Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI)

Analisis Penyebab Pengembalian Klaim BPJS Pasien Rawat Inap Ditinjau Dari Proses Pengkodean Di RSUD Majenang

Awlia Varasemitha Zahra — 2024-08-31

Pending Claim is a refund because there is no agreement between BPJS Health and FKRTL regarding coding rules and medical determination (claim dispute). The correct diagnosis and action code will determine the smooth process of submitting claims for medical services to BPJS Health and reduce the number of claim returns. This study aims to determine the causes of inpatient claim returns in terms of the coding process at Majenang Hospital. The research method used is a qualitative method with an observational descriptive design. Data was obtained from pending claims from July to September 2023. Data collection methods were observation and interviews. Majenang Hospital research results showed that 371 claims were returned and 187 claims were returned due to coding confirmation. Factors inhibiting the accuracy of a diagnosis or action code are the use of combined codes, errors in determining the main diagnosis, differences in perception, and discrepancies in supporting results with the diagnosis. Efforts that can be made to minimize the number of claim returns include reviewing diagnosis or action codes, communicating between DPJP, the casemix team and BPJS verifiers, coding training and having an SPO.

Analisis Kepuasan Pengguna Sistem Rekam Medis Elektronik Menggunakan Metode EUCS di RS Hermina Kota Padang

Syamsul Kamal — 2024-08-31

There are 6 Pillars of Health Transformation, one of which is the 6th pillar, namely Health Technology Transformation, which has a role in utilizing information technology so that with health information technology we can make good use of developments in digital technology, so that the process of digitizing health technology can grow better and grow better. developing in the world of health. In Minister of Health Regulation Number 24 of 2022 concerning Electronic Medical Records, it is stipulated that all Health Facilities at the end of December 2023 must implement RME, where the change from Manual Medical Records to Electronic Medical Records (RME). The aim of this research is to look at user satisfaction regarding the content, appearance, data accuracy, timeliness and ease of Hinai application for RME at Hermina Hospital. The method used in this research is the Quantitative Method with a descriptive approach. In carrying out data processing, the EUCS method was used with 18 samples. This research was carried out in May 2024 at Hermina Hospital, Padang City. The results of the research showed that users were very satisfied with the performance of the Hinai application, where the content got a score of 79 and a TCR of 87.78% for the display, a score of 81 and a TCR of 90.89 were obtained, for data accuracy it was 79.2 and the TCR was 80%, for accuracy When we got a score of 80 and a TCR of 88.89%, then for convenience we got a result of 80.4 and a TCR of 89.32, where for all categories it can be said that users of the Hinai application are very satisfied with the presence of this application and can continue using it in the future. . It is recommended that there be a continuation of this research for further development regarding the Hinai Application program in the future.

Analisis Kelengkapan Desain Formulir Pasien Rawat Jalan Di Puskesmas Purwokerto Timur I

Lintang Dwi Cahyani — 2024-08-31

Puskesmas is one of the health service institutions provided by the Indonesian government and is the spearhead of the national health system. Efforts in establishing quality health centre service quality, that is, by paying attention to every aspect of it. The anatomical and physical aspects are used here. Please note the number of measurement cards for patients. One of them is processing the patient's medical record form design. Medical record forms are designed and used for maintenance and monitoring. The design of the form aims to improve and complete aspects of the outpatient form design that are currently still in use and to improve the quality of health services at the Purwokerto Timur I Health Center. The objective of this research is to identify the completeness of the outpatient forms available at the Purwokerto Health Center. Timur I. This analysis uses a quantitative method with a cross-sectional descriptive approach. The subject of this study was the outpatient form at the Purwokerto Timur I Health Center. The results obtained from this study were quite good, that is, there was an outpatient form at the Purwokerto Timur I Health Center, but the results of the analysis of this form still need to be improved in completeness. There is a completeness of 76,92% in the form. The aspect of the content that has the best completeness of the form.

