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All Journal Media Kesehatan Masyarakat Indonesia Public Health of Indonesia PEDAGOGIA Jurnal Rekam Medis dan Informasi Kesehatan Jurnal Pengabdian Masyarakat AbdiMas Jurnal Manajemen Informasi dan Administrasi Kesehatan JOURNAL OF SCIENCE AND SOCIAL RESEARCH Jurnal Kesehatan Jurnal Manajemen Informasi Kesehatan Indonesia (JMIKI) Indonesian of Health Information Management Journal (INOHIM) PREPOTIF : Jurnal Kesehatan Masyarakat Jurnal JTIK (Jurnal Teknologi Informasi dan Komunikasi) Jurnal Kesehatan Tambusai KESANS : International Journal of Health and Science Indonesian Journal of Health Information Management (IJHIM) Journal of Hospital Management Indonesian Journal of Health Information Management Services (IJHIMS) Holistik Jurnal Kesehatan Jurnal Akuntansi, Ekonomi dan Manajemen Bisnis
Temesvari, Nauri Anggita
Universitas Esa Unggul
Chemistry Computer Science & IT Control & Systems Engineering Decision Sciences, Operations Research & Management Dentistry Economics, Econometrics & Finance Education Health Professions Medicine & Pharmacology Nursing Physics Public Health Social Sciences

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PERANCANGAN INSTRUMEN AUDIT KUALITAS DOKUMENTASI KLINIS KASUS NON BEDAH DI RUMAH SAKIT UKRIDA Ayuningtyas, Meta; Muchlis, Husni Abdul; Hosizah, Hosizah; Temesvari, Nauri Anggita
PREPOTIF : JURNAL KESEHATAN MASYARAKAT Vol. 10 No. 1 (2026): APRIL 2026
Publisher : Universitas Pahlawan

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31004/prepotif.v10i1.57516

Abstract

Pendokumentasian berkualitas harus memenuhi kriteria kelengkapan, akurasi, ketepatan waktu, konsistensi, sehingga diperlukan audit rekam medis melalui analisis kualitatif. Hasil Observasi periode Oktober-November 2024 terhadap 80 berkas rekam medis kasus bedah menggunakan Medical Record Quality Scoring Tool (MeReQ) menunjukan Completeness 64%, Operative Procedures 78%, Acuracy 100%, Tracking 50%, Informed Consent 89%. Beberapa komponen mencapai 100% tanda vital, ringkasan pulang, catatan terapi. Selain itu komponen riwayat kesehatan keluarga 6%, pelacakan instrumen operasi 0%, alternatif 61%, data ini menunjukan kualitas dokumentasi perlu ditingkatkan. Penelitian bertujuan merancang instrumen audit kualitas dokumentasi klinis kasus non bedah di rumah sakit. Penelitian menggunakan metode Research and Development (R&D) model ADDIE, meliputi tahap analisis, perancangan, pengembangan, dan uji coba. Penelitian bulan Desember 2025. Tahap analisis melalui wawancara dengan 10 informan Dokter Spesialis, Perawat, Kepala Instalasi Rekam Medis, Tim Mutu, Verifikator Internal. Tahap perancangan dan pengembangan dengan mengintegrasikan indikator kualitas dokumentasi klinis (legible, reliable, precise, complete, consistent, clear, timely) dan Standar Akreditasi Rumah Sakit (STARKES 2024). Uji coba instrumen pada 50 berkas rekam medis kasus non bedah periode September–Oktober 2025 oleh 5 orang Perekam Medis dan Informasi Kesehatan dengan pengalaman kerja minimal 6 bulan. Uji validitas menggunakan Content Validity Index (CVI). Hasil penelitian sebagian besar item memperoleh nilai I-CVI 1,00, dua item nilai I-CVI 0,80, dan nilai S-CVI/Ave 0,98, menunjukkan validitas isi sangat baik. Instrumen audit layak digunakan sebagai alat evaluasi kualitas dokumentasi klinis kasus non bedah di Rumah Sakit UKRIDA
Patient Age: A Determining Factor in Mobile JKN Adoption Susi Arianti; Hosizah Markam; Nauri Anggita Temesvari; Tria Saras Pertiwi
Jurnal JTIK (Jurnal Teknologi Informasi dan Komunikasi) Vol 10 No 4 (2026): OCTOBER 2026
Publisher : Lembaga Komunitas Informasi Teknologi Aceh (KITA), Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.35870/jtik.v10i4.6975

