Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI)

Rancangan Bangun Aplikasi Berbasis Mobile Pengukur Kualitas Rekam Medis Di Rumah Sakit Aisyiyah Siti Fatimah Tulangan

Maura Aulia Ismail, Laili Rahmatul Ilmi, Umi Khoirun Nisak — Sat, 28 Feb 2026 00:00:00 +0000

The quality of medical record completeness is very vital, hence it needs to be taken seriously. Sifi Fatimah Tulangan Hospital focuses on quality control, necessitating innovation to facilitate users in maintaining quality, which is achieved through the design and development of a mobile-based medical record quality measurement application. This research aims to assist in monitoring and evaluating the quality and completeness of medical record filling. This type of research is action research with a Research and Development (RnD) design. There are 8 steps involved in this research, starting with primary data collection through interviews with users using an interview guide to understand their needs as a basis for designing and developing the mobile-based application. Subsequently, 7 steps are taken to produce products, including initial design, creating user flow, creating use case diagrams, creating activity diagrams for mobile-based UI (User Interface) design, and designing the application wireframe.Needs as the basis for designing and building mobile-based applications, followed by 7 steps taken to produce products including initial design, creating user flow, creating use case diagram, creating activity diagram for mobile-based UI (User Interface) design, designing wireframe for medical record quality measurement application, conducting design using Figma application, and the results of the trials. The design results that meet the needs are then developed by the IT department at the hospital, and the output of this research is a journal and intellectual property rights.

Perancangan Penggunaan Kode Diagnosis Jaminan Kesehatan Nasional Di Rumah Sakit Soeharto Heerdjan

Sat, 28 Feb 2026 00:00:00 +0000

Hospitals frequently encounter challenges in the BPJS Kesehatan claims process, such as diagnostic coding errors, data discrepancies, and incomplete medical record documentation. These issues result in claims delays, financial disruptions, and a decline in service quality. This study aims to design an electronic pocketbook of National Health Insurance (JKN) diagnosis codes as a guide for healthcare workers to expedite and simplify the claims process. The study was conducted at Soeharto Heerdjan Hospital from October to December 2024 using the Research and Development (R&D) method with the ADDIE model in three stages: analysis, design, and development. Six informants from the analysis and coding unit and the patient verification and assurance unit were involved as data sources. Data collection techniques included in-depth interviews, questionnaires, and document reviews, followed by descriptive analysis. The results showed that the 34-page electronic pocketbook, designed in PDF format, contains diagnoses, ICD-10 codes, severity levels, and management procedures, with hyperlinks for easy information retrieval. The feasibility test showed a validity level of 95.8% for content and 91.6% for media. Therefore, this pocketbook is highly valid and suitable for use as a guide in the BPJS claims process, and can support work efficiency and improve the quality of hospital services.

Hubungan Kelengkapan Resume Medis Rawat Inap BPJS Dengan Persetujuan Klaim BPJS Di RS Advent Medan 2024

Sat, 28 Feb 2026 00:00:00 +0000

Minister of Health Regulation Number 269/MENKES/PER/III/2008, states that a discharge summary (resume) is carried out by a doctor or dentist on a patient. BPJS claims are submissions of costs incurred by BPJS participant patients from the hospital to BPJS Kesehatan, carried out every month and billed to BPJS Kesehatan. The purpose of this study was to determine the relationship between the completeness of the inpatient medical resume and the approval of BPJS claims at Medan Adventist Hospital. This study uses a quantitative descriptive research method with a cross-sectional research design where data collection was carried out through interviews and checklists carried out in June 2024. be concluded that most BPJS claim applications were not approved Based on the results of the study, the completeness of medical resumes in 50 incomplete and unapproved files amounted to 31 files with a percentage of 38% while those that were complete and approved amounted to 19 files with a percentage of 62%. From the results of the study, it can due to the large number of incomplete medical resumes. Suggestions for healthcare workers are required to understand and implement Standard Operating Procedures (SOPs) for completing medical resumes in accordance with applicable regulations, both hospital regulations and regulations contained in legislation. Improve healthcare workers' discipline in completing medical resumes by recording any missing components of the medical resume, then conducting a joint evaluation within a certain timeframe, especially for those directly involved in recording medical resumes and the BPJS claims section.

