Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI)

Analisis Ketepatan Kode Diagnosis Pasien Rawat Jalan Pada Poli Saraf Di RSUD Dr. Rasidin Padang

2026-06-20T04:00:24+00:00

The clarity of diagnosis writing is an important factor in coding determination. One of the issues found is the illegibility of diagnoses and the lack of completeness in filling out medical resumes, which is caused by the use of terminology in Indonesian and abbreviations that do not conform to standard norms, making it difficult for coders to read and interpret the diagnoses. The research aims to examine the accuracy of the diagnostic codes for outpatient patients in the neurology clinic. The type of research used is quantitative with a cross-sectional method, conducted at the Dr. Rasidin General Hospital in Padang. The research population consists of 532 medical record files, and the sample taken amounts to 84 outpatient medical record files using simple random sampling techniques. The type of research used is quantitative with a cross-sectional method, conducted at the Dr. Rasidin General Hospital in Padang. The research population consists of 532 medical record files, and the sample taken amounts to 84 outpatient medical record files using simple random sampling technique. The research was conducted using observations and a checklist, as well as univariate analysis. Data processing includes editing, coding, tabulation, and data cleaning. The research results indicate that out of 84 medical record files, 28 (33.3%) had unclear diagnoses due to illegible handwriting, 34 (40.5%) were incomplete due to time constraints, and 26 (31.0%) had incorrect codes due to the ambiguity and incompleteness of the diagnosis writing. The ambiguity and incompleteness of diagnosis writing affect the accuracy of coding. In the future, it is hoped that diagnosis writing will adhere to ICD-10 guidelines to facilitate the assignment of diagnosis.

Peran Rekam Medis Elektronik Dalam Mendukung Deteksi Dini Dan Pengawasan Tuberkulosis (TBC) DI RSU Nurhayati Cikajang

2026-07-23T08:58:20+00:00

Tuberculosis (TB) is one of the most prevalent infectious diseases at Nurhayati Cikajang General Hospital, accounting for 44.3% of all infectious disease cases in the first quarter of 2025. This study aims to examine the role of Electronic Medical Records (EMR) in facilitating the early detection and monitoring of tuberculosis cases at the hospital. A descriptive qualitative approach was employed, utilizing interviews, observations, and document reviews involving four informants purposively selected from the Medical Records Unit. The findings indicate that EMR enables healthcare professionals to access information regarding visit history, laboratory results, and patient diagnosis history in a rapid and integrated manner, thereby facilitating the early identification of tuberculosis cases. Diagnosis coding based on ICD-10, performed via the EMR system, is also crucial for generating accurate data for RL 5.1 reporting and conducting surveillance activities. Tuberculosis case data for 2025 shows a decline, dropping from 95 cases in the first quarter to 52 cases in the fourth quarter. Challenges encountered include internet connectivity issues and limited staffing. In conclusion, EMR plays a vital role in the early detection and monitoring of tuberculosis; therefore, the hospital should strengthen its network systems and workforce to optimize the system's utilization.

Analisis Hubungan Antara Sosio-Demografi Dengan Kepuasan Pengguna SNOMED-CT Dalam Manajemen Data Penyakit Ginjal Di Indonesia

2026-07-25T02:29:54+00:00

Evidence regarding the relationship between sociodemographic factors and SNOMED CT user satisfaction remains limited, particularly within the context of kidney disease data management. This study aimed to analyze the relationship between sociodemographic factors and SNOMED CT user satisfaction regarding kidney disease data management in Indonesia. A cross-sectional study design was employed, involving 334 medical coders from across Indonesia who were recruited via purposive sampling during a webinar. Data were collected using a self-administered questionnaire developed by the researchers. Descriptive and bivariate analyses were conducted, the latter utilizing logistic regression. The results indicated that age was significantly associated with satisfaction (OR=2.68; 95% CI=1.01–7.09; p=0.047), while length of employment showed a significant but negative association (OR=0.55; 95% CI=0.30–0.97; p=0.041). Conversely, gender and training history did not demonstrate a significant relationship with satisfaction. Specific sociodemographic factors namely age and work experience—were associated with SNOMED CT user satisfaction levels, whereas gender and training had no significant impact. These findings highlight the importance of considering individual characteristics when optimizing SNOMED CT implementation in healthcare facilities.

