bluuebunny/crossref_metadata_2025 huggingface dataset:
ANALISIS PENYEBAB UNCLAIMED BERKAS BPJS PASIEN RAWAT INAP DI RUMAH SAKIT UMUM IMELDA PEKERJA INDONESIA (RSU IPI) MEDAN
Authors: Valentina  , Niat Sehati Halawa Merlin
Published: December 2021

Pending atau sering disebut dengan unclaimed yang artinya tidak terklaim atau tertunda. Hal ini disebabkan terdapat kasus yang ditatalaksanakan di rumah sakit tersebut diragukan kesimpulan medisnya karena ketidakcocokan atau ketidaklengkapan data-datanya. Tujuan penelitian ini untuk menganalisis penyebab unclaimed berkas BPJS pasien rawat inap berdasarkan identifikasi input dan proses. Jenis penelitian ini menggunakan metode kualitatif dengan fenomenologi. Waktu penelitian dilakukan pada bulan Februari-Juli 2018 di RSU Imelda Pekerjaan Indonesia Medan. Populasi yaitu rekam medis BPJS rawat jalan yang dipending pada bulan Februari-Juli 2018 sebanyak 490 berkas. Sampel diambil secara proposional stratified random sampling yang berjumlah 83 berkas. Informan kunci berjumlah 6 orang yang terdiri dari 1 orang kepala ruangan BPJS RSU IPI,3 orang  petugas koder BPJS RSU IPI dan 2 orang petugas administrasi BPJS. Data dikumpulkan melalui wawancara dan observasi. Untuk analisis data dirangkum secara deskriptif melalui reduksi data, penyajian dan penarikan kesimpulan. Hasil penelitian ini menunjukkan penyebab unclaimed berkas BPJS pasien rawat inap di Rumah Sakit Umum Imelda Pekerja Indonesia (RSU IPI) Medan adalah jumlah SDM, sarana, teknologi, perencanan berupa ketersediaan SOP, dan evaluasi. Berdasarkan 83 berkas BPJS yang terpending ada 45% berkas BPJS dikarenakan dari kesalahan pengkodingan, 22% dikarenakan dari indikasi medis dan 33% dikarenakan  administrasi. Disarankan untuk pihak rumah sakit agar menambah jumlah SDM, perbaikan terhadap sarana dan teknologi, perencanaan dan evaluasi sehingga dapat menurunkan jumlah unclaimed berkas BPJS pada rumah sakit.
TINGKAT PENGETAHUAN PETUGAS REKAM MEDIS TERHADAP PELAKSANAAN PENYUSUTAN DAN PEMUSNAHAN BERKAS REKAM MEDIS DIRUMAH SAKIT UMUM MADANI MEDAN TAHUN 2018
Authors: Syahputra Wiguna Ary , Fahrani Aulia
Published: December 2021

Penyusutan rekam medis merupakan suatu kegiatan pengurangan arsip dari rak penyimpanan dengan cara memindahkan berkas rekam medis in-aktif dari rak aktif ke rak in-aktif. Pemusnahan rekam medis merupakan suatu kegiatan penghancuran secara fisik arsip rekam medis yang telah berakhir fungsi dan nilai guna rendah. Pengetahuan Petugas rekam medis sangat mempengaruhi terhadap berlangsungnya proses penyusutan dan pemusnahan berkas rekam medis. Tujuan penelitian ini adalah untuk mengetahui tingkat pengetahuan petugas rekam medis terhadap pelaksanaan penyusutan dan pemusnahan berkas rekam medis dirumah sakit Madani Medan Tahun 2018. Tempat yang dipilih menjadi tempat penelitian adalah Rumah Sakit Umum Madani Medan. Metode penelitian analitik cross sectional dengan pendekatan observasi.  Populasi dalam penelitian ini adalah petugas rekam medis yang berjumlah 10 orang. sampel dalam  penelitian ini adalah seluruh pegawai di unit rekam medis yang berjumlah 10 orang pegawai rekam medis. Dari hasil penelitian diperoleh data bahwa Lebih dari 80 % petugas rekam medis tidak mengerti mengenai proses penyusutan dan pemusnahan berkas rekam medis sehingga mengakibatkan belum terlaksanakannya proses penyusutan dan pemusnahan di Rumah Sakit Umum Madani Medan. peneliti dapat menarik kesimpulan bahwasanya Tingkat Pengetahuan Petugas Rekam Medis di Rumah Sakit Umum Madani sangat kurang sehingga peneliti menyarankan agar kepada pihak rumah sakit untuk dapat menambah petugas rekam medis yang berlulusan D3 rekam medis.
TINJAUAN SISTEM PENYIMPANAN REKAM MEDIS MENURUT STANDAR AKREDITASI PUSKESMAS DI PUSKESMAS SUKARAMAI TAHUN 2019
Authors: Valentina
Published: December 2021