Gambaran Pengetahuan dan Sikap Pasien Post Bedah Elektif tentang Informed Consent di RS X Tahun 2024

Dela Nurfadhilatussifah — 2024-08-31

Informed consent is giving consent after obtaining complete information. The patient has the right to accept or reject some or all of the assistance measures that will be provided. This decision depends on the patient's knowledge and attitude regarding consent to medical treatment. Several cases of medical malpractice in Indonesia actually started with the failure to implement informed consent properly. The aim of this research is to analyze the knowledge and attitudes of post-elective surgery patients regarding informed consent at Hospital X. This type of research is descriptive quantitative. The sampling technique uses accidental sampling. The population in this study was 42 patients after elective surgery in December 2023. The research instrument used a questionnaire sheet. The results of the study showed that of the 42 post-elective surgical patients regarding informed consent at Hospital Efforts are needed to simplify explanations in language that is easy for patients to understand and use certain media to improve patient understanding.

Faktor - Faktor Yang Mempengaruhi Proses Pengkodean Diagnosis Di Rumah Sakit Umum Daerah Cilacap

Dina Febriana — 2024-08-31

Hospitals are health institutions that provide medical services to individuals as a whole, including inpatient, outpatient, and emergency care. Hospitals need to improve the quality of their services. This can be done by having a good medical record unit. Medical records are documents that contain information about the patient's identity, examination, treatment, procedures, and other services provided to the patient. An important data processing to store data in medical records is coding. Classifying and providing codes for disease diagnosis is known as coding. Writing codes on medical records must be precise and accurate. The impact of coding errors can affect the quality of medical records. Based on an initial survey related to coding carried out at Cilacap Regional Hospital, a problem was found that officers had difficulty reading the doctor's writing. This study aims to determine what factors influence the diagnosis coding process at Cilacap Regional Hospital. This research is a type of qualitative research with data collection method instruments through observation and interviews. The research subjects amounted to 2 people, namely coder officers and the head of the medical records unit. The results of the study obtained several factors that influence the coding process including; Writing a diagnosis that is difficult to read, incompleteness in medical records can affect the coding process that will be carried out by the coder, and the absence of a medical dictionary as a coding support book in finding unknown terms in coding.

Analisis Ketepatan Kode Diagnosis Pada Kasus Penyakit Infeksi Saluran Pernapasan di Rumah Sakit Umum Daerah Ajibarang

Annisa Zahra Syifani — 2024-08-31

Coding is one of the activities of processing medical record data by providing codes with letters or numbers or a combination of letters and numbers that represent data components. Coding is the activity of providing codes for the main diagnosis and secondary diagnosis in accordance with the 2010 version of ICD-10 published by WHO and providing action and procedure codes in accordance with the 2010 version of ICD-9-CM. Accuracy in coding disease diagnoses and actions is something that must be considered by medical recorders. The accuracy of coded data is crucial for medical recorders. The purpose of this research was to ascertain the level of coding accuracy in cases of respiratory tract infections at Ajibarang Hospital. The research was conducted using the descriptive quantitative analysis method with a sample of 90 medical records of patients with respiratory tract infections in August–October 2023 at RSUD Ajibarang. The conclusion of this research showed that of the 90 medical records of respiratory tract infection cases at Ajibarang Regional Hospital in August–October 2023 studied, there were 19 medical records with inappropriate codes (21.11%) and 71 medical records with appropriate codes (78.89%), which were identified as inaccurate factors using 5M (man, money, material, method, and machine).

Keselamatan dan Kesehatan Kerja (K3) Petugas Rekam Medis Ruang Filling di Rumah Sakit Bhayangkara Tingkat III Banjarmasin

