Every hospital is required to maintain medical records. In the medical record there is a medical resume form which is very important to complete, because it contains the entire medical history of the patient. Problems were still found related to filling out incomplete medical resume forms at Batu Bara General Hospital.The purpose of this study was to determine the factors related to the completeness of inpatients medical resume at Batu Bara General Hospital. This type of research used an observational research method by using cross sectional design. The total population were 36 doctors who work at Batu Bara General Hospital.The sampling technique used total sampling. The research instrument was questionnaire and checklist sheet. Data analysis used Chi Square test. The results showed that from 36 doctors, 23 doctors (64%) had knowledge in the good category about filling out medical resume sheets and 13 doctors (36%) had knowledge in the poor category while 27 doctors (75%) had attitudes in the good category. and 9 doctors (25%) had bad attitude.The results of Chi Square test showed that there was significant relationship between doctor's knowledge and the completeness of a medical resume with P value of (0.003) (P-value <0.05) and Prevalence Ratio (PR) = 0.081. Meanwhile, the results of the Chi Square test showed that there was a significant relationship between the attitude of doctor and completeness of medical resume with P value (0.021) (P-value <0.05) and Prevalence Ratio (PR) = 0.200. The hospital should provide understanding and socialization to doctors that it is important to complete medical records, especially on medical resume sheets
Perkembangan zaman telah menjadikan kebutuhan semakin kompleks. Kebutuhan akan kemudahan dalam mengakses teknologi mengharuskan suatu perusahaan untuk meningkatkan kinerjanya demi memenuhi faktor kepuasan pelanggan Pentingnya penggunaan teknologi informasi mulai disadari oleh organisasi modern, terutama dalam era globalisasi dimana perusahaan/instansi dituntut untuk semakin kompetitif dan berdaya saing. Oleh karena itu menjadi penting untuk memacu tingkat pemanfaatan dan penggunaan teknologi informasi di organisasi. Manfaat penggunaan Rekam Medis Elektronik (RME) telah diakui secara luas. Salah satu manfaatnya adalah pemeriksaan data yang berkelanjutan berkualitas, terutama ketika pembuatan dan pengumpulan data dilakukan secara otomatis. Misalnya data dari perangkat laboratorium, atau dari radiologi. Manfaat lain kemampuan penyimpanan data dalam jumlah besar dalam waktu komputasi singkat, menghasilkan hasil yang handal. Tujuan dari pemanfaatan RME sebagai solusi berbasis Informasi Teknologi (IT) yang dapat meningkatkan pertukaran informasi dan komunikasi antar tenaga kesehatan yang lebih efektif karena data saling terintegrasi. Metode penyuluhan dilakukan menggunakan peresentasi dan interaksi kepada pegawai di Rumah Sakit Umum Cut Meutia Kabupaten Aceh Utara. Kesimpulan akhir dari kegiatan pengabdian masyarakat ini adalah dari kegiatan penyuluhan pegawai dapat mempermudahkan pekerjaanya dengan pemanfaatan rekam medis elektronik di instalasi rawat jalan rumah sakit
The implementation of RME will be able to provide effective and efficient management of patients, doctors and clinics as well as improve good outcomes for hospitals. The purpose of the study was to determine the relationship between business expectations and performance expectations with the use of electronic medical records by outpatient installation officers at the Cut Meutia General Hospital, North Aceh Regency in 2022. The type of research is quantitative research, the nature of the research is cross-sectional. This research was conducted at the outpatient installation of the Cut Meutia General Hospital, North Aceh. The study population was all employees in the outpatient installation, totaling 337 people. The sample in the study amounted to 185 people. The results showed that there was a relationship between business expectations and the use of electronic medical records in the outpatient installation of the Cut Meutia General Hospital, North Aceh. There is a relationship between performance expectations and the use of electronic medical records in the outpatient installation of the Cut Meutia General Hospital, North Aceh. It is recommended to the management of the Cut Meutia General Hospital, North Aceh in an effort to further increase business expectations and productivity of officers' performance in order to encourage and motivate officers to continue their education to a higher level or attend seminars in accordance with their disciplines.
Hospitals are required to have a SIMRS that functions according to Law of the Republic of Indonesia Number 44 of 2009 concerning raft houses. However, based on data from the Ministry of Health in 2019 out of 2,761 hospitals in Indonesia, only 1,564 hospitals (56%) use SIMRS and function. The purpose of this study was to analyze the factors associated with the use of SIMRS in Sembiring General Hospital using a cross sectional research design. Total population of 258 people, with a total sample of 72 health workers using a proportional stratified random sampling method. The research instrument is a questionnaire. Data analysis methods are univariate, bivariate with chi square test and multivariate with multiple linear regression tests. The results showed that of 72 health workers as many as 47 people (65%) stated that the use of SIMRS was in the good category and 35 people (35%) stated that the utilization of SIMRS was in the poor category. The results of the bivariate analysis address effort expectations, performance expectations, social influence and facilitating conditions related to the use of SIMRS with a value of p <0.05. The results of multivariate analysis showed that efforts expectations were the factors most related to the use of SIMRS with a coefficient value (0.012). It is recommended that hospitals provide SIMRS that is easy to operate, in order to improve the performance of health workers with the influence of a good social environment and the conditions of the supporting facilities.
Memiliki rekam medis sangat penting untuk mencapai tertib administrasi di rumah sakit. Masih terdapat permasalahan di RSUD Deli Medan terkait dengan perilaku pengisian dokumen rekam medis dimana ditemukan dokumen rekam medis yang tidak diisi secara lengkap. Hal ini disebabkan karena keterbatasan waktu pemberi pelayanan saat kunjungan pasien banyak, kurangnya kesadaran petugas tentang pentingnya melengkapi pengisian rekam medis. Tujuan penelitian ini adalah hubungan antara pengetahuan tentang nilai guna rekam medis dengan perilaku pengisian dokumen rekam medis oleh petugas kesehatan di RSUD Deli Medan dengan pendekatan cross sectional. Jumlah populasi 133 orang, dengan jumlah sampel 57 orang dan metode pengambilan sampel adalah proportional stratified random sampling. Instrumen penelitian menggunakan angket dan observasi. Analisis data menggunakan uji Spearman Rank. Hasil penelitian menunjukkan 57 tenaga kesehatan sebanyak 20 orang (35%) memiliki pengetahuan dalam kategori baik tentang nilai guna rekam medis dan 37 orang (65%) memiliki pengetahuan dalam kategori kurang sedangkan 17 orang (30%) kesehatan pekerja memiliki perilaku baik dalam kategori baik dan 40 orang (70%) memiliki perilaku dalam kategori buruk. Hasil uji korelasi menunjukkan bahwa terdapat hubungan yang signifikan antara pengetahuan tentang nilai guna rekam medis dengan perilaku pengisian dokumen rekam medis dengan nilai p-value (0,000 0,05) dan nilai koefisien korelasi sebesar 0,645. Disarankan agar pihak rumah sakit memberikan pelatihan dan sosialisasi kepada tenaga kesehatan untuk meningkatkan kinerja dalam proses pendokumentasian rekam medis
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