Abstract

The Mobile JKN application represents a significant national initiative to modernize health insurance services in Indonesia, yet adoption rates remain suboptimal despite near-universal population coverage. This study examined the influence of patient demographic characteristics on Mobile JKN utilization for outpatient registration at RSUD Sejiran Setason, a regional hospital in Bangka Belitung. A quantitative cross-sectional study was conducted with 345 respondents selected through accidental sampling. Data were collected using a structured questionnaire measuring four demographic variables (age, gender, education, occupation) and Mobile JKN usage status. Binary logistic regression analysis was employed to determine predictor effects on adoption behavior. Mobile JKN adoption was 38.60%, indicating substantial underutilization. Among demographic predictors, only age demonstrated significant positive influence (p = 0.006, Exp(B) = 1.023), with each additional year increasing adoption likelihood by 2.3%. Gender (p = 0.633), education (p = 0.947), and occupation (p = 0.449) showed no significant effects. The demographic model explained merely 4.4% of variance (Nagelkerke R² = 0.044), suggesting that unmeasured factors substantially determine adoption behavior. Age positively predicts Mobile JKN adoption, contradicting conventional digital divide assumptions, while other demographic characteristics prove insufficient for predicting digital health platform utilization. Implementation strategies should transcend demographic targeting and address systemic, psychological, and technological determinants to achieve equitable digital health transformation in regional Indonesian healthcare settings.
HUBUNGAN PERSEPSI ETIKA PROFESI DENGAN PERILAKU KERJA PMIK DPD PORMIKI DKI JAKARTA Ersa Shamira A nom; Nauri Anggita Temesvari
JOURNAL OF SCIENCE AND SOCIAL RESEARCH Vol. 7 No. 4 (2024): November 2024
Publisher : Smart Education

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.54314/jssr.v7i4.2306

Abstract

Abstract: Perceptions of ethics and work behavior are two things that cannot be separated because perceptions of ethics influence the work behavior of the medical recording profession so that medical recorders can run well. The aim of this research is to determine the relationship between perceptions of professional ethics and the behavior of medical recorders and health information in DPD PORMIKI DKI Jakarta.  The sample consisted of 91 people using quota sampling. Analysis uses the Spearman Correlation Test. The research results show that PMIK's work behavior has a minimum value of 54 and a maximum of 80, mean +/std.deviation 69.76+/7.473 and 95% CI lower-upper 68.20-71.31 and perception of professional ethics a minimum value of 30 and a maximum of 52 , mean+/-std.deviation 45.68+/5.938 and 95%CI lower-upper 44.44- 46.92, r results (0.290) level of strength is sufficient, the positive correlation coefficient value of the relationship between the two variables is said to be in the same direction and the p-value 0.005, the relationship between variables is significant, there is a relationship between perceptions of professional ethics and PMIK work behavior. Training facilities for work ethics and behavior, internal research on perceptions and collaboration with educational institutions. Keywords: Medical Recorder and Health Information, Work Behavior, Perception of                  Professional Ethics Abstrak: Persepsi etika dengan perilaku kerja merupakan dua hal yang tidak dapat dipisahkan karena persepsi etika mempengaruhi perilaku kerja dari profesi perekam medis sehingga perekam medis bisa menjalankan tugasnya dengan baik. Tujuan dari penelitian ini adalah untuk mengetahui hubungan persepsi etika profesi dengan perilaku perekam medis dan informasi kesehatan di DPD PORMIKI DKI Jakarta.  Sampel terdiri dari 91 orang menggunakan kuota sampling. Analisis menggunakan Uji Korelasi Spearman. Hasil penelitian menunjukkan bahwa perilaku kerja PMIK nilai minimum 54 dan maximum 80, mean +/std.deviasi 69,76+/7,473 dan 95%CI lower-upper 68,20-71,31 dan persepsi etika profesi nilai minimum 30 dan maximum 52, mean+/-std.deviasi 45,68+/5,938 dan 95%CI lower-upper 44,44- 46,92, hasil r (0,290) tingkat kekuatan cukup, bernilai koefisien korelasi positif  hubungan kedua variabel dikatakan searah dan p-value 0,005 hubungan antar variabel bernilai signifikan ada hubungan antara persepsi etika profesi dengan perilaku kerja PMIK. Saran pelatihan etika dan perilaku kerja, penelitian internal tentang persepsi dan kolaborasi dengan institusi pendidikan. Kata kunci: Perekam Medis dan Informasi Kesehatan, Perilaku Kerja, Persepsi Etika Profesi
KETEPATAN PENGODEAN DIAGNOSIS TURBERKULOSIS DI RSUD KOTA TANGERANG Lusiana Darmawan; Nauri Anggita Temesvari; Hosizah Hosizah
JOURNAL OF SCIENCE AND SOCIAL RESEARCH Vol. 7 No. 4 (2024): November 2024
Publisher : Smart Education

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.54314/jssr.v7i4.2313

Abstract

Abstract: Disease coding is one of the important things in providing health information. Coding is used to code diseases according to WHO regulations regarding diagnosis codes consisting of letters and numbers, thereby facilitating the disease reporting process. Coding relies heavily on the clarity of the diagnosis written by the doctor to provide quality information. Inaccuracy of the codes given during the coding process will affect the hospital's reporting activities and decision making. The aim of this research is to determine the relationship between the clarity of writing a diagnosis and the accuracy of coding a diagnosis of tuberculosis at the Tangerang City Regional Hospital. This type of research is quantitative research using a cross sectional research design. The sample consisted of 72 inpatient medical records of tuberculosis patients using a purposive sampling technique. Data analysis was carried out using univariate analysis and bivariate analysis with the Chi-Square test. The results of the study showed that the clarity of writing a clear diagnosis was 49 (68.1%) and the writing of a tuberculosis diagnosis was unclear in 23 (31.9%) of the inpatient medical records of tuberculosis patients. Meanwhile, the accuracy of coding a diagnosis of tuberculosis was 38 (52.8%), and the accuracy of coding an incorrect diagnosis was 34 (47.2%) from 72 medical records. The p-Value = 0.000 (0.000<0.05) so that there is a significant relationship between the clarity of writing a diagnosis and the accuracy of coding a diagnosis of tuberculosis. Keywords: Clarity, Coding Accuracy, Tuberculosis Abstrak: Pengodean penyakit merupakan satu diantara hal penting dalam penyediaan informasi kesehatan. Pengodean digunakan untuk memberi kode penyakit sesuai aturan WHO tentang kode diagnosis yang terdiri dari huruf angka sehingga memudahkan proses pelaporan penyakit. Pengodean sangat bergantung pada kejelasan penulisan diagnosis yang ditulis dokter guna menyediakan informasi yang berkualiktas. Ketidaktepatan kode yang diberikan pada proses pengodean akan berpengaruh terhadap legiatan pembuatan pelaporan dan pengambilan keputusan rumah sakit. Tujuan penelitian ini adalah untuk mengetahui hubungan kejelasan penulisan diagnosis dengan ketepatan pengodean diagnosis penyakit tuberkulosis di RSUD Kota Tangerang. Jenis penelitian ini adalah penelitian kuantitatif dengan menggunakan desain penelitian Cross Sectional. Sampel terdiri dari 72 rekam medis rawat inap pasien tuberkulosis dengan teknik pengambilan secara purposive sampling. Analisis data dilakukan dengan analisis univariat dan analisis bivariat dengan uji Chi-Square. Hasil penelitian menunjukkan bahwa kejelasan penulisan diagnosis yang jelas sebanyak 49 (68,1%) dan penulisan diagnosis tuberkulosis yang tidak jelas sebanyak 23 (31,9%) rekam medis rawat inap pasien tuberkulosis. Sedangkan ketepatan pengodean diagnosis penyakit tuberkulosis sebanyak 38 (52,8%), dan ketepatan pengodean diagnosis yang tidak tepat sebanyak 34 (47,2%) dari 72 rekam medis. Nilai p-Value = 0,000 (0,000<0,05) sehingga ada hubungan bermaksa antara kejelasan penulisan diagnosis dengan ketepatan pengodean diagnosis penyakit tuberkulosis. Kata kunci: Kejelasan, Ketepatan Pengodean, Tuberkulosis 
HUBUNGAN KELENGKAPAN RESUME MEDIS DENGAN KETEPATAN KODE DIAGNOSIS FRACTURE DAN INJURY DI RSUD KOTA TANGERANG Ade Rizqa Rahayu; Nauri Anggita Temesvari
JOURNAL OF SCIENCE AND SOCIAL RESEARCH Vol. 7 No. 4 (2024): November 2024
Publisher : Smart Education

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.54314/jssr.v7i4.2345

Abstract

Abstract: Fracture cases in 2020 in Indonesia, which is the largest country in Southeast Asia, occurred at 1.3 million each year with a prevalence of 5.5% of the population of around 238 million. In the coding of fracture cases, inaccuracies were still found, the cause of these inaccuracies occurred because they did not add a 5-character code. So the aim of this research is to determine the relationship between the completeness of a medical resume and the accuracy of fracture and injury diagnosis codes at Tangerang City Regional Hospital. This type of research is quantitative using a cross sectional design. The sampling technique in this study used a saturated sampling technique, where the entire population in this study was sampled. The sample in this study was 68 medical resumes of fracture and injury patients. Data analysis was carried out using univariate analysis and bivariate analysis with the Chi-Square analysis test (X2). The results showed that there were 29 (42.6%) incomplete medical resumes and 39 (57.4%) complete resumes. Meanwhile, the accuracy of incorrect fracture and injury diagnosis codes was 53 (77.9%) and the accuracy of correct fracture and injury diagnosis codes was 15 (22.1%). The p-value = 0.000 (0.000 < 0.05) so there is a relationship between the completeness of the medical resume and the accuracy of the fracture and injury diagnosis code at the Tangerang City Regional Hospital. Keywords: Medical Resume, Accuracy Of Diagnosis Codes, Fractures And Injuries Abstrak: Kasus fracture tahun 2020 di Indonesia yang merupakan negara terbesar di Asia Tenggara kejadiannya sebesar