Husin Husin — 2024-08-31

Filling unit rekam medis mempunyai peran penting dalam pemeliharaan rekam medis terutama dalam hal penyimpanan dan perlindungan rekam medis. Penyimpanan rekam medis dapat berjalan dengan baik apabila fasilitas penunjang dalam kegiatan penyimpanan tersedia dan lingkungan kerja mendukung sehingga dapat memudahkan dalam pengambilan, penyediaan dan penyimpanan rekam medis. pengambilan dan penyimpanan dokumen rekam medis, petugas filling pernah tertimpa dokumen rekam medis, tergores dokumen rekam medis, rak rekam medis, petugas filling terjatuh saat mengambil dokumen rekam medis yang tinggi. Sehingga diteliti serta diketahui penerapan keselamatan dan kesehatan kerja (K3) berdasarkan faktor sumber daya manusia dan faktor lingkungan kerja di Rumah Sakit Bhayangkara Tingkat III Banjarmasin. Jenis penelitian dalam penelitian ini adalah kualitatif dengan pendekatan deskriptif. Subjek penelitian ini berjumlah 3 orang yaitu Kepala Unit Rekam Medis sebagai informan 1, Petugas filling rawat jalan sebagai informan 2 dan petugas filling rawat inap sebagai informan 3. Instrument penelitian ini menggunakan pedoman wawancara danobservasi. Hasil penelitian ini adalah Penerapan keselamatan dan kesehatan kerja (K3) di Rumah Sakit Bhayangkara Tingkat III Banjarmasin belum berjalan baik berdasarkan faktor sumber daya manusia dalam penggunaan alat pelindung diri (APD) sebagian besar menggunakan masker, berdasarkan faktor lingkungan kerja pada ruang filling rawat jalan pencahayaan dan jarak antar rak belum memenuhi standar, pada ruang filling rawat inap suhu, kelembaban, pencahayaan dan jarak antar rak belum memenuhi standar. Sehingga perlu sosialisasi penerapan penggunaan APD dan pengecekan sarana prasarana secara berkala terhadap sarana prasarana untuk pemenuhan standar ruang filling

Kelengkapan Pengisian Rekam Medis Elektronik Pasien di Poli Umum Puskesmas Surabaya Timur

Lilis Masyfufah — 2024-08-31

The digital transformation of health is one proof of technological developments in health services. The implementation of health digitalization in the Surabaya City environment has started on November 10 2014 and in 2020 it will be ready to transform into an Electronic Health Record (EHR). The implementation of EHR began with the implementation of RME at Surabaya City Health Centers since March 2022. However, RME implementation is still not optimal, so research needs to be carried out on the completeness of RME at East Surabaya Regional Health Centers. This research method uses a type of quantitative research that collects data in the form of numbers using an observational approach. The population used is RME patients at Community Health Centers in the East Surabaya Region, namely Menur Health Center and Keputih Health Center, while the research sample will be taken using the Cochran Formula. The results of the identified data will be processed using Microsoft Excel for quantitative analysis and will be presented in table form to describe the object. The results of the research show that incomplete filling in of patients' RME at the East Surabaya Community Health Center General Polyclinic is found in the Identity, Important Reports and Authentication components, while the Documentation component is 100% complete. It can be concluded that the incompleteness of RME filling at the East Surabaya Community Health Center reaches 70%, the data is not complete.

Audit Kode Klinis Pasien Rawat Inap Jaminanan BPJS Kesehatan Di Rumah Sakit Tipe C Dan D Wilayah DIY

Hosizah Hosizah — 2024-08-31

The quality of diagnosis codes is an important part of the hospital management level. The impact of a lack of quality diagnosis codes is the potential to reduce hospital income. A clinical coding audit needs to be conducted to review and analyze discovered errors and attempt to trace their source. The purpose of this research is to audit the code. The research approach was carried out through a quantitative descriptive approach. The research population was inpatient medical records of BPJS Health patients. Sample calculations use Slovin, with a margin of error of 10%. In this study, the clinical coding audit involved 3 coders in each hospital, coding experts from senior practitioners from Type B Hospitals and experts from academics. The results of the clinical code audit showed that the timeliness aspect was 100%, accuracy was 92.5%, completeness was 91.0%, relevance, and legitimacy were 87.5% each, while the lowest was in the reliability aspect at 80.0%. The results of the legibility aspect are in line with the results of relevance. This shows that determining clinical codes for case mix purposes must be supported by complete documentation of the patient's medical records.

