462, 2024, doi: https://doi.org/10.5281/zenodo.11083581.
A. Ariyani, L. Indawati, P. Fannya, and N. A. Rumana, “Tinjauan Lama Waktu Penyediaan Rekam Medis Pasien Rawat Jalan Klinik Kandungan di RSUD Tebet,” Indones. J. Heal. Inf. Manag., vol. 2, no. 1, pp. 1–6, Feb. 2022, doi: 10.54877/ijhim.v2i1.36.
D. G. Dewi, L. Candra, Y. Gumayesty, H. M. Ulfa, and Y. Harnani, “Analisis Pengolahan Berkas Rekam Medis Di Rumah Sakit Lancang Kuning Pekanbaru Tahun 2021,” Media Kesmas (Public Heal. Media), vol. 2, no. 1, pp. 307–316, Apr. 2022, doi: 10.25311/kesmas.Vol2.Iss1.502.
S. Sugiarsi and Rohmadi, “Literatur Review: Mengapa Rekam Medis Tidak Lengkap?,” Indones. Heal. Inf. Manag. J., vol. 8, no. 2, pp. 45–52, 2020.
D. R. A. Tiorentap, “Evaluasi Manfaat Penerapan Rekam Medis Elektronik di Negara Berkembang: Systematic Literature Review,” Indones. Heal. Inf. Manag. J., vol. 8, no. 2, pp. 69–79, 2020, doi: https://doi.org/10.47007/inohim.v8i2.218.
N. M. Putri, W. Z. Qomarania, and H. Hosizah, “Tinjauan Pelaksanaan Review Rekam Medis dalam Rangka Persiapan Akreditasi Rumah Sakit Berdasarkan Standar Akreditasi SNARS-1 di RSUD Sultan Thaha Saifuddin Kabupaten Tebo Provinsi Jambi,” Indones. Heal. Inf. Manag. J., vol. 9, no. 1, pp. 47–56, 2021.
A. S. Hasibuan and G. Malau, “Ketidak Lengkapan Dokumen Rekam Medis Rawat Inap pada Pasien Diabetes Mellitus di RSU Imelda Medan,” J. Ilm. Perekam dan Inf. Kesehat. Imelda, vol. 4, no. 2, pp. 675–679, Dec. 2019, doi: 10.52943/jipiki.v4i2.92.
L. Widjaya and S. Siswati, “Model Kuantitatif Audit Pendokumentasian terhadap Kelengkapan Rekam Medis,” J. Manaj. Inf. Kesehat. Indones., vol. 7, no. 1, pp. 44–51, Mar. 2019, doi: 10.33560/jmiki.v7i1.220.
A. S. Wariyanti, H. Harjanti, and S. Sugiarsi, “Potret Kelengkapan Rekam Medis Puskesmas Sebelum dan Setelah Akreditasi,” J. Manaj. Inf. Kesehat. Indones., vol. 7, no. 2, pp. 152–157, Oct. 2019, doi: 10.33560/jmiki.v7i2.248.
I. Irmawati, A. Danuri, S. Sudiyono, and F. Rahmawati, “Analisis Kuantitatif Rekam Medis Pasien Rawat Inap Di Bangsal Mawar RSUD Ungaran,” J. Rekam Medis dan Inf. Kesehat., vol. 1, no. 1, pp. 11–15, Mar. 2018, doi: 10.31983/jrmik.v1i1.3574.
S. J. Swari, G. Alfiansyah, R. A. Wijayanti, and R. D. Kurniawati, “Analisis Kelengkapan Pengisian Berkas Rekam Medis Pasien Rawat Inap RSUP Dr. Kariadi Semarang,” Arter. J. Ilmu Kesehat., vol. 1, no. 1, pp. 50–56, Nov. 2019, doi: 10.37148/arteri.v1i1.20.
S. N. Ulfa and L. Widjaya, “Faktor-Faktor Yang Mempengaruhi Kelengkapan Rekam Medis Rawat Inap Dengan Menggunakan Diagram Fishbone di Rumah Sakit Pertamina Jaya Tahun 2017,” Indones. Heal. Inf. Manag. J., vol. 5, no. 1, pp. 39–44, 2017, doi: https://doi.org/10.47007/inohim.v5i1.141.
A. Maliki, Saimi, and H. Purnama, “Analisis Ketidaklengkapan Dokumen Rekam Medis Pada Kasus Rawat Inap di RSUD Patut Patuh Patju Gerung,” J. Kesehat. Qamarul Huda, vol. 6, no. 1, pp. 17–23, 2018.