Perancangan Sistem Pelaporan Terintegrasi (SIPORSI) Berbasis Google Spreadsheet untuk Pencatatan dan Pelaporan Kasus Tuberkulosis di Puskesmas Pembantu Kelurahan Serangan

Sat, 28 Feb 2026 00:00:00 +0000

Background: Puskesmas Pembantu (Pustu) Kelurahan Serangan lacks structured TB case recording and reporting mechanisms, relying on manual registers and informal WhatsApp reporting, causing data inconsistency and reporting delays. Objective: To design Integrated Reporting System (SIPORSI) (based on Google Spreadsheet suitable for TB case recording and reporting at Pustu Kelurahan Serangan. Methods: Research and Development approach using ADDIE model conducted from March to December 2024. Six healthcare workers were selected using purposive sampling. Data collection through semi-structured interviews, document analysis, and infrastructure identification. Qualitative analysis with thematic approach was used. Results: SIPORSI was successfully developed using ADDIE model. Analysis phase identified inadequate existing system, documentation gaps, high loss to follow up (37.5%), and low contact investigation (25%). Design and Development phases produced user-centered system with automatic validation and role-based access control integrated with national SITB. Implementation through structured training showed competency improvement of 33.3% (SIPORSI Knowledge domain: 66.7%). Evaluation demonstrated significant improvements: data quality (+31.8%), time efficiency (70.9%), SUS score (85.7/"Excellent"), loss to follow up reduction (37.5% to 8.3%), contact investigation increase (25% to 91.7%), and 100% reporting timeliness. Conclusion: SIPORSI has proven to be an effective evidence-based solution in addressing TB recording system fragmentation in primary healthcare facilities through combination of accessible cloud-based technology, user-centered design, and structured training. The system has great potential for replication in other auxiliary health centers as a contribution to achieving Indonesia's TB elimination target by 2030.

Perancangan UI/UX Pada SIMKLINIK Bagian Pendaftaran Di Klinik Jaya Kusuma Husada

Moh Maulana, Wisoedhanie Widi Anugrahanti — Sat, 28 Feb 2026 00:00:00 +0000

At the Jasa Kusuma Husada Clinic, patient registration management still uses a manual, paper-based system. The use of this system has the potential to cause inefficiencies in service time, patient identification errors, and data duplication. Based on these problems, the researcher designed the user interface (UI) and user experience (UX) on the registration section of the clinic management information system (SIMKLINIK) at the Jaya Kusuma Husada Clinic. The method used in this study was Research and Development (R&D). The results of this study, the design aspects of the User Interface (UI) and User Experience (UX) in the registration section of the clinic management information system (SIMKLINIK), were observed on 22 assessment indicators covering aspects of navigation, icon clarity, design consistency, and flexibility of use, showing that they meet the expected standards. In conclusion, the UI / UX design for the registration section of SIMKLINIK has been prepared based on the results of the user needs analysis

Analisis Beban Kerja Petugas Pada Unit Rekam Medis Di RSUD Pasar Rebo Jakarta Timur

Muhammad Dudayev Caesar Putra, Hafida Sofa Andini — Sat, 28 Feb 2026 00:00:00 +0000

Pasar Rebo Regional Hospital's medical records unit has not had a workload calculation for a long times, so it is very necessary to conduct a workload analysis calculation, to prevent excessive workload on medical records unit staff. The workload analysis calculation that was previously carried out also used WISN (Workload indicators of staffing need), which is no longer valid. This research is a descriptiv study using the ABK Kes method (Health Workload Analysis). The research was conducted in the medical records unit of Pasar Rebo Regional Hospital. The populations in this study was all medical record staff at Pasar Rebo Regional Hospital, totaling 46 people. The data in this study were analyz use the ABK Kes method to obtain the number of record staff needed at Pasar Rebo Regional Hospital. Based on the results of the calculations of staff needs using the ABK Kes method, the number of Human Resources needed for the medical records unit is 55 people. Thus, it can be conclude that the numbers of staff in the medical record unit at Pasar Rebo Regional Hospital does not match its needs, where Pasar Rebo Regional Hospital lacks 9 staff/officers in the medical records unit.

Analisis Manajemen Risiko Rekam Medis dalam Upaya Peningkatan Mutu Pelayanan di Klinik X Surakarta

Ade Amallia, Chayanita Sekar Wijaya, Zidni Ilma Nafi’a — Sat, 28 Feb 2026 00:00:00 +0000

