bluuebunny/crossref_metadata_2025_split huggingface dataset:
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 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.
TINJAUAN PELAKSANAAN NILAI GUNA REKAM MEDIS BAGI PASIEN DI RUMAH SAKIT UMUM IMELDA PEKERJA INDONESIA (RSU IPI) MEDAN TAHUN 2018
Authors: Christy Johanna , Putri S Afni Efani 
Published: December 2021

ABSTRAK
Rekam medis adalah berkas yang berisi catatan dan dokumen tentang identitas pasien, pemeriksaan, pengobatan, tindakan dan pelayanan lain kepada pasien pada sarana pelayanan kesehatan. Tujuan penelitian ini adalah untuk mengetahui bagaimana pelaksanan nilai guna rekam medis bagi pasien. Jenis penelitian ini adalah deskriptif bertujuan menggambarkan secara sistematis fakta dan karakteristik objek dan subjek secara tepat. Waktu penelitian ini dilakukan pada bulan Juli di Rumah Sakit Umum Pekerja Indonesia Medan (RSU IPI) Tahun 2018. Populasi dalam penelitian adalah 440 berkas rekam medis. Dalam melakukan penelitian, peneliti mengambil sampel sebanyak 81 berkas rekam medis. Berdasarkan hasil penelitian yang dilakukan di RSU IPI pelaksanaan nilai guna rekam medis sudah terlaksana dengan baik, dilihat dari tersedianya ringkasan masuk dan keluar, resume, lembar operasi, identifikasi bayi, lembar persetujuan tindakan, lembar kematian pada setiapberkas pasien pulang meninggal, asuhan keperawatan didalam berkas rekam medis. Tetapi dalam pengisian berkas rekam medis petugas rekam medis belum mengimplementasikan nilai guna rekam medis dengan baik. Kesimpulannya pelaksanaan nilai guna rekam medis sudah baik namun dalam pengisian berkas rekam medis lebih di perhatikan sesuai Permenkes 269 Tahun 2008 Tentang rekam Medis sehingga pelaksaaan nilai guna rekam medis dan pengisisan berkas rekam medis berjalan lebih baik.

Kata Kunci: Rekam Medis, Nilai Guna Rekam Medis, Berkas Rekam Medis

ABSTRACT

Medical record is a document that contains records and documents about patient identity, examination, treatment, care and other services for patients in health care facilities. The purpose of this study was to study how the implementation of the use of medical records for patients. This type of research is descriptive which addresses the systematic problem and the appropriate characteristics of objects and subjects. When this study was conducted in July at the Medan Indonesian Workers General Hospital (RSU IPI) in 2018. The population in this study was 440 medical record documents. In conducting research, researchers took 81 samples of medical records. Based on the results of research conducted at the IPI General Hospital, the implementation of the use value of medical records has been carried out well, seen from the availability of incoming and outgoing assessments, proceeding, surgery sheets, accessing infants, action approval sheets, consent sheets on each patient's return documents, medical care care. However, in applying medical records, medical record officers have not applied the use value of medical records properly. Conclusion the reclamation of the value of the medical record has been better in the reclamation of the medical record is better with the approval in accordance with Minister of Health Regulation 269 of 2008 About the Medical Record requires the implementation of the value of the medical record and the filling of the medical record better.
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.
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
SUPERVISÃO CLÍNICA EM ENFERMAGEM PARA OTIMIZAR A AVALIAÇÃO DO AUTOCUIDADO
Authors: Rocha Inês Alves da Rocha e Silva , Rodrigues Manuel Agostinho Caldas , Pinto Cristina Maria Correia Barroso , Carvalho António Luís Rodrigues Faria de 
Published: December 2021

Objetivo: avaliar a concordância no grau de dependência do autocuidado atribuído pelo perito, enfermeiros e registros, identificando estratégias de supervisão clínica que os enfermeiros implementassem para otimizar a avaliação do autocuidado. Método: estudo descritivo-exploratório, quantitativo, com 108 utentes e 44 enfermeiros de um hospital do norte de Portugal. Em 2017, aplicou-se o “Instrumento de Avaliação do Autocuidado” e o “Questionário de Avaliação da Frequência de Estratégias de Supervisão Clínica em Enfermagem”. Realizou-se análise estatística descritiva e calculou-se o coeficiente de concordância. Resultados: a concordância entre perito e enfermeiros na avaliação do grau de dependência do autocuidado alimentar-se e posicionar-se é fraca, mas moderada no autocuidado higiene. O “feedback”, “formação contínua” e “apoio” são as estratégias que os enfermeiros mais gostariam de implementar. Conclusão: é essencial que as organizações de saúde avaliem a concepção dos cuidados prestados, e identifiquem estratégias de supervisão clínica, de forma a potenciar sua melhoria.
ESTRATÉGIAS PARA A REDUÇÃO DE ERROS DE MEDICAÇÃO DURANTE A HOSPITALIZAÇÃO: REVISÃO INTEGRATIVA
Authors: Costa Claudia Regina de Barros , Santos Sara Soares dos , Godoy Simone De , Alves Leila Maria Marchi , Silva Ítalo Rodolfo , Mendes Isabel Amélia Costa 
Published: December 2021