Sistem penyimpan rekam medis menjadi salah satu penilaian dalam standar akreditasi puskesmas. Sistem penyimpanan berkas rekam medis sangat penting untuk dilakukan dalam institusi pelayanan kesehatan, karena sistem penyimpanan dapat mempermudah berkas rekam medis yang akan disimpan dalam rak penyimpanan, mempercepat ditemukan kembali atau pengambilan berkas rekam medis yang disimpan di rak penyimpanan, mudah pengembaliannya, dan melindungi berkas rekam medis dari bahaya pencurian, bahaya kerusakan fisik, kimiawi, dan biologi. Tujuan penelitian ini untuk mengetahui penyimpanan rekam medis berdasarkan standar akreditasi puskesmas di Puskemas Sukaramai. Jenis penelitian menggunakan metode penelitian kualitatif dengan pendekatan fenomologi. Penelitian dilakukan pada bulan Oktober 2018-Januari 2019. Populasi adalah seluruh petugas rekam medis di Puskesmas Sukaramai. Sampel penelitian berjumlah 6 orang yang diambil secara purposive sampling. Instrumen penelitian yaitu pedoman wawancara dan direkam menggunakan alat perekam audio serta lembar check list untuk observasi. Hasil penelitian diketahui bahwa sistem penyimpanan yang dilakukan di Puskesmas Sukaramai menggunakan family folder, sistem penjajarannya menggunakan Straight Numerical Filing (SNF), pengambilan berkas rekam medis masih sering dilakukan oleh petugas lain yang bukan petugas rekam medis, tidak adanya penggunaan tracer, dan belum menggunakan buku ekspedisi peminjaman, serta sistem pengembalian berkas rekam medis tidak dipulangakan pada akhir jam kerja. Disarankan bagi pihak puskesmas untuk menambah jumlah petugas rekam medis sesuai kualifikasi pendidikan formal serta pembagian tugas tanggung jawab yang jelas, memberikan pelatihan pada petugas filling, pengambilan rekam medis hanya dilakukan oleh petugas filling, membuat tracer dan buku ekspedisi peminjaman rekam medis serta menentukan waktu pengembalian berkas rekam medis.
TINJAUAN SISTEM PENYIMPANAN BERKAS REKAM MEDIS DI RUMAH SAKIT UMUM PUSAT H ADAM MALIK TAHUN 2019
Authors: Andi Ritonga Zulham , Maya Sari Faradila
Published: December 2021

Pelaksanaan rekam medis dimulai dari penerimaan pasien sampai dengan pengambilan kembali berkas rekam medis. Salah satu bagian yang sangat berperan yaitu penyimpanan berkas rekam medis yang baik dan bebas dari akses informasi terhadap orang-orang yang tidak mempunyai kepentingan pada pelayanan kesehatan. Desain penelitian yang digunakan adalah kualitatif dengan menggunakan pedoman wawancara dan observasi. Lokasi penelitian dilakukan di Rumah Sakit Umum Pusat (RSUP) H Adam Malik Medan. Informan dalam penelitian ini adalah seluruh petugas penyimpanan berkas rekam medis di RSUP H Adam Malik sebanyak 9 orang. Hasil penelitian menunjukkan bahwa sistem penjajaran berkas rekam medis yang diterapkan di  RSUP H Adam Malik Medan menggunakan sistem angka akhir. Penyimpanan menurut lokasi menggunakan sentralisasi yaitu berkas rekam medis rawat jalan dan rawat inap dijadikan satu file. Adanya prosedur penyimpananan, penjajaran, peminjaman, pengambilan dan penomoran berkas rekam medis. Dari hasil wawancara dan observasi faktor yang memengaruhi penyimpanan berkas rekam medis adalah petugas penyimpanan, prosedur dan fasilitas yang mendukung dalam penyimpanan berkas rekam medis.
GAMBARAN APLIKASI PENGINGAT PASIEN TB PARU BERBASIS SMS GATEWAY DI PUSKESMAS GLUGUR DARAT
Authors: Noviar Panggabean Terry , Putra Marpaung Andreas
Published: December 2021

Perkembangan dan kemajuan teknologi di berbagai bidang, dapat dimanfaatkan pada bidang kesehatan khususnya untuk dapat membantu dalam proses pengobatan. Beberapa bentuk pemanfaatan kemajuan teknologi pada bidang kesehatan yang banyak digunakan misalnya Rontgent, scanning, pemeriksaan darah, serta berbagai aplikasi yang digunakan oleh pihak Puskesmas untuk melayani pasien. Salah satu bentuk layanan pasien yang memanfaatkan teknologi adalah dengan cara memberikan layanan pengobatan kepada pasien di rumah. Pengelolaan sumberdaya informasi secara efektif bagi organisasi asuhan kesehatan sama pentingnya dengan menjaga informasi yang up to date. Informasi adalah sumberdaya kritis yang perlu dipelihara dengan hati–hati sebagaimanasumberdaya manusia, sumberdaya keuangan dan perlengkapan utama. Dalam era globalisasi pemerintah dalam memberikan pelayanan kesehatan kepada pasien sangat diutamakan dan merupakan hal yang penting. Pelayanan yang didapatkan oleh pasien adalah pelayanan yang cepat, praktis dan memungkinkan agar pasien tidak pindah ke tempat lain untuk mendapatkan kepuasan yang lebih baik. Walaupun sebenarnya unit rekam medis merupakan jenis pelayanan yang relatif sederhana tetapi perlu diperhatikan karena di unit ini tempat mencatat dan menampilkan kembali data pasien sehingga sangat berperan penting, ini berhubungan dengan kesan pertama dan rasa nyaman dalam proses selanjutnya yang akan berlangsung. Pengambilan data digunakan untuk mendapatkan data sampel sebagai acuan untuk pengembangan perangkat lunak. Data yang dimaksud adalah data pasien TB Paru di Puskesmas Glugur Darat yang telah mendaftar di loket.  Data yang digunakan untuk implementasi, data kunjungan pasien di gunakan sebagai data penghitung tingkat kesuksesan perangkat lunak di Puskesmas Glugur Darat.
HUBUNGAN RIWAYAT SAKIT DAN ASUPAN GIZI (ENERGI DAN PROTEIN) DENGAN STATUS GIZI LANSIA DI WILAYAH KERJA PUSKESMAS PADANGMATINGGI KOTA PADANGSIDIMPUAN
Authors: Christy Johanna
Published: December 2021