The quality of healthcare services is a crucial element in ensuring patient safety, where the management of digital medical records plays a strategic role in supporting service continuity and clinical decision-making. This study aims to analyze risk management in medical record services at Clinic X, Surakarta, and formulate improvement recommendations to enhance service quality. The research applies a descriptive qualitative approach using the Failure Mode and Effect Analysis (FMEA) method. Data were collected through workflow observations and interviews with medical record officers and Diginic system administrators. Risk assessment involved identifying processes, determining failure modes, evaluating severity, occurrence, and detection levels, and calculating the Risk Priority Number (RPN) to prioritize corrective actions. The findings reveal that the highest RPN values are associated with patient registration without ID cards, Diginic system disruptions, and non-compliance with BPJS registration through the Mobile JKN application. These risks affect patient identification accuracy, service flow, and patient experience. Meanwhile, duplicate and delayed data entries have lower risk priorities but still impact operational efficiency and data accuracy. The study concludes that service quality can be improved through strengthened patient identity verification, the establishment of operational procedures during system failures, staff capacity development, and patient education on Mobile JKN use. Future research is recommended to expand the study scope and integrate FMEA with Root Cause Analysis for more comprehensive risk mitigation strategies.

Permasalahan Clinical Coding Pada Sistem Casemix Penyebab Pending Claim Pasien Jaminan BPJS Di Rumah Sakit X

Sugeng Santoso, Suryo Nugroho Markus, Kori Puspita Ningsih — Sat, 28 Feb 2026 00:00:00 +0000

Background: Clinical coding accuracy is a vital factor in the financial stability of hospitals under the BPJS Health casemix system. Errors in clinical coding frequently lead to pending claims, which hinder the hospital's cash flow. Objective: This study aims to analyze the underlying causes of casemix coding issues in pending claims for BPJS Health patients at Hospital X. Method: This research employed a descriptive analytical method with a qualitative approach. Data were collected through in-depth interviews with five informants, consisting of two clinical coders, one casemix coordinator, and two physicians, as well as document observations of medical records and claim regulations. Result: The findings indicated a pending claim rate of 10.2%, with 33.3% of these cases caused specifically by clinical coding errors. The primary causes were categorized into three factors: (1) Human Resources, involving low coder competency in ICD-10/9-CM guidelines and medical pathognomonics; (2) Documentation Process, including incomplete medical resumes and a lack of clinical evidence provided by physicians; and (3) System, characterized by the infrequent socialization of the latest claim regulations and technical agreements. Conclusion: Accuracy in casemix coding is highly dependent on the synergy between comprehensive clinical documentation and the coder's expertise. Hospitals are recommended to implement continuous professional training and routine medical audits to minimize financial risks.

Gambaran Faktor Terhambatnya Pelaksanaan Analisis Rekam Medis Rawat Inap Di RS Akademik UGM

Ery Rustiyanto, Fathiya Akhsani, Qisti Nur Azizah — Sat, 28 Feb 2026 00:00:00 +0000

Background: Medical record quality assurance is one of the implementations. Efforts to maintain the quality of these records include analyzing inpatient medical records at the Gadjah Mada University (UGM) Academic Hospital. The analysis of inpatient medical records at the Gadjah Mada University (UGM) Academic Hospital is carried out by two people, with an average of 1,680 inpatients per month in 2024. Observations at the analyst's workplace reveal a significant accumulation of unanalyzed medical records. This accumulation of medical records disrupts other processes, such as the difficulty of locating inpatient records for patients who wish to borrow them, either by staff or for research purposes. Medical record analysis is performed on paper/manual medical records, and some have switched to electronic medical records. This is quite time-consuming for staff, as they must consult both manual and electronic medical records. Meanwhile, based on the trend in the number of inpatient visits during 2024, it is predicted that in 2025 the number of inpatient visits will increase to around 2,000 patients or even more per month. Objective: To identify factors hindering the analysis of inpatient medical records at the Gadjah Mada University (UGM) Academic Hospital. Research Method: This study used a descriptive design with a qualitative approach to identify factors hindering the implementation of inpatient medical record analysis at the Gadjah Mada University (UGM) Academic Hospital, using Fishbone analysis.

Tinjauan Alur Prosedur Pelayanan Berdasarkan Jenis Pasien dan Penyelenggaraan Rekam Medis di Klinik X Kabupaten Sukoharjo

Sat, 28 Feb 2026 00:00:00 +0000

The flow of procedures in patient care and medical record management is important for healthcare providers. If these two components are carried out properly, they can increase patient satisfaction with healthcare services. The purpose of this study is to review and provide a systematic overview of the flow of patient care procedures and medical record management at Clinic X in Sukoharjo Regency. This descriptive study was conducted at an outpatient clinic in Sukoharjo Regency. The objects of this study were the procedural flow of patient services and medical record management. The results of this study showed that the service system provided accommodated several types of patients, including general patients, BPJS patients, and partner patients from the clinic. The registration system is available in two models: online and offline BPJS registration. The Service Procedure Flow at Clinic X is already available and running well. Medical record management is already in place and is guided by Indonesian Minister of Health Regulation No. 24 of 2022. A suggestion for the future is that several services that still use manual medical records can be transferred to electronic medical records so that the services provided are more effective and efficient.

