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Tuti Herawati
Institut Teknologi dan Kesehatan Mahardika
Dentistry Health Professions Nursing Public Health Veterinary

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Analisis Pengolahan Pelaporan Eksternal RL 4A Berdasarkan Sistem Informasi Rumah Sakit Di Rumah Sakit Cirebon Tuti Herawati; Fina Monika
MEJORA Medical Journal Awatara Vol 3 No 1 (2025): January
Publisher : Awatara Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.61434/mejora.v3i1.265

Abstract

The hospital, as a healthcare service provider, must have data requirement indicators in the digital era, one of which is hospital reporting data (RL). One type, RL4a, includes morbidity and mortality data of inpatients (both living and deceased) within a one-year period. Data collection is conducted from January 1 to December 31, then recapitulated and reported through RL4a submission in the SIRS online system. This study aims to analyze the external reporting process of RL4a based on the hospital information system at Pertamina Cirebon Hospital. The research employs a quantitative descriptive method. The variables studied include RL4a external reporting, with the research objects being the SIRS online system and the instrument used being a checklist sheet. The study results indicate that the RL4a external reporting process at Pertamina Cirebon Hospital refers to the register book, disease index, coding, and the top 10 disease reports. Data processing findings show that 90% of reports comply with standards, while the remaining 10% do not. The discrepancies are due to inaccurate codification validity in relation to patient diagnoses during data entry into the SIRS, as well as the manual, one-by-one data entry method. This condition impacts work efficiency and effectiveness.
Analisis Kelengkapan Pengisian Soap Pada Rekam Medis Elektronik Rawat Jalan Di Rumah Sakit Pertamina Cirebon Tuti Herawati
MEJORA Medical Journal Awatara Vol 2 No 3 (2024): Juli
Publisher : Awatara Publisher

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

Abstract

Completeness of the health history form is important because it provides information for further treatment or action. Progress notes can use SOAP (Subjective, Objective, Analysis and Planning. The aim of this research is to determine the analysis of the completeness of SOAP filling in outpatient EMR at Pertamina Cirebon Hospital. This type of research uses descriptive methods with a quantitative approach. In this research, the data tool used is using a checklist sheet. The data collection method uses observation. The sample used for random sampling was 99 SOAP Electronic Medical Records. Based on observations of the completeness of filling out the SOAP at the Pertamina Cirebon Hospital, filling in the EMR SOAP is in the incomplete category and is still not in accordance with the Hospital's SPM which states that the completeness of filling in electronic medical records must be 100%. Results: 37 outpatient electronic medical record SOAPs with a percentage (37.4%) in the complete category and 62 outpatient EMR SOAPs with a percentage (62.6%) incomplete. It is hoped that the hospital will provide outreach to PPA about the importance of completing electronic medical records and developing an EMR application that has a 100% accuracy level in filling in completeness
Co-Authors Fina Monika