One of the increasing benchmarks of the progress of a nation is seen from the life expectancy of its population. Increasing life expectancy is reflected in the increasing number of elderly (elderly) population. The increasingly elderly population in Indonesia will have a major impact on the management of health problems. This study aims to see aims to know the history of illness, energy intake and protein intake with nutritional status in the elderly in the work area of ​​Padangmatinggi in Padangsidimpuan Health Center.This research type is quantitative with cross sectional research design. This study was conducted by assessing the food method of food recall 24 hours. Nutritional status with IMT / U. The sample in this study amounted to 100 people who are elderly. Data analysis is univariate, and bivariate with Chi Square Test. The result of bivariate test shows that there is correlation between history of illness (p=0,000), energy intake (p=0.000), and protein intake (p=0.000) with nutritional status. Cadres should more often give counseling about balanced nutrition to the community, especially elderly to improve knowledge, attitudes, and behavior of balanced nutrition in elderly and always monitor nutritional status of elderly through posyandu elderly in order to maintain normal BMI. The health office is more often to monitor the nutritional status and health of the elderly in the working area of ​​Padang municipal health center of Padangsidimpuan in order to maintain the normal nutritional status in the elderly and the elderly to avoid degenerative diseases.
ANALYSIS OF OPERATING REPORT FORM DESIGN IN SPECIAL KIDNEY RASYIDA MEDAN
Authors: Purba Erlindai
Published: December 2021

Abstract

 

Form design is the activity of designing a form based on the transaction needs of service activities and the preparation or preparation of organizational reports. The surgery report is a surgical procedure for patients. To find out the design of the operation report form at the Rasyida Kidney Special Hospital in 2018. This type of research is a qualitative descriptive study. This research was conducted at the Rasyida Kidney Hospital in Medan, the population and sample used in this study were 1 Operation Report form used at the Rasyida Kidney Hospital in Medan, using the observation method. Based on the results of research on the design of the operation report form in Medan Rasyida Kidney Hospital, the anatomic aspects have not included a complete form heading and there is no clear introduction. From the physical aspect it is not appropriate because it still uses Kuwarto paper with a weight of 70 grams. While the content aspect is appropriate because it has been adapted to the 2008 Minister of Health Regulation. Based on the results of the study it can be suggested that the paper material should be replaced with A4 paper of at least 80 grams to reduce the risk of tearing and the need to add an explanation about filling out the operating report.
PENGARUH KELENGKAPAN PENGISIAN MEDICAL DISCHARGE SUMMARY PASIEN RAWAT INAP TERHADAP IMPLEMENTASI SNARS EDISI 1 ELEMEN PENILAIAN MIRM 15 DI RUMAH SAKIT AMC CILEUNYI
Authors: Sonia Dina , Maulinabila Ayulia
Published: December 2021

This research aims to determine the effect of fillings completeness of inpatient medical discharge summary on implementation SNARS 1st  edition MIRM 15 valuation element at Rumah Sakit AMC Cileunyi.The research method used quantitative method with descriptive approach, The data collecting that by distributing quessioneir, observation, interview and compeleted with literature study which has a close relevance to the problem. The sampling technique used is sampling technique saturated.From the research of this research, the problem that arise among others: 1) The high number of incomplete replenishment of inpatien medical discharge summary. 2) The absence of standard procedure operational (SPO) for discharge summary, and 3) Unfulfilled SNARS accreditation standard 1st edition MIRM 15 valuation element related discharge summary The advice given to fix the problem is 1) Make a review team every room that aims to coordinate and control the incomplete doctor registers. It is expected that the doctor may improve the completeness of the filling of medical records. 2) Socializing the new design in accordance with the provisions of the SNARS edition 1 MIRM 15 valuation element and reinforcing the filling instructions by making the SPO filling discharge summary.
ANALISIS KEBUTUHAN SUMBER DAYA MANUSIA TERHADAP BEBAN KERJA DI BAGIAN REKAM MEDIS MENGGUNAKAN METODE (WORK LOAD INDICATOR STAFFING NEED) DI RUMAH SAKIT UMUM PERMATABUNDA MEDAN TAHUN 2019
Authors: Melati Hutauruk Puput , Br Gurning Meha Marito
Published: December 2021

Human Resources (HR) is needed so that the availability of qualified medical personnel and in accordance with the needs of medical personnel needed to ensure the implementation of health development in order to improve the highest degree of public health. The purpose of this research is to know the planning of human resources (HR) needs of the medical record unit at the Medan Permata Bunda Hospital This type of research is descriptive. The method used in this study is the method of observation and interviews. The population in this study was a medical record unit of 9 people. Samples were taken by total sampling. Available working time based on the amount of effective work totaling 2475 / year, in 1 effective working day is 7 hours. The number of outpatient visits was 43669 patients / year, while the number of inpatient visits was 9284 patients / year. The standard time allowance for officers is 0.01 minutes. Based on the calculation of workforce requirements using the WISN formula that has been carried out in the medical record unit of the Permata Bunda General Hospital in Medan, there were 13 officers, and the number of officers in the medical record unit was 9 people. It is recommended to Permata Bunda General Hospital to add 4 medical record officers with D3 Medical Record education qualifications.
TINJAUAN KEPUASAN PASIEN DI PELAYANAN RAWAT JALAN TERHADAP WAKTU TUNGGU PENYEDIAAN BERKAS REKAM MEDIS DI RSU IMELDA PEKERJA INDONESIA MEDAN TAHUN 2019
Authors: Simanjuntak Marta
Published: December 2021