Perancangan Panduan Tata Laksana Penyusutan Rekam Medis Di RSUD Balaraja Kab. Tangerang

Dwiyani Nur Fatimah, Deasy Rosmala Dewi — Sat, 28 Feb 2026 00:00:00 +0000

RSUD Balaraja Kab. Tangerang already has an SPO for the retention of active medical record files into inactive medical records and an SPO for the destruction of medical record files, there is no archive retention schedule yet. For the implementation of the reduction of medical records according to schedule, a procedure guideline is made. This study aims to design a procedure guideline for the reduction of medical records using the Delphi method which was carried out in October 2024 - November 2024. Data collection through observation of the medical record room, interviews with the head of the medical record installation and a questionnaire for the application of the Delphi method, with 5 stakeholders consisting of the Head of Medical Services, the Medical Service Operational Work Team, the Public Relations and Program Planning Administration Work Team, the Treasurer, and the Head of the Medical Record Installation. The results of this study describe the facilities and infrastructure and procedures for implementing the reduction of medical records at RSUD Balaraja Kab. Tangerang, preparing a guideline for the management of medical record reduction, verifying the results of filling out the questionnaire that has been agreed upon by stakeholders with a standard deviation of 0 which means there is no difference of opinion and proposing the design of a guideline for the management of medical record reduction consisting of chapter 1 definition, chapter 2 scope, chapter 3 procedures, and chapter 4 documentation. The conclusion is a draft design of a guideline for the management of medical record reduction which contains the procedures and schedule for the implementation of medical record reduction at RSUD Balaraja Kab. Tangerang.

Pengaruh Kualitas Pelayanan dan Fasilitas Terhadap Minat Kunjungan Ulang Pasien Rawat Jalan Rumah Sakit TK III dr. Bratanata Jambi

Dwi Amrina, Listautin Listautin, Renny Afriany N — Sat, 28 Feb 2026 00:00:00 +0000

The quality of health services plays an important role in the reputation of health service institutions in the community. Good quality of service and facilities can increase patient satisfaction and encourage patients to make repeat visits. This study aims to analyze the influence of service and facility quality on the interest of outpatient revisits in hospitals TK III dr. Bratanata Jambi. The research approach uses a quantitative method with an associative study design.. The research sample amounted to 100 new outpatient respondents who were selected using purposive sampling techniques. Data were collected through questionnaires and observations, analysis using Chi-Square test, Partial T test and F test with the help of SPSS version 25. The results of the analysis showed that the quality of service had a significant effect on the interest of patient revisits with a value of p = 0.001 (<0.05), and facilities showed a significant influence with a value of p = 0.000 (<0.05). A simultaneous test (F test) confirmed that the quality of service and facilities together had an effect on the interest of repeat visits (F value = 6.755, p < 0.05). The quality of services and facilities has a significant effect on the interest of outpatient revisits at the hospital TK III dr. Bratanata Jambi.

Analisis Kesiapan Implementasi Rekam Medis Elektronik Menggunakan Pendekatan DOQ-IT Di Klinik Pratama Wulandari Tahun 2025

Sat, 28 Feb 2026 00:00:00 +0000

The implementation of Electronic Medical Records (EMR) is a mandatory requirement for all healthcare facilities in Indonesia to improve service quality, accelerate patient information access, and support data interoperability through a national platform. The purpose of this study was to analyze the readiness for the implementation of EMR using the DOQ-IT approach by assessing the influence of human resources, organizational work culture, governance and leadership, and IT infrastructure in healthcare services. This research used a descriptive quantitative method with total sampling of 16 respondents from various healthcare professions at Wulandari Primary Clinic. Data were collected using the DOQ-IT questionnaire consisting of multiple-choice questions. The analysis results showed that the overall assessment score was 74.44, which falls into Category II (fairly ready). This indicates that while there are strong capabilities in certain readiness components, weaknesses remain in others. Based on the four readiness aspects, only IT Infrastructure had the lowest classification score (2.50). The most prepared aspect was Human Resources (2.86), followed by Organizational Culture (2.67), and Governance and Leadership (2.58). Recomendation that need to be considered: Improve IT infrastructure, conduct regular training for staff, strengthen the role of leaders, conduct regular evaluations so that RME runs effectively