Objetivo: sintetizar o conhecimento relacionado às estratégias para redução de erros de medicação durante a hospitalização de pacientes adultos. Método: revisão integrativa da literatura realizada em outubro de 2020 por meio da busca de publicações nas bases de dados eletrônicas: Web of Science, Pubmed, Cumulative Index of Nursing and Allied Health Literature, Literatura Latino-Americana e do Caribe em Ciências da Saúde e Google Scholar. Resultados: amostra composta por 12 estudos, cujas estratégias para a redução de erros de medicação foram apresentadas de acordo com as categorias: envolvimento do farmacêutico clínico nas atividades clínicas, implantação de tecnologiasda informação, estratégias educacionais mediadas por simulação e jogos, e redução da carga de trabalho. Conclusão: associado às tecnologias, o envolvimento do farmacêutico clínico com a equipe médica e de enfermagem resultará em melhorias na redução dos eventos adversos a medicamentos e na qualidade da assistência prestada ao paciente
U-Pb and Sm-Nd Evidence for Episodic Orogenic Gold Mineralization in the Kalgoorlie Gold Camp, Yilgarn Craton, Western Australia
Authors: McDivitt Jordan A. , Hagemann Steffen G. , Kemp Anthony I.S. , Thébaud Nicolas , Fisher Christopher M. , Rankenburg Kai 
Published: December 2021

Abstract
Different genetic and timing models for gold mineralization in the Kalgoorlie gold camp (Yilgarn craton, Western Australia) suggest either broadly synchronous, late-stage mineralization related to metamorphic fluids at ca. 2640 Ma or a punctuated mineralization history from ca. 2675 to 2640 Ma with the involvement of early magmatic-hydrothermal systems (represented by the Fimiston, Hidden Secret, and Oroya gold-telluride lodes) and late metamorphic fluids (represented by the Mt. Charlotte gold stockwork veins). The results of U-Pb and Sm-Nd geochronological studies of zircon, apatite, and titanite from pre-ore dikes and syn-ore dikes constrain the absolute timing of mineralization and provide new evidence to this timing controversy. Emplacement ages constrained by U-Pb sensitive high-resolution ion microprobe (SHRIMP) zircon data are interpreted to be similar for both the pre-ore dikes (n = 10) and syn-ore dikes (n = 7) at ca. 2675 Ma. An inferred emplacement age of ca. 2675 Ma for the syn-ore dikes is supported by a Sm-Nd isochron age from apatite (laser ablation-inductively coupled plasma-mass spectrometry; LA-ICP-MS) of 2678 ± 15 Ma and by a U-Pb titanite age (LA-ICP-MS) of 2679 ± 6 Ma. The results of chemical abrasion-isotope dilution-thermal ionization mass spectrometry U-Pb zircon analysis from the pre- and syn-ore dikes are complicated by multistage Pb loss, reverse discordance, and potential inheritance. However, the data are compatible with the emplacement of Fimiston/Hidden Secret gold mineralization at ca. 2675 Ma and suggest a younger age for Oroya mineralization at ca. 2665 Ma. These results contrast with models for orogenic gold deposits that invoke broadly synchronous, late-stage mineralization related to metamorphic fluids at ca. 2640 Ma. The bulk of the Kalgoorlie gold camp’s estimated 2,300 t Au endowment was emplaced at ca. 2675 Ma as Fimiston/Hidden Secret Au mineralization. This early Au mineralization was deformed and overprinted twice by subordinate Au mineralization at ca. 2665 (Oroya mineralization) and ca. 2640 Ma (Mt. Charlotte mineralization). Gold mineralization in the Kalgoorlie gold camp was protracted in nature from ca. 2675 to 2640 Ma and reflects the interplay of early magmatic (Fimiston, Hidden Secret, Oroya) and late metamorphic (Mt. Charlotte) hydrothermal fluid systems in the formation of hybrid intrusion-related and metamorphic orebodies.
De impact van Laval anno 2021
Authors: Laagland Femke 
Published: December 2021

