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All Journal Jurnal Informasi Kesehatan Indonesia (JIKI) Jurnal manajemen informasi kesehatan Jurnal Kesehatan Pengabdian Masyarakat Jurnal Health Information Management and Medical Record
Syarah Mazaya Fitriana
Poltekkes Kemenkes Yogyakarta
Dentistry Education Health Professions Library & Information Science Medicine & Pharmacology Neuroscience Nursing Public Health

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Tinjauan Faktor Penyebab Ketidaklengkapan Pengisian Rekam Medis Rawat Jalan dengan Metode Fishbone dan USG di RSUD X Zanu Nury Latifah; Anton Kristijono; Syarah Mazaya Fitriana; Abdul Hadi Kadarusno
Journal of Health Information Management and Medical Record Vol. 2 No. 1 (2026): Volume 2 No 1 ( Juni ) 2026
Publisher : Poltekkes Kemenkes Yogyakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.29238/himmr.v2i1.3260

Abstract

Kelengkapan rekam medis merupakan bagian penting dalam proses pencatatan pelayanan, pengobatan pasien, dan pengajuan klaim asuransi, sehingga perlu dilakukan evaluasi terhadap ketidaklengkapan pengisiannya, terutama pada pelayanan rawat jalan dengan jumlah kunjungan pasien yang tinggi. Kelengkapan pengisian Rekam Medis Elektronik rawat jalan di Rumah Sakit X belum memenuhi standar sesuai ketentuan yaitu 100%. Tujuan mengetahui tingkat kelengkapan rekam medis rawat jalan periode bulan Oktober–Desember 2025 dan mengetahui faktor penyebab ketidaklengkapan menggunakan metode Fishbone dan USG. Penelitian deskriptif dengan metode campuran dilakukan pada Januari–April 2026. Pengumpulan data melalui Google Form, wawancara, dan kuesioner kepada tiga responden. Hasil penelitian menunjukkan rata-rata kelengkapan pengisian rekam medis rawat jalan 88,72%. Berdasarkan Analisis Fishbone ditemukan faktor penyebab ketidaklengkapan rekam medis yaitu tingginya beban kerja, sosialisasi pengisian RME, anggaran, tidak ada penghargaan atau punishment, belum ada SOP Pengisian RME, perangkat masih terbatas, dan format, tampilan, serta fitur RME yang belum tersedia. Berdasarkan analisis USG prioritas utama penyebab ketidaklengkapan rekam medis yang harus segera ditindaklanjuti adalah belum optimalnya penerapan sistem RME. Oleh karena itu, diperlukan evaluasi, pengembangan sistem RME secara berkelanjutan untuk meningkatkan kelengkapan rekam medis, dan mendukung pelayanan kesehatan.
Optimalisasi Mutu Pelayanan Rekam Medis melalui Edukasi, Pelatihan, Pendampingan, dan Implementasi Sistem Informasi Manajemen Klinik bagi Petugas PMB Jurusan Kebidanan Poltekkes Kemenkes Yogyakarta : Optimizing Medical Record Service Quality through Education, Training, Mentoring, and Implementation of a Clinic Management Information System for Staff at the Independent Midwifery Practice (PMB), Department of Midwifery, Poltekkes Kemenkes Yogyakarta Arif Nugroho Triutomo; Nita Budiyanti; Hari Wibowo; Syarah Mazaya Fitriana
Jurnal Kesehatan Pengabdian Masyarakat (JKPM) Vol. 6 No. 2 (2025): 2
Publisher : Poltekkes Kemenkes Yogyakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.29238/jkpm.v6i2.3444