I. S. Purwanti, D. Prihatiningsih, and N. L. P. Devhy, “Studi Deskriptif Kelengkapan Dokumen Rekam Medis,” J. Rekam Medis dan Inf. Kesehat., vol. 3, no. 1, pp. 36–39, Mar. 2020, doi: 10.31983/jrmik.v3i1.5194.
H. Zhang, L. Feng, J. Wang, T. Zhu, and L. Jin, “Investigating product innovation pathway from a modular standpoint: A case study of large aircraft assembly line,” Heliyon, vol. 10, no. 1, pp. 1–11, Jan. 2024, doi: 10.1016/j.heliyon.2023.e23356.
H. A. Asih and I. Indrayadi, “Perkembangan Rekam Medis Elektronik di Indonesia: Literature Review,” J. Promot. Prev., vol. 6, no. 1, pp. 182–198, 2023, doi: https://doi.org/10.47650/jpp.v6i1.736.
Kementerian Kesehatan Republik Indonesia, Keputusan Menteri Kesehatan Republik Indonesia Nomor 129 Tahun 2008 Tentang Standar Pelayanan Minimal Rumah Sakit. Jakarta: Kementerian Kesehatan Republik Indonesia, 2008.
Komisi Akreditasi Rumah Sakit (KARS), Instrumen Survei Akreditasi KARS Sesuai Standar Akreditasi RS Kemenkes. Jakarta: Komisi Akreditasi Rumah Sakit (KARS), 2022.
Kementerian Kesehatan Republik Indonesia, Peraturan Menteri Kesehatan Nomor 24 Tahun 2022 tentang Rekam Medis. Jakarta: Kementerian Kesehatan Republik Indonesia, 2022.
Pemerintah Indonesia, Peraturan Pemerintah (PP) Nomor 71 Tahun 2019 tentang Penyelenggaraan Sistem dan Transaksi Elektronik. Jakarta: Pemerintah Indonesia, 2019.
J. Tarigan, “Akibat Hukum Tanda Tangan Elektronik Dokumen Digital Dalam Pembuktian Perdata,” J. Rechten Ris. Huk. dan Hak Asasi Mns., vol. 3, no. 3, pp. 33–38, Jun. 2022, doi: 10.52005/rechten.v3i3.77.
Konsil Kedokteran Indonesia, Manual Rekam Medis. Jakarta: Konsil Kedokteran Indonesia, 2006.
A. H. Alghamdi, A. M. Ibrahim, W. A. Asrar, K. Alsharef, and M. H. Alshehri, “Assessment of the completeness and quality of medical records used in the primary health care centers: case study in Jeddah, Western Region, Saudi Arabia,” Int. J. Acad. Res., vol. 6, no. 4, pp. 60–64, 2014.
S. Suyoko, F. Agiwahyuanto, D. Ernawati, J. Prasetya, and M. T. Abiyasa, “Analisis Data Rekam Medis Elektronik di Rumah Sakit (Studi Perancangan Dan Evaluasi Sistem Informasi Analisis Kuantitatif),” J-REMI J. Rekam Med. dan Inf. Kesehat., vol. 5, no. 3, pp. 219–233, 2024, doi: https://doi.org/10.25047/j-remi.v5i3.4666.
E. L. Irwanto, S. Syofyan, and Y. A. Mannas, “Urgensi Pembuktian Rekam Medis Elektronik Dalam Perspektif Hukum Di Indonesia,” UNES Law Rev., vol. 5, no. 4, pp. 1641–1653, 2023, doi: https://doi.org/10.31933/unesrev.v5i4.496.
S. Setiatin, I. S. Ningrum, and A. Z. Andhani, “Evaluasi E-Medrec pada Bagian Analisis Rekam Medis Kuantitatif Rawat Inap di Rumah Sakit TK II Dustira Cimahi,” J. Ilm. Perekam dan Inf. Kesehat. Imelda, vol. 8, no. 2, pp. 231–241, Aug. 2023, doi: 10.52943/jipiki.v8i2.1379.
Rangga, Y. Syahidin, and M. Hidayati, “Perancangan Sistem Informasi Kelengkapan Rekam Medis Rawat Jalan Dengan Metode V-Model,” J. Teknol. Inf., vol. 3, no. 2, pp. 1–12, 2021.
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2024 Faik Agiwahyuanto, Suyoko Suyoko, Sylvia Anjani, Maulana Tomy Abiyasa, Jaka Prasetya

This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.