Tingkat Kepuasan Tenaga Kesehatan terhadap Penggunaan Aplikasi Rekam Medis Elektronik Berbasis Web di Fasilitas Pelayanan Kesehatan

2026-07-10T08:09:25+00:00

Digital transformation in the healthcare sector has encouraged the implementation of web-based Electronic Medical Records (EMRs) to improve the efficiency and quality of healthcare services. The successful implementation of EMRs depends not only on technological aspects but also on user satisfaction, which serves as a key indicator of system acceptance. This study aimed to analyze healthcare workers' satisfaction with the use of a web-based EMR application in a healthcare facility. A quantitative approach with a descriptive cross-sectional design was employed. The study involved 27 healthcare workers selected using a total sampling technique. Data were collected through a Likert-scale questionnaire and analyzed descriptively using mean scores. The results showed that the overall level of user satisfaction was categorized as satisfied. The highest mean scores were obtained for the indicators of ease of learning the application (mean = 4.33), faster documentation process (mean = 4.33), and ease of patient data retrieval (mean = 4.26). In contrast, the indicator related to technical issues, such as system errors or slow performance, received the lowest mean score (mean = 2.78), indicating the need for improvements in technological infrastructure. In conclusion, the web-based EMR application improves work efficiency, facilitates access to patient information, and supports the quality of healthcare services. Continuous optimization of servers, network infrastructure, and user training is essential to enhance user satisfaction and ensure the successful implementation of the system.

Gambaran Pemahaman Petugas Koder Mengenai Kodefikasi Penyakit Sistem Kardiovaskular Mengacu Pada ICD-10 Di RSU Imelda Pekerja Indonesia Tahun 2024

2026-08-11T04:58:55+00:00

Knowledge is the result of the act of knowing, occurring after an individual perceives a specific object through the human senses—namely sight, hearing, smell, taste, and touch. The majority of human knowledge is acquired through the eyes and ears. This study aims to determine the level of knowledge among medical coders regarding disease coding for the cardiovascular system based on ICD-10 at RSU Imelda Pekerja Indonesia in 2024. A qualitative research method with a descriptive approach was employed. The study involved five subjects (informants). Data collection techniques included observation and interviews guided by an interview protocol. Regarding educational background, all participating coders shared the same qualification: a Diploma III (D-III) in Medical Record and Health Information Management (RMIK). Coders with more than five years of experience demonstrated superior knowledge compared to those with less than five years of experience; this was particularly true for coders who had previously worked in registration and analysis departments, as their experience in the analysis section provided them with familiarity regarding the content of medical records. The study concludes that educational background does not directly influence coding accuracy at RSU Imelda Pekerja Indonesia, as all participating coders held the same educational qualification (D-III RMIK).

Membedah Fenomena Dropping Pasien Jiwa: Analisis Niat Keluarga Berdasarkan Theory Of Planned Behavior Di RS Soeharto Heerdjan

2026-07-10T08:20:55+00:00

The low family intention to pick up post-treatment mental patients at Soeharto Heerdjan Hospital is characterized by the increasing number of patient dropping cases, indicating that the discharge process does not only depend on medical aspects but also on family psychosocial factors. This study aims to analyze the influence of attitudes, subjective norms, and perceived behavioral control on family intention to pick up mental patients using a quantitative cross-sectional approach with multiple linear regression. The study population of 430 families of inpatient mental patients was sampled by 81 respondents through accidental/convenience sampling techniques, with primary data from a Likert scale questionnaire 1-4. The results showed the family intention index (56.25), attitude (50.29), subjective norms (51.82), and perceived behavioral control (44.42) in the moderate category; all three variables simultaneously had a significant effect on family intention (p<0.05) with an adjusted R² of 0.730, explaining 73% of the variation in intention. The main obstacles included social support, cost, and time constraints. Suggestions from this study include increasing early education, family counseling, and hospital logistical support to optimize family readiness and intentions in the process of returning mental patients.

Kepatuhan Pelaksanaan Prosedur Pelayanan Rekam Medis Dilihat Dari Tanggung Jawab Petugas Di Rumah Sakit Advent Medan

2026-08-11T04:50:59+00:00

Work responsibility refers to how the behavior, attitude, and actions of staff relate to their jobs. Responsibility is a mandatory form of compliance with regulations and carrying out duties as they should be, when employees have found a meeting point between their work and what has been assigned by the company. The purpose of this research is to understand the work responsibilities of medical record staff concerning compliance with medical record service procedures at Advent Hospital. The research method used is descriptive with a qualitative approach. The data collection methods employed are interviews and observations, conducted in 2025, with a research subject consisting of 5 medical record staff, and the research object being the SOP for medical record services. The results of the research conducted indicate that the 5 medical record staff are responsible. Compliance with medical record services concerning several SOPs has been carried out according to procedures, while retention and destruction have not been implemented in accordance with the procedures outlined in the SOP. The conclusion is that the use of time at work, collaboration with others, and integrity or awareness are good, so the level of compliance of medical record staff at Advent Hospital Medan is that the medical record staff comply with their duties according to the existing SOP.