Abstract

Quality medical record services are an important component in supporting the efficiency and quality of healthcare delivery. A preliminary assessment at the Independent Midwifery Practice (PMB), Department of Midwifery, Poltekkes Kemenkes Yogyakarta, identified several problems, including the continued use of manual medical record documentation, suboptimal utilization of computers, relatively long registration service times, and limited storage capacity for medical record documents. This community service program aimed to improve staff knowledge and competency regarding Electronic Medical Records (EMR) through education, training, mentoring, and implementation of a Clinic Management Information System (SiKlik), while improving the quality of registration services. The program was conducted from March to October 2024 using a blended approach and involved 12 staff members at the Independent Midwifery Practice (PMB), Department of Midwifery, Poltekkes Kemenkes Yogyakarta. The activities included EMR education, demonstration and hands-on practice in using SiKlik, mentoring during system implementation in the registration process, and evaluation using pretest and posttest assessments. Service quality was evaluated through a satisfaction survey involving 30 patients who had received services before and after EMR implementation. The results showed that the mean staff knowledge score increased by 24 points, from 65 at pretest to 89 at posttest. All participants (100%) were able to operate the basic functions of SiKlik, and system utilization in daily services reached 100%. The implementation of SiKlik also improved registration service efficiency, with the mean service time decreasing from 35 minutes to 15 minutes. All patients (100%) reported that the service was faster, and overall patient satisfaction reached 100%. The education, training, mentoring, and implementation of SiKlik demonstrated positive outcomes in improving staff competency, service efficiency, and patient satisfaction. The implementation of a Clinic Management Information System can support the transition from manual to electronic medical records and contribute to improving the quality of services at the Independent Midwifery Practice (PMB), Department of Midwifery, Poltekkes Kemenkes Yogyakarta.
Gambaran Adopsi Rekam Medis Elektronik di Rumah Sakit X Tahun 2025 Windi Ayudhiaswari; Anton Kristijono; Syarah Mazaya Fitriana; Abdul Hadi Kadarusno
Journal of Health Information Management and Medical Record Vol. 2 No. 1 (2026): Volume 2 No 1 ( Juni ) 2026
Publisher : Poltekkes Kemenkes Yogyakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.29238/himmr.v2i1.3272

Abstract

Latar Belakang: Digital Maturity Index (DMI) digunakan untuk menilai kematangan transformasi digital pelayanan kesehatan, termasuk Rekam Medis Elektronik (RME). Rumah Sakit Nur Hidayah Bantul telah menerapkan RME sejak tahun 2022 dan mengalami peningkatan nilai DMI komponen RME hingga tahun 2025. Namun, gambaran adopsi RME berdasarkan komponen RME dalam DMI tahun 2025 belum diketahui secara mendalam. Tujuan: Mengetahui gambaran adopsi RME di Rumah Sakit Nur Hidayah Bantul Tahun 2025 berdasarkan aspek fungsi RME, patient-centered care, kedalaman RME, dan layanan personalisasi pasien. Metode Penelitian: Metode kualitatif deskriptif. Pengumpulan data dilakukan melalui instrumen checklist, observasi, studi dokumentasi, dan wawancara tidak terstruktur. Data dianalisis secara deskriptif untuk menggambarkan penerapan RME di rumah sakit. Hasil Penelitian: Adopsi RME di Rumah Sakit Nur Hidayah Bantul memperoleh nilai DMI komponen RME sebesar 4,36 pada kategori managed. Aspek fungsi RME telah mendukung pencatatan dan pengelolaan data pasien secara elektronik. Aspek patient-centered care telah mendukung evaluasi kepuasan pasien. Aspek kedalaman RME telah mendukung pengelolaan data pasien secara lengkap, meskipun fitur clinical decision support, identifikasi pasien berbasis teknologi, dan informed consent elektronik belum optimal. Aspek layanan personalisasi pasien telah mendukung kemudahan akses pelayanan, tetapi akses resume medis pasien secara online masih dalam pengembangan. Kesimpulan: Adopsi RME di Rumah Sakit Nur Hidayah Bantul tahun 2025 telah berjalan baik dengan nilai DMI komponen RME sebesar 4,36 pada kategori managed. Pengembangan fitur pendukung keputusan klinis, identifikasi pasien berbasis teknologi, informed consent elektronik, dan akses informasi medis pasien secara online masih diperlukan. Kata Kunci: RME, DMI, Adopsi RME, Rumah Sakit, Nur Hidayah.
ANALISIS AKURASI KODE DIAGNOSIS SECARA MANUAL DAN ARTIFICIAL INTELLIGENCE DI PUSKESMAS UMBULHARJO I Rezqa Amaliza; Nita Budiyanti; Syarah Mazaya Fitriana; Abdul Hadi Kadarusno; Mutiara Pertiwi; Rahmah Nindyakinanti
Jurnal Informasi Kesehatan Indonesia (JIKI) Vol. 12 No. 1 (2026): Jurnal Informasi Kesehatan Indonesia
Publisher : Politeknik Kesehatan Kemenkes Malang