The outpatient registration place is the place where patients first met with the officer, ideally the average waiting time for record services is 10 minutes. The purpose of this study was conducted to determine patient satisfaction with the waiting time for the provision of medical records in RSU Imelda Workers Indonesia Medan. Methodology This research uses descriptive research method with a quantitative approach. The tools used were questionnaire and Likert scale. The population in this study were all outpatients. The sample size was 30 patients and the medical record file. Data analysis uses univariate analysis. The sampling technique uses accidental sampling. This research was conducted at the Imelda Indonesian Workers Hospital in Medan. From this study the results obtained by the time required by officers to provide medical record files are 11 medical record files (36.7%) right and 19 medical record files (63.3%) incorrect. The level of outpatient satisfaction based on 5 dimensions, namely the Responsiveness dimension, said 12 patients were satisfied (40%), the Reability dimension stated 19 patients were dissatisfied (63.3%), the Assurance dimension was satisfied as many as 15 patients (50%), the Emphaty dimension stated as many as 14 patients (46.7%), and Tangible dimensions stated that they were quite satisfied as many as 17 patients (56.7%). Conclusion, The level of patient satisfaction is mostly stated quite satisfied. Suggestions, It is necessary to improve the performance of health services from the Reability dimension through work culture efforts, such as the formation of a compact working group because they have received training in accordance with technological developments and community expectations, so that health care workers are responsive, timely and accurate in serving patients.
Analisis Kelengkapan Formulir A (Evaluasi Awal MPP) Dan Formulir B (Catatan Implementasi) Pasien Rumah Sakit
Authors: Yasli Dicho Zhuhriano , Leonard Devid , Srimayarti Berly Nisa
Published: December 2021

Completeness of the Inpatient Examination Form is a problem that often causes complaints in several hospitals. The purpose of this study was to conduct a literature review related to the incomplete analysis of filling in form A, MPP Initial Evaluation and Form B Implementation Notes. The collection method is secondary data, the steps are determining keywords, exploration and title selection, reading articles that have not been eliminated. At that stage, the reference list of selected articles is reviewed to determine other related studies. The articles contained in the summary list The results of the literature review, namely, still found incompleteness in filling out medical record forms, the responsibilities and attitudes of officers in filling out medical record files can be said to be still not optimal. The human resources involved are still lacking, for example the assembling officer also serves the file preparation so that the assembly function is not optimal. Based on the literature review of several related articles, further research is needed on other causes of incompleteness in filling out medical record file forms and the obstacles experienced by doctors in filling out medical record files.
Tinjauan Pelaksanaan Kerahasiaan Rekam Medis Di Puskesmas Kuranji Padang
Authors: Maisa Putra Deni , Rahmadhani
Published: December 2021

The medical record is also a documentation of the patient's condition and the contents of the medical record are medical secrets, especially in the storage of status in the filling room, which must be kept confidential, secure, and the medical record layout, whether it is appropriate or not by every health worker. The purpose of this study was to determine the Knowledge Review and Attitudes of Officers and Patients on the Confidentiality of Medical Record Files Primary Health Center at Kuranji Padang. This type of research is descriptive with a quantitative approach, the research sample is 90 patients and 4 health center officers using accidental sampling technique with data collection using questionnaires for patients and table cklis for officers. The results showed that there are still officers whose knowledge and attitude in maintaining the confidentiality of medical records (50%) or 2 people are still lacking and more than half of the knowledge (51.1%) and attitudes (52.2%) of patients towards maintaining the confidentiality of record files medical who do not understand and know. It can be concluded that Kuranji Primary Health Center, both patients and officers, is still lacking in maintaining the confidentiality of medical records. It is hoped that the head of the Primary Health Center will prepare Standard Operating Procedures (SOP) on medical records so that officers and patients know about medical records and about the confidentiality of medical records. In implementing the confidentiality of medical records, competent and professional medical record officers should know and understand more about medical records, participate in training and provide information to patients so that the confidentiality of medical records is maintained and can create good service.
Ketidaktepatan Kode Diagnosis Kasus Neoplasma Menggunakan ICD-10 Di RSUP H.Adam Malik Medan Tahun 2019
Authors: Christy Johanna , Evi Efriamta Siagian
Published: December 2021

ABSTRAK

                Informasi peyakit dirumah sakit tidak akan lengkap dan bermanfaat apabila belum diolah, maka untuk itu perlu dilakukan pengkodean. Penelitian ini bertujuan untuk mengetahui ketepatan kode diagnosis pada kasus neoplasma menggunakan ICD-10 di RSUP. H. Adam Malik tahun 2019. Penelitian ini menggunakan metode kuantitatif dengan pendekatan cross sectional, Jumlah sampel yang digunakan sebanyak 93 dokumen dan 4 orang responden. Ketepatan kode morfologi diagnosis neoplasma diperoleh hasil 88 (95%) kode tepat 6 karakter, 0 (0%) kode tepat 5 karakter, 0 (0%) kode tepat 4 karakter, 3 (3%) kode tidak tepat sama sekali dan 2 (2%) tidak dikode. Ketepatan kode topografi diperoleh hasil 79 (85%) kode tepat 4 karakter, 8 (9%) kode tepat 3 karakter, 4 (4%) kode tepat 2 karakter, 0 (0%) kode tepat 1 karakter, 0 (0%) kode tidak tepat sama sekali dan 0 (0%) kode tidak dikerjakan. Faktor yang menjadi penyebab ketidaktepatan dalam pengodean adalah petugas coding sulit untuk membaca tulisan dokter sehingga penulis menyarankan sebaiknya dalam pengkodingan diagnosis tetap mengikuti kaidah dan aturan yang ada pada ICD-10.

 

Kata Kunci: Ketepatan, Diagnosis, Neoplasma, Pengkodean

 

 

Abstract

Information for patients in hospitals will not be complete and useful if it has not been processed, so coding is necessary. This study aims to determine the accuracy of the diagnosis code in cases of neoplasm using ICD-10 in RSUP. H. Adam Malik in 2019. This study used a quantitative method with a cross sectional approach. The number of samples used was 93 documents and 4 respondents. The accuracy of the morphological code for the diagnosis of neoplasm was 88 (95%) the code was exactly 6 characters, 0 (0%) the code was exactly 5 characters, 0 (0%) the code was exactly 4 characters, 3 (3%) the code was not correct at all and 2 ( 2%) is not coded. The accuracy of the topographic code is 79 (85%) the code is exactly 4 characters, 8 (9%) the code is exactly 3 characters, 4 (4%) the code is exactly 2 characters, 0 (0%) the code is exactly 1 character, 0 (0%) code is not correct at all and code 0 (0%) is not working. The factor that caused the inaccuracy in coding was that it was difficult for coding officers to read the doctor's writings, so the authors suggested that the coding of the diagnosis should still follow the rules and regulations in the ICD-10.

