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All Journal Jurnal Rekam Medik & Manajemen Informasi Kesehatan (RAMMIK)
Maghfirina Nawinda Putri
Institut Teknologi, Sains, dan Kesehatan RS. dr. Soepraoen Kesdam V/BRW
Dentistry Health Professions Medicine & Pharmacology Public Health Veterinary

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Optimalisasi Standar Operasional Prosedur Koding di Rumah Sakit Pindad Turen Malang Sayidatun Nisa Rushdiya Nayyara; Bella Ayu Rosyita Sari; Dania Putri Ramadani; Hanum Salsabillah Reka Aulia; Maghfirina Nawinda Putri; Nia Ariska; Nuril Fauziyah Febriyani; Sabrina Widad Nur Fauziah; Achmad Jaelani Rusdi; Agus Syukron Ma’ruf; Mochammad Yusril Rizkyawan
Jurnal Rekam Medik & Manajemen Informasi Kesehatan Vol. 5 No. 2 (2026): October
Publisher : Indonesian Journal Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.47134/rmik.v5i2.1941

Abstract

Standar Operasional Prosedur (SOP) coding rekam medis merupakan pedoman penting dalam menjamin akurasi, konsistensi, dan kelengkapan proses pengkodean diagnosis serta tindakan medis di rumah sakit. Penelitian ini bertujuan untuk mengevaluasi pelaksanaan SOP coding yang sedang berjalan serta mengoptimalkan alur kerja coding di Rumah Sakit Umum Pindad Turen Malang agar sesuai dengan standar ICD-10 dan ICD-9-CM. Metode penelitian menggunakan pendekatan deskriptif kualitatif melalui observasi langsung terhadap proses coding serta wawancara dengan petugas rekam medis. Hasil menunjukkan bahwa sebagian besar prosedur coding telah dilaksanakan sesuai standar, meliputi pemeriksaan kelengkapan berkas, identifikasi diagnosis dan tindakan, penentuan kode, hingga proses verifikasi. Namun, masih ditemukan beberapa hambatan seperti ketidaklengkapan dokumentasi medis, penggunaan singkatan yang tidak baku, serta perbedaan pemahaman antarpetugas coding. Melalui kegiatan sosialisasi, penyusunan ulang SOP, dan peningkatan pelatihan petugas, optimalisasi SOP coding mampu meningkatkan akurasi hasil kode, memperlancar proses klaim, serta mendukung kualitas data rekam medis. Kesimpulannya, SOP coding perlu dievaluasi secara berkala dan didukung koordinasi yang baik antarpetugas untuk mencapai kualitas coding yang lebih optimal dan sesuai standar pelayanan kesehatan.
Himbauan Membawa Dokumen Identitas Dalam Mengakses Pelayanan Kesehatan Di Pukesmas Kalipare Malang Amanda Eka Kurnia; Sayidatun Nisa Rushdiya Nayyara; Maghfirina Nawinda Putri; Nur Khamdiyatus Solicha; Fita Rusdian Ikawati; Lilik Afifah; Christian Eka Putra Joel
Jurnal Rekam Medik & Manajemen Informasi Kesehatan Vol. 5 No. 2 (2026): October
Publisher : Indonesian Journal Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.47134/rmik.v5i2.1942

Abstract

Completeness of patient identity documents is an important aspect in supporting smooth administrative processes and healthcare services at community health centers (Puskesmas). Incomplete documents may hinder the registration, identification, verification, and recording of patient data. This study aims to analyze the importance of reminding patients about the obligation to bring identity documents when accessing healthcare services at Kalipare Community Health Center, Malang. This descriptive qualitative study used survey and field observation approaches over three months. Primary data were collected through a survey of 200 puskesmas visitors selected by purposive sampling and interviews with 15 health workers, while secondary data came from administrative records, outreach reports, and literature. Data were analyzed descriptively using percentages and cross-tabulation, and interview data were analyzed thematically. Observations showed that reminders were delivered through a pamphlet listing the required documents (KTP/KIA, KK, BPJS/KIS card, and referral letter when required) and their benefits: faster registration, easier service, more accurate data recording, and better use of BPJS facilities. Patients who brought complete documents went through administration more easily, whereas incomplete documents added staff tasks such as data searching, confirmation, and re-checking of requirements, making registration less efficient. Interviews indicated that patients who knew the requirements were better prepared, while those who forgot needed additional explanation. In conclusion, continuous reminders serve as a preventive effort that supports orderly administration and efficient services and should become part of the registration flow. Puskesmas are advised to add reminder channels, such as digital media, and future studies should evaluate their effectiveness quantitatively.
Co-Authors Achmad Jaelani Rusdi Agus Syukron Ma’ruf Amanda Eka Kurnia Bella Ayu Rosyita Sari Christian Eka Putra Joel Dania Putri Ramadani Fita Rusdian Ikawati Hanum Salsabillah Reka Aulia Lilik Afifah Mochammad Yusril Rizkyawan Nia Ariska Nur Khamdiyatus Solicha Nuril Fauziyah Febriyani Sabrina Widad Nur Fauziah Sayidatun Nisa Rushdiya Nayyara