Show Abstract | Download Original | Original Source | Check in Google Scholar

Abstract

Ketidakakuratan kode diagnosis ICD-10 di puskesmas berdampak pada kualitas data morbiditas dan pelaporan penyakit, dengan kesalahan yang umumnya terjadi pada subkategori (Munandziroh et al., 2024). Artificial Intelligence (AI) terbukti mampu meningkatkan akurasi kodefikasi. Penelitian ini menganalisis perbedaan akurasi kode diagnosis ICD-10 antara metode manual dan AI serta identifikasi kelompok kesalahan pemberian kode di Puskesmas Umbulharjo I. AI yang digunakan dalam menetapkan kode adalah Claude , hasil penetapan tersebut dilanjutkan dengan mengidentifikasi kelompok kesalahan kode. Pendekatan deskriptif kuantitatif dengan desain cross sectional menggunakan sampel 398 rekam medis rawat jalan tahun 2025 melalui metode simple random sampling . Hasil kode manual dan kode AI divalidasi oleh expert judgement sesuai ICD-10 Volume II 2010. Hasil penelitian pemberian kode manual oleh Puskesmas Umbulharjo diperoleh keakuratan sejumlah 93 rekam medis (23,37%), sedangkan pemberian kode menggunakan AI diperoleh sejumlah 345 rekam medis (86,68%). Hasil identifikasi kesalahan kode manual didominasi kelompok kesalahan subkategori sejumlah 291 rekam medis (95,41%) dan kelompok kesalahan kategori (14 kasus, 4,59%), sedangkan kesalahan kode menggunakan AI meliputi kelompok kesalahan subkategori 53 rekam medis (100%). Hasil penelitian menunjukkan adanya akurasi yang signifikan antara kode manual dan AI , sehingga mempertegas potensi AI sebagai alat bantu kodefikasi dengan verifikasi akhir oleh PMIK.
Analysis Accuracy of Diagnosis Codes and Procedure Code in JKN Patient Delivery Cases at RS X Special Region of Yogyakarta Syarah Mazaya Fitriana; Riska Pradita; Vidya Widowati; Kavita Reni Tahayu
Jurnal Manajemen Informasi Kesehatan (Health Information Management) Vol. 9 No. 2 (2024): Health Information and Management
Publisher : Sekolah Tinggi Ilmu Kesehatan Sapta Bakti

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.51851/jmis.v9i2.608

Abstract

One of the activities in accordance with PMIK competency is the classification and coding of diseases and actions. The provision of diagnosis and action codes refers to the ICD-10 and ICD-9-CM rules. According to WHO (2016), coding of childbirth cases consists of conditions or complications (O00-O99), method of delivery (O80-O84), and Outcome of delivery (Z37,-). In practice in health care facilities, there are still inaccuracies in diagnosis and action codes in childbirth cases because they are classified as complex codes. The purpose of this study was to determine the process of implementing diagnosis and action codes, the process of implementing claims and factors causing pending claims, the percentage of accuracy of diagnosis and action codes and factors causing inaccuracy of diagnosis and action codes in childbirth cases of JKN patients at RS X Bantul. The type of research uses qualitative descriptive research. With a sample of objects of 75 medical records of childbirth cases of JKN patients with a simple random sampling technique and a sample of subjects of 4 informants with a purposive sampling technique. Data collection by observation, document study and in-depth interviews with 4 informants. The data validation technique in this study used source triangulation and technique triangulation. The results showed that the coding process was carried out by looking at medical records and then inputting the code into the SIMRS. The claim implementation process was carried out cumulatively and submitted to BPJS every 7th or 8th. In the case of pending labor, claims were caused by code incompatibility between the hospital and BPJS. The percentage of accuracy of the complication component was 54.7% (41), method of delivery (46.7)% (35), and outcome of delivery 94.7% (71), and action 29.3% (22). In addition, the results of the inaccuracy of the complication component were 45.3% (34), method of delivery 53.3% (40), and outcome of delivery 5.3% (4), and action 70.7% (53). The factors causing inaccuracy of diagnosis codes and actions were influenced by human resources who verified the code did not meet the competence of medical recorders, and there was no special training for coding officers. There is no budget allocated specifically for the implementation of the codification process. There is already an SOP on coding but the written procedures are still incomplete. Inaccuracy of diagnosis and action codes in cases of JKN patient labor can cause delays in payments to the hospital.
Co-Authors Abdul Hadi Kadarusno Anton Kristijono Arif Nugroho Triutomo Hari Wibowo Kavita Reni Tahayu Mutiara Pertiwi Nita Budiyanti Nita Budiyanti Rahmah Nindyakinanti Rezqa Amaliza Riska Pradita Vidya Widowati Windi Ayudhiaswari Zanu Nury Latifah