 

Keywords: Accuracy, Diagnosis, Neoplasm, Encoding
Perancangan Ulang Formulir Rawat Jalan Untuk Mendukung Praktik Di Laboratorium RMIK Unjaya
Authors: Puspita Ningsih Kori , Hardjo Kuswanto
Published: December 2021

Laboratorium Prodi RMIK (D-3) Fakultas Kesehatan Universitas Jenderal Achmad Yani Yogyakarta (Unjaya) memiliki formulir rawat jalan. Saat ini format formulir masih minimal, belum menggambarkan format dokumentasi rekam medis yang terintegrasi. Penelitian ini menggunakan metode deskriptif, dengan pendekatan studi kasus. Subjek penelitian ini adalah Ketua Prodi RMIK (D-3), Kepala Laboratorium, dosen dan staf laboratorium Prodi RMIK (D-3) Fakultas Kesehatan Universitas Jenderal Achmad Yani Yogyakarta. Informan triangulasi pada penelitian ini adalah praktisi senior rekam medis di RSUD Tipe B Kota Yogyakarta. Peneliti melakukan studi pendahuluan dan studi pustaka untuk mengidentifikasi masalah. Selanjutnya analisis data dilakukan identifikasi kebutuhan perancangan ulang desain formulir berdasarkan aspek fisik, anatomi dan isi. Hasil analisis tersebut digunakan sebagai dasar untuk perancangan ulang formulir rawat jalan. Terdapat 2 usulan perancangan ulang formulir rekam medis rawat jalan. Pemilihan desain dan bahan formulir dilakukan dengan diskusi bersama informan triangulasi, perbaikan desain sesuai masukan dari informan triangulasi untuk mendapatkan desain akhir dari perancangan formulir rawat jalan. Hasil analisis pada aspek fisik, anatomi dan isi menunjukkan perlu dilakukan perancangan ulang formulir pada aspek anatomi dan isi dengan menghilangkan item nomor registrasi, kelas/ruangan, pekerjaan, menambahkan riwayar alergi, riwayat penyakit, assasmen nyeri dan kode ICD, serta merestrukturisasi dokumentasi rekam medis terintegrasi dengan format SOAP.
Tinjauan Pelepasan Informasi Rekam Medis Kepada Pihak Ketiga Di RSU Imelda Pekerja Indonesia Medan
Authors: Purba Erlindai , Sidabutar Hesty Afriani
Published: December 2021

The Imelda Workers General Hospital of Indonesia does not yet have specific routines regarding the release of medical record information to third parties. however, they have used regular procedures for providing information and borrowing medical records in general, This study aims to determine the number of requests for medical record information. This type of research is descriptive, namely the research method carried out with the aim of making an objective state. The population was 4 people and the sample size was 4 people as the total sampling with the research methodology using quantitative methods. How to collect data by interview and observation. The results showed that the services of the Imelda Hospital for Indonesian Workers in Medan according to legalized death certificates amounted to 34 percent (0.56%), claims for raharja services amounted to 56 percent (0.92%), audits and insurance claims were 69 percent (1.14%) , research or education as much as 54 percent (0.89), post mortem as much as 28 percent (0.46%), BPJS as much as 5,790 percent (99.00%). Based on the results of the study, it is known that knowing the data on the number of requests for medical record information in January-June 2020 is 6,224 with a percentage (99.97%). As well as the absence of a special SPO on procedures and utilization of medical record information of deceased patients, however, they have used the permanent procedure of providing information and borrowing medical records in general. It is recommended that hospitals and medical record officers provide regular training or coaching to officers. And to health workers, especially medical records, in order to maintain the confidentiality of patient medical record information and carry out the established procedures properly.
Analisis Pengimplementasian Pendistribusian Berkas Rekam Medis Pasien Rawat Jalan Di Rumah Sakit X Bandung
Authors: Alya Nurul Maulani  , Aura Nurzilal Ridwan  , Meira Hidayati  , Aris Susanto
Published: December 2021

Medical records are an important part of the treatment of patient health, one form of service in each public health facilities is the distribution of medical record files. Based on research conducted at Hospital X Bandung, in the distribution of medical records the system used has not fully used electronic, the data entered into the application will then be searched manually by the officer for further medical record files distributed to each polyclinic concerned. The purpose of this study is to find out how the distribution of outpatient medical records at Hospital X Bandung using descriptive qualitative research methods that are research that aims to explain and describe the on distributing outpatient medical record documents with subjects in this study is an outpatient medical record document at Hospital X Bandung while the object in this study is the medical record officer in the distribution and filing. Thus, it can be concluded that the implementation of the distribution of medical record files has been quite effective and in accordance with the standard of time that has been set and Standard Operating Procedure that has been made despite some problems and constraints that always occur at the time of distribution of medical records, one of them is the application system used errors or buffering, the code on each polyclinic is sometimes confused with each other, but the officers can solve the problem.
Tinjauan Sistem Penyelenggaraan Rekam Medis Menurut Standart Akreditasi Puskesmas di Puskesmas Pangakalan Berandan Tahun 2020
Authors: Simanjuntak Esraida , Fajar Insani
Published: December 2021