Analisis dan Perancangan Sistem Informasi Terintegrasi pada Poli KIA di Puskesmas Jayengan Dengan Metode Prototype

2026-07-15T07:38:27+00:00

Jayengan Community Health Center has implemented a Community Health Center Management Information System for registration, but the Maternal and Child Health Clinic still uses manual methods for recording patient examinations. This condition results in inefficient service processes, potentially leading to data errors, duplicate recordings, and slowing down patient care. This study aims to analyze the existing system, identify problems, and design an integrated web-based health information system using the Prototype method. Data collection was conducted through interviews and direct observation with registration officers, doctors, midwives, and the head of the community health center. The system design included the creation of Use Case Diagrams, Activity Diagrams, Data Flow Diagrams, Entity Relationship Diagrams, database structures, and system interfaces. The research results resulted in a web-based health information system design that includes patient registration, patient data, the Maternal and Child Health Clinic, medical records, reports, and a dashboard. The integration of the Maternal and Child Health Clinic into the system allows doctors and midwives to access and input examination data digitally, eliminating the need for physical documents and duplicate recording processes.

Design User Interface Rekam Medis Elektronik Dengan Metode Participatory Design Di Klinik Rawat Inap Islam Aisyiyah Pandaan

2026-07-23T08:51:51+00:00

Advances in information technology in the healthcare sector have encouraged healthcare facilities to implement Electronic Medical Records (EMR) in accordance with Minister of Health Regulation Number 24 of 2022. However, the Aisyiyah Islamic Inpatient Clinic in Pandaan still faces various obstacles in managing medical records, such as the use of a semi-manual system, duplication of patient data, delays in service delivery, recording errors, and difficulties in retrieval of patient data. These conditions result in ineffective service processes and potentially impact the quality of healthcare services. Therefore, this study aims to design an Electronic Medical Record User Interface (UI) that meets user needs using Participatory Design methods. This study employed Research and Development (R&D) methods with a Participatory Design approach that actively involved users at every stage of the design. Data collection was conducted through observation, interviews, Focus Group Discussions (FGDs), and literature review with healthcare workers at the Aisyiyah Islamic Inpatient Clinic in Pandaan. The research stages included identifying user needs, creating mockups and wireframes, evaluating the design, revising it, and validating the user interface design. The research results show that users require a UI that is simple, easy to understand, responsive, and aligned with the healthcare workflow. Expected features include automatic validation to prevent data duplication, examination input templates, integration between service units, and a faster and more stable system. The resulting UI design is able to facilitate data input, search for patient information, and improve service efficiency in the clinic. Thus, the design of an Electronic Medical Record User Interface based on Participatory Design is expected to be a solution in supporting the digital transformation of healthcare services that are more effective, safe, and integrated.

Kesiapan Penggunaan Tanda Tangan Elektronik Tersertifikasi pada Rekam Medis Elektronik di RSU X Tasikmalaya

2026-07-15T07:34:28+00:00

The implementation of electronic medical records requires secure and accountable authentication of medical documents, including certified electronic signatures. At RSU X Tasikmalaya, non-certified electronic signatures were still used, resulting in additional verification processes, particularly in claims. This study aimed to analyze the readiness for implementing certified electronic signatures in electronic medical records at RSU X using the Doctor’s Office Quality-Information Technology (DOQ-IT) framework. A descriptive qualitative design was employed. Four informants representing managerial, medical records, information technology, and admission perspectives were selected using purposive sampling. Data were collected through semi-structured interviews, observations, and document analysis, with source and technique triangulation. The results showed that readiness for implementing certified electronic signatures was not fully optimal across the four DOQ-IT domains. Human resource readiness was suboptimal because training had not been conducted systematically or evenly. Organizational culture was generally adaptive to digital technology, although resistance and shared account practices remained barriers to accountability. Leadership governance was supported by internal policies, cross unit coordination, implementation planning, and budget preparation, but operational procedures had not been established. Technological infrastructure had a technical foundation to support implementation, although infrastructure performance was uneven and individual access controls required strengthening. RSU X was therefore not fully ready for comprehensive implementation of certified electronic signatures. Technical training, transition support, operational SOPs, individual user accounts, and network capacity strengthening are recommended to support secure, consistent, and sustainable implementation.

Pengaruh Kualitas Pengodean dan Kelengkapan Rekam Medis terhadap Pending Klaim Rawat Inap di RSUD Sidoarjo Barat

2026-07-25T02:31:44+00:00

Pending claims remain a common issue in the BPJS Health reimbursement process and may delay hospital claim payments. This study aimed to analyze the completeness of claim documents, the accuracy of diagnosis coding, and the factors contributing to pending inpatient BPJS claims at RSUD Sidoarjo Barat. A descriptive quantitative study with a prospective approach was conducted using 98 inpatient claim files selected through purposive sampling. Data were collected through observation using a checklist and analyzed descriptively. The results showed that all claim files were administratively complete (100%). Diagnosis coding was accurate in 85% of the files, while 15% were still inaccurate. Claim verification indicated that 86% of claims were eligible for payment and 14% remained pending. Medical factors were identified as the main cause of pending claims, followed by administrative and supporting factors. The findings indicate that complete documents alone cannot prevent pending claims if diagnosis coding is still inaccurate. Therefore, improving coding accuracy and claim verification is necessary to reduce pending BPJS claims.