De impact van Laval anno 2021
De auteur neemt in deze bijdrage het Europese arrest Laval uit 2007 onder de loep. Het arrest Laval had een wezenlijke impact op Nederland als zogenoemd hogelonenland. Inmiddels zijn veertien jaar verstreken en zijn de Handhavingsrichtlijn en de herziene Detacheringsrichtlijn aangenomen en geïmplementeerd. Wat betekenen deze richtlijnen voor de impact van Laval? Hebben de nieuwe richtlijnen het arrest Laval naar de geschiedenisboeken verwezen of doolt de geest nog steeds rond? Het zal blijken dat Laval anno 2021 de gemoederen nog steeds bezighoudt.
Overpeinzingen omtrent de vakbond als ondernemersorganisatie en de regulering van de positie van de zzp’er
Authors: Verburg Leonard 
Published: December 2021

Overpeinzingen omtrent de vakbond als ondernemersorganisatie en de regulering van de positie van de zzp’er
Vakbonden fungeren bij het behartigen van belangen van zzp’ers als ondernemersorganisaties. De enorme aanwas van zzp’ers compliceert daarmee ons systeem van arbeidsvoorwaardenvorming. De zzp’ers vallen in het krachtenveld van de sociale partners vaak tussen wal en schip. Het zou daarom juist zijn als de belangenbehartigers van zzp’ers losstaan van de sociale partners. Via de toetreding van zzp’ers tot besloten netwerken kunnen zzp’ers mededingingsrechtelijke beperkingen aan tariefafspraken ontgaan. Op soortgelijke wijze kunnen zzp’ers premielasten ontlopen die het SER-akkoord van juni 2021 voor zzp’ers op tafel legt. In beide gevallen speelt de vraag hoe men op heldere wijze de zzp’er kan afbakenen ten opzichte van andere ondernemers.
Comparison of Static Model, Adaptation Study, and CFD Simulation in Evaluating Thermal Comfort Based on Köppen Climate Classification System in Churches in Indonesia
Authors: Hildegardis Cornelia , Saraswati Anak Agung Ayu Oka , Putra I Dewa Gede Agung Diasana , Dewi Ni Ketut Agusinta 
Published: December 2021

This research examined thermal comfort in church buildings in Indonesia by making a comparison between three different Indonesian climatic regions using three different research models. A static model, an adaptation study model and a CFD simulation were used to find the similarities and differences between the results generated from determining thermal comfort in church buildings in the three regions. The comparison revealed that church buildings had different PMV scores at each measuring point that were inversely proportional to the subjects’ response on thermal comfort inside the buildings, i.e. points adjoining with openings affect a low PMV score and a high perceived thermal sensation, and vice versa. The CFD simulation showed that changing the conditions of the openings affects air velocity and flow into the building, which influences the subjects’ thermal comfort response inside the churches.
Vertical Bearing Capacity of Precast Pier Foundation Filled with Demolished Concrete Lumps
Authors: Lei Bin , Li Wengui , Tang Zhuo , Yang Fuzhi 
Published: December 2021

The application of recycled compound concrete made of demolished concrete lumps (DCLs) and fresh normal concrete in pier foundation can effectively improve the utilization efficiency of construction waste resources. In this study, two prefabricated pier foundations based on recycled compound concrete (dimension of Ø800 × 2500 mm and Ø1000 × 2500 mm) and two cast-in-place pier foundations based on ordinary concrete (dimension of Ø800 × 2500 mm and Ø1000 × 2500 mm) were tested. Special attention was devoted to the load-settlement curve characteristics of the precast pier foundation of compound concrete, the load transfer law of the pier-soil system, the soil pressure distribution at the bottom of the pier, and the failure mode. The results showed that the Q-S curve of precast concrete pier foundation made of recycled compound concrete is slow deformation at loading, which is consistent with that of cast-in-place concrete pier foundation. The load transfer theory of pier-soil system is established, and its accuracy is verified by experimental analysis. The precast foundation of recycled compound concrete is the same as the cast-in-place foundation of ordinary concrete. The failure form of prefabricated pier foundation made of recycled compound concrete was a local shear failure, while the failure form of ordinary concrete cast-in-place pier foundation was piercing-type shear failure. The feasibility of relevant theoretical methods for calculating the vertical ultimate bearing capacity is examined.