Puskesmas are required to maintain medical records containing data and information on patient care. Implementation according to accreditation standards, namely criteria 3.2 Registration Process and 3.8 Administration of medical records which are divided into 3.8.1 Coding, 3.8.2 Medical Record Access Rights 3.8.3 Clinical Information Filling and 3.8.4 Storage. The purpose of the study was to find out the implementation of the medical record management system according to the Puskesmas accreditation standards at the Pangkalan Berandan Health Center in 2020. This type of research was qualitative with a Phenomenology approach. The place of research was conducted at the Pangkalan Berandan Health Center. Time of study in July 2020. Research population is all medical record officers at the Pangkalan Berandan Health Center. The research sample is 5 officers. The research instrument was interview guide and check list sheet for observation. The results of the study revealed that the outpatient registration process had been carried out according to criteria 3.2 but there was no inpatient numbering of medical records. Coding was not carried out according to criteria 3.8.1, namely the absence of coding SOPs carried out by doctors using ICD 10, Medical Record Access Rights were carried out according to criteria 3.8. 2 but the implementation is not fully carried out in accordance with the SOP, the lending process is not recorded in the expedition book, Assembling is in accordance with criteria 3.8.3 but recording corrections are carried out using stip-ex and the storage process has been carried out according to criteria 3.8.4 but retention is not carried out according to the guidelines legislation. It is recommended for registration to give medical record numbers to inpatients, coding to make SOPs and given coding training, access rights to medical records to record loans in expedition books, assembling to be given socialization in terms of correcting recording of medical record files and storing tracers as well as in the retention process. given socialization about the implementation of retention.
İlköğretim Okullarında Görev Yapan Öğretmenlerin İlköğretim Müfettişlerine İlişkin Tutumlarının İncelenmesi
Authors: DÖNMEZ Gökhan
Published: December 2021

Bu çalışmada, öğretmenlerin, ilköğretim müfettişlerinin, rehberlik, teftiş ve olumlu duygular geliştirmelerine ilişkin tutumları belirlenmeye çalışılmıştır. Bu bağlamda çalışmada verileri toplamak için Sümbül ve İnandı (2005) tarafından geliştirilen 20 maddelik ölçekten yararlanılmıştır. Araştırma yöntemi olarak nicel yöntem olarak betimsel tarama modeli kullanılmıştır. Araştırmanın çalışma grubunu, 2018–2019 eğitim-öğretim yılında Mersin ili Erdemli ilçesinde seçilen 3 ilkokul, 2 ortaokul ve 2 anaokulunda görevli olan toplam 129 öğretmen oluşturmaktadır. Ölçekle elde edilen veriler, yüzde, frekans, ortalama, standart sapma, t testi ve tek yönlü varyans analizi (anova) ile çözümlenmiştir. Anaokulu, ilkokul ve ortaokullarda görev yapan öğretmenlerin, ilköğretim müfettişlerinin, rehberlik, teftiş ve olumlu duygular geliştirmelerine ilişkin genel tutumları “kararsızım” şeklinde olmuştur.
Contentions and Prospects of Land Reform in Nepal: A Historical Review
Authors: Adhikari Jagannath
Published: December 2021

This paper traces how the government policies on land rights have evolved over recent decades in Nepal and analyses the roles of existing power relations and vested interests in shaping their development and implementation. It is shown that historically entrenched power relations existing in the patrimonial political system have led to a highly unequal distribution of land. Ways to reduce inequality in land ownership to provide access to land for real farmers are essential, but due to these same entrenched power relations, they have not been implemented in earnest and land reforms over the last few decades have been unsuccessful. As a result, the same types of pre-capitalist social relations have persisted in rural areas. These relations have not been able to generate an agrarian surplus that can be invested in agriculture or other sectors of the economy. Furthermore, the concept of ‘property rights’ in relation to land has created a new problem in agrarian development in recent years, by fostering an environment in which people invest in land not to increase production but for speculation. As a result, it has become extremely difficult for poor people to purchase land to have a housing lot or for farming. The present democratic politics and institutions in the post 2006 context have still not shown any capacity or the interest to address the issue of land. Accordingly, the prospects for change at the moment seem bleak even though the rhetoric has increased. Moreover, the changed context calls for a new concept of land reform. This would take into account changes in the agrarian structure and an agrarian economy where mobility is high and injection of cash from outside the country has increased. It is finally argued that successful land reform should be led by grassroots political movements, with limited external intervention.
Introduction to Special Issue on Civil Society in Nepal
Authors: Shrestha Celayne Heaton
Published: December 2021

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Land Right from Below in Nepal and the Role of Land Monitoring: Civil Society Perspective in Converging Equity and Efficiency
Authors: B. Nepali* Purna
Published: December 2021

Land issue is complex, dynamic and contentious in Nepal. After Nepal became a democratic country in 1951, land reform has been a highly discussed issue. Slogan like, ‘land to the tiller’ became a popular agenda for each political parties having different understandings and interpretations on land issue specifically during the last decades’ armed conflict (1996-2006). To move ahead in this direction, scientific land reform has been laid a top priority in Comprehensive Peace Agreement 2006, Interim Constitution 2007 and newly promulgated constitution of Nepal 2015 to address equity and efficiency issues. There is a big debate going on equity and efficiency in the country. Realizing strengths of both issues, following analytical framework such as agrarian political economy and democratic and pro-poor land governance, it is found that civil society monitoring is playing a pivotal role in converging equity and efficiency issues of land reform. Such monitoring initiatives generate evidences that serve to exert pressure on effective response by Government to collective demands for justice. By combining equity and efficiency, Nepal’s civil society and citizen-led initiatives are definitively promoting an active engagement of reformist actors and change-makers for generating equitable economic growth. Few determinants of this citizen led initiative are: activism and engagement, clear and articulated demand, efficient and accountable,mechanism and putting voice of vulnerable groups.
Addressing Nepal’s Land and Agrarian Crisis: An Introduction
Authors: Sugden Fraser , Seddon David , B. Nepali* Purna
Published: December 2021

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Enhancing Water Access in Nepal’s Terai-Madhesh
Authors: Sugden Fraser
Published: December 2021

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The Consensual Politics of Development: A Case Study of Hydropower Development in the Eastern Himalayan Region of India
Authors: Joshi Deepa , Platteeuw Joas , Teoh Juliana
Published: December 2021

Criticism and contestation of large dam projects have a long, strong history in India. In this paper, we analyze diverse civil-society responses to large dam projects in the Eastern Himalaya region of India, which has in the past decades been presented as a clean, green, climate-mitigating way of generating energy, but critiqued for its adverse impacts more recently. We draw our findings primarily based on interviews with NGOs involved in environmental and/or water issues in Darjeeling, interviews with those involved in a local people’s movement ‘Affected Citizens of Teesta’, and participatory research over the course of three years between 2015 and 2018. Our findings show how doing development for the state, the market and/or donor organizations compromises the ability of NGOs in the Darjeeling region to hold these actors accountable for social and environmental excesses. In the same region, dam projects in North Sikkim led to a local people’s movement, where expressions of indigeneity, identity and place were used to critique and contest the State’s agenda of development, in ways that were symptomatically different to NGOs tied down by relations of developmental bureaucracy. Our findings reveal how the incursion of State authority, presence and power in civil-society undermines the civil society mandate of transformative social change, and additionally, how the geographical, political, institutional and identity-based divides that fragment diverse civil-society institutions and actors make it challenging to counter the increasingly consensual politics of environmental governance.
Bukti Acara Pemeriksaaan Kepolisian sebagai Data Sejarah : Upaya Merekontruksi Kekerasan Banyuwangi Tahun 1998-1999
Authors: Kusairi Latif
Published: December 2021

Writing a history of violence often encounters obstacles in finding data. This is due to the concern and silence of the perpetrators to reveal the chronology of historical events. The process of searching for archived data is sometimes also not found in archival institutions. In the other hand, historians are not yet very familiar with the data obtained from the authorities. The history of violence reconstruction with the issue of dukun santet in Banyuwangi is also the same. Investigation the data found many obstacles such as historical actors who do not want to tell incidents that happened. The role of the police archives and the court is very important, because in the minutes of the examination and the news of the court has been written. Historians need to view the archives of the court as an alternative when historians have difficulties in finding the data. At this point historians must be able to pick up archives not only fixated on archival institutions, but can look for the archives through institutions such as courts to see the chronology of violence that has occurred and has been tried in judicial institutions. Historians can go further for data analysis and can see the results of interviews conducted by the judiciary. This study will discuss the role of historians in seeking data from the court as a primary source.
Barns økonomiske situasjon – et generasjonsperspektiv
Authors: Johansen Vegard
Published: December 2021

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É POSSÍVEL ALIAR DESENVOLVIMENTO URBANO COM A SUSTENTABILIDADE DAS UNIDADES DE CONSERVAÇÃO? O CASO DA REGIÃO METROPOLITANA DE BELÉM/PA
Authors: Magalhães José Leonardo Lima
Published: December 2021

A expansão das metrópoles tem causado um recrudescimento das ameaças e impactos nas áreas verdes urbanas nativas. O modelo de sustentabilidade ambiental só será possível a longo prazo quando for aliado ao desenvolvimento da cadeia produtiva de setores socioeconômicos que retiram seu sustento da floresta, direta ou indiretamente. Neste capítulo, é feito um resumo das principais atividades sustentáveis existentes (e potenciais) nas áreas protegidas existentes na região metropolitana de Belém e as indicações para a sua manutenção e expansão em um cenário de ampliação dos investimentos na bioeconomia sustentável. O destaque vai para o ecoturismo responsável e o incentivo às cadeias produtivas de manejo de baixo impacto do açaí e do cacau. O financiamento de empreendimentos turísticos que respeitem a integridade dos ecossistemas naturais onde são implementados devem ser exigidos e fomentados pelo poder público. Além disso, a expansão desenfreada do cultivo das culturas do açaí e cacau em áreas com manejo intenso pode resultar na diminuição da biodiversidade regional em áreas com florestas nativas. Neste último caso, pode ocorrer a diminuição de polinizadores e a completa exaustão de importantes serviços ambientais para a região, incluindo a produtividade das próprias culturas. A gestão das unidades de conservação urbanas da região metropolitana de Belém deve favorecer a ordenação territorial e o uso sustentável dos recursos naturais. Agregar valor em produtos da bioeconomia local é um imperativo em uma metrópole amazônica que cresce desordenadamente e ameaça a manutenção das áreas verdes nativas para as gerações futuras.
Risk Factors for Deep Vein Thrombosis in Pregnancy and Puerperium at a Tertiary Care Hospital in Muzaffarabad, AJK
Authors: Hafiz Mudasar , Nazir Muanzza , Hussain Syeda Abida , Rafique Rubina , Shabir Nosheena , Akhtar Yasmin
Published: December 2021

Aim: Risk factors of deep vein thrombosis in pregnancy and puerperium in our setting. Study Design: Descriptive Cross-sectional study Place and duration of study: Departments of Obs & Gynae and General Medicine, CMH Muzaffarabad, AJK from 20th December, 2019 to 20th June, 2020. Methodology: A total of 385 females were included. Demographic data including age, parity, gravidity, BMI, obesity and timing of DVT occurrence was noted. The associated risk factors including mode of delivery in postpartum women, smoking status, past history of DVT, gestational diabetes and Diabetes Mellitus were noted. Results: Mean age of the participants was 26.1±5.3 years. Frequency of women developing deep vein thrombosis during pregnancy was 84.9% and 15.1% women developed DVT during puerperium. Past history of DVT was present in 26.5%. 31.7% of women were known diabetics and 29.1% developed gestational diabetes during current pregnancy. Frequency of smoking was 4.2%. 8% women presented with DVT in first trimester, 139(36.1%) in second trimester and 154 (40%) in third trimester. Conclusion: DVT is more common in the third trimester of pregnancy than in puerperium. Obesity, Diabetes Mellitus and past history of DVT were significant risk factors identified in the study. Keywords: Pregnancy, Postpartum Period, Deep Vein Thrombosis
To Determine the Frequency of Necrotizing Enterocolitis in Preterm Infants
Authors: Hussain Nusrat , . Suleman , Wajdan Amna , Bashir Rabia , Saleem Rabia , Akhtar Sajid
Published: December 2021

Aim: To determine the frequency of necrotizing enterocolitis in preterm infants Place and duration of study: It is a descriptive cross-sectional study in Pediatric Medicine Department, Nishtar Hospital Multan from March, 2021 to August, 2021 Methodology: The preterm neonates were called for follow up every week for 4 weeks to diagnose Necrotizing enterocolitis. Results; Out of 174 cases, 101 (58%) were males while 73 (42%) were females. Necrotizing enterocolitis (NEC) was noted in 61 (35.1%) while NEC in breastfeeding infants was 14/74 (18.9%) and in formula feeding infants NEC was 47/100 (47%). Conclusion; High frequency of necrotizing enterocolitis was observed in this study among formula fed preterm infants as compared to breastfed preterm infants. Keywords; Breastfeeding, formula feeding, Necrotizing enterocolitis
Frequency of Anticardiolipin Antibodies in Women with Recurrent Fetal Loss
Authors: Farooq Nazia , Naeem Akhtar Ahmad , Rizwan Muhammad , Tariq Hira , Tariq Anam , Noor Ammar , Lodhi Yasmeen
Published: December 2021

Aim: To find out the frequency of Anticardiolipin Antibodies in women with recurrent fetal loss Study design & duration: One year descriptive study Methods: Seventy five females were included in the study with ages ranging from 20-40 years with minimum two miscarriages. Diabetic females and females with history of bacterial or viral diseases were excluded from the study. Results: In this group the mean age was 27.60±3.29 years. Mean number of fetal losses was 2.95±1.45 whereas mean duration of marriage was 5.79±4.11 years. Conclusion: It is suggested that the patient with history of recurrent miscarriages must be screened for Anticardiolipin Antibodies to bring them out of psychological and physical trauma. Keywords: Anticardiolipin Antibodies (aCL), Recurrent fetal loss (RFL), aPTT
To compare the frequency of postoperative sore throat with I-gel versus laryngeal mask airway in patients
Authors: Kamal M. J. Ahmed , Zaheer Baber , Ahmed Durrani Naveed , Ahmad Khaleel , Tabassam Sumara , Rashid Zakariya , Nishat Mufassar
Published: December 2021

Background: In case of general anesthesia, airway maintenance along with least complications is the most important goal of team of anesthesiologists. In case of clinical practice, the laryngeal mask airway (LMA) devices have superiority in managing supraglottic airway. Recently i-gel airway has been introduced as supraglottic airway equipment (disposable). Aim: To make comparison between laryngeal mask and I-gel with respect to postoperative complication of sore throat in case of patients who were given general anesthesia. Study design: Randomized trial Setting: Anesthesia Department Study duration: 6 after synopsis approval in total 6months of duration Methods: Candidates were divided randomly divided into two groups. In case of members of group A, patients were given i-gel where as members of group B, disposable LMA was given. General anesthesia was administered according to the standardized protocols. A day after operation, candidates were check post operatively for 24 hours, for sore throat and information was documented on Performa. Results: The candidates mean age was 44.23±15.11years in case of i-gel group members whereas 46.10±15.56 years in case of LMA group. In case of i-gel group, there were about twenty five males members and thirty five were females members . In case of LMA group members, there were about twenty six males and thirty four female members . In present case research, sore throat postoperatively was seen in case of 17(14.2%) cases, i.e. 4 (6.7%) in i-gel group while 13(21.7%) in case of LMA group. The significant difference was witnessed between members of both groups (p<0.05). Conclusion: Thus i-gel is better than LMA for general anesthesia as it has fewer chances of side effects like postoperative sore throat. Keywords: Postoperative sore throat, I-gel, laryngeal mask airway, general anesthesia
Outcomes of Nonalcoholic Fatty Liver Disease In Covid Positive Diabetic Patients: Cross Sectional Study
Authors: Hussain Azhar , Iftikhar Mehwish , Rizvi Amna , Latif Muhammad , Javed Ahmed Muhammad , Zartash Saba , Laique Talha
Published: December 2021

Background: SARS-CoV-2 principally invades the respiratory system. ACE receptor are also abundant throughout the hepatobiliary system and their increased expression on hepatocyte make patients with NAFLD more vulnerable. Aim: To see outcomes of COVID positive diabetic patients suffering from Nonalcoholic fatty liver disease (NAFLD). Study design: Cross Sectional Study. Methodology: 150 diabetic and COVID PCR positive were recruited from COVID ward of Services Hospital in Lahore. Clinical parameters like BMI, SpO2, Hepatomegaly and lab parameters like HbA1C, AST ALT were noted in spreadsheet. Statistical analysis was done using SPSS v.25. Statistical significance for difference in proportions is calculated using Pearson’s Chi-Squared test. P less than 0.05 was considered statistically significant. Results: Around 84(56%) were males and 66(44%) females, smoked were 27(18%), mean age (years) was 59.7333 ±11.35023, mean BMI (kg/m²) was 30.1425±7.30673, 87(58%) patients had NAFLD, who experienced sever disease (53.2%; x^2=0.010) and more mortalities (60.2%;x^2=0.453) as compared to those who do not had condition. Conclusion: We concluded that NAFLD makes COVID-19 infected patients more fragile. Such patients experienced sever disease and more mortalities however need of mechanical ventilation remains almost equal between those who has NAFLD and those who didn’t had. Keywords: Nonalcoholic fatty liver disease, COVID-19, Diabetes, Mortality and Severity.