Rumah sakit merupakan institusi pelayanan kesehatan yang menyelenggarakan pelayanan kesehatan secara paripurna. Salah satu pelayanan yang ada di rumah sakit adalah rekam medis. Kemajuan zaman menuntut rumah sakit untuk terus mengembangkan teknologi informasi, khususnya rekam medis. Selain kemajuan zaman, setiap tahun jumlah kunjungan pasien terus meningkat, sehingga volume pekerjaan akan semakin padat. Oleh karena itu dibutuhkan penerapan teknologi informasi berupa rekam medis elektronik yang keberadaannya sangat membantu petugas rekam medis. Tujuan penelitian ini adalah mengetahui penerapan teknologi informasi di unit rekam medis RSUD Ngudi Waluyo Wlingi. Metode penelitian yaitu kualitatif dengan pendekatan case study. Objek penelitian adalah pelaksanaan penyelenggaraan rekam medis dengan informan yaitu petugas rekam medis. Hasil penelitian yaitu penerapan teknologi informasi di unit rekam medis RSUD Ngudi Waluyo berupa layanan mesin fingerprint, medical online service berupa SMS gateway, dan sistem informasi manajemen. Penerapan teknologi tersebut telah mampu membantu petugas rekam medis dalam melaksanakan tugas dan meningkatkan pelayanan kepada pasien. Kesimpulan dari penelitian ini yaitu RSUD Ngudi Waluyo Wlingi telah menerapkan teknologi informasi dalam penyelenggaraan rekam medis walaupun tidak secara keseluruhan. Penerapan teknologi informasi mampu mempercepat kerja petugas dan antrian pasien lebih efisien.
Recording and reporting has now undergone a process of evolution from paper to digital. Likewise, the recording and reporting of health services in the City of Probolinggo uses the SIDeKa-Pro application. In practice, there are still health service facilities that are late in filling out data in the SIDeKa-Pro application. As many as 56% of health care facilities in Probolinggo City in 2020 were late in filling out the top 10 outpatient disease data in the SIDeKa-Pro application. Then, as many as 38% of health service facilities in Probolinggo City in January -March 2021 were late in filling out data on the top 10 outpatient diseases in the SIDeKa-Pro application. The purpose of this study was to determine the level of data occupancy of the top 10 outpatient diseases before and after standard operating procedures (SOP). This study used a cohort study. This type of research is experimental, namely one shoot case study. The population in this study were all data managers in health facilities that had been registered in the SIDeKa-Pro application as many as 32 health care facilities. The sampling technique used is total sampling. The existence of the SOP for Data Filling in SIDeKa-Pro was able to increase the discipline of health care facility managers in filling out data for the top 10 outpatient diseases in the SIDeKa-Pro application. This study only examines the level of discipline in data entry. For further research, it is possible to examine the effect of SOP on employee performance. This research can be useful across organizations that utilize applications in data recording and reporting.
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