Sistem Pelepasan Informasi Rekam Medis Dalam Menjamin Aspek Hukum Kerahasiaan Rekam Medis Di RSU. Imelda Pekerja Indonesia Tahun 2023

Abdul Malik Ritonga — 2024-08-31

Privacy, confidentiality and release of information are communications containing certain confidential information provided by patients to their doctors to be kept confidential, unless the patient has given written consent to release the information from their medical records. The aim of this research is to determine the procedures for the medical record information release system in ensuring the legal aspects of confidentiality at RSU. Imelda Indonesian Worker. This type of research is descriptive, namely a research method carried out with the aim of creating an objective picture of a situation. Research time is from January to August 2023 at RSU. Imelda Indonesian Worker. The subjects in this research were medical records officers, the research informant was the head of medical records. From the results of the research, it is known that the procedures for the release of medical record information system run in accordance with SPO number 002/SPO/MRMIK/2022, there is no specific SPO regarding the confidentiality of medical records but confidentiality has been carried out well in accordance with the SPO for the release of medical record information and in line with the 24 year Health Ministerial Regulation. 2022 regarding medical records, at RSU. Imelda, an Indonesian worker, releases a lot of information for insurance. The obstacle in releasing medical information is patients/families who do not bring a power of attorney and identification, where the patient's family does not understand the importance of a power of attorney. It is hoped that hospitals will create special SOPs regarding the confidentiality of medical records and provide information to patients/families about the requirements and procedures for releasing medical information by placing banners or posters in the information section or other strategic places.

Tinjauan Pengisian Formulir Informed Consent Pasien Dengan Tindakan Hecting di Puskesmas X Kabupaten Tasikmalaya

Reza Maulana Gunawan — 2024-08-31

Approval for medical action or Informed Consent is required to ensure that the patient has understood all the information provided to make a decision and the patient gives consent or refusal. Informed consent is useful as legal evidence to reduce the risk of problems or claims against doctors or health care facilities for actions taken on patients. So the completeness of filling out the informed consent form is very important in community health centers. The X Health Center, Tasikmalaya Regency, has not fully complied with the completeness of filling out the informed consent form.Knowing the completeness of filling out the Informed Consent Form for Patients with Hectating Actions at the X Community Health Center, Tasikmalaya Regency. The research method used was a quantitative descriptive design with a sample of 44 Informed Consent patients with Hecting procedures based on the total sampling of patient visits in the 2023 treatment room. The results of the research on the completeness of filling out informed consent in the Patient Identification review were 78% complete, the Important Report review was 67% complete, the Authentication review was 63% complete, the Good Documentation review was 81.2% complete and from the four components of the recording review the results were 69% complete and 31% incomplete. The completeness of filling out informed consent has an important role in supporting the quality of service aspects as well as the legal aspects of the form as legal evidence for patients and health service facilities.

Faktor-Faktor Yang Mempengaruhi Ketepatan Kode Diagnosa External Cause Kasus Kecelakaan Sepeda Motor Di RSU Imelda Pekerja Indonesia Medan Tahun 2023

Marta Simanjuntak — 2024-08-31

Codefication classification is an activity that groups diseases based on certain. Coding of disease diagnoses must be carried out accurately and completely. The assignment of disease diagnosis codes is in accordance with ICD-10 rules. External cause is a code used to classify the external cause of an illness whwther caused by accidents, injuries, burns, poisoning, side effects of other cause. Factors thar influence the accuracy of external cause diagnosis codes are discrepancies in giving diagnosis codes, erros and discrepancies in giving additional codes for descriptions of activity and place of occurrence. As a passenger or driver, do not include the external cause code in the wxisting diagnosis. This research was conducted at RSU Imelda Pekerja Indonesia Medan with the aim of research to determine the factors that influence the accuracy of the external cause diagnosis code for motorbike accident cases at RSU Imelda Pekerja Indonesia Medan in 2023. This research uses quantitative analytical methods with a cross sectional approch. The research results showed that there was a significant influence of the variable completeness of assessment eith coding accuracy with a value (p value 0.002 < 0,05), there was an influence of completeness of laboratory examination with coding accuracy with a value ( p value 0.045 < 0,05), there was an influence og the quality of code officers according to length of service with value (p value 0.003 < 0,05) and there is an influence on the quality of code officers according to training followed by value (p value 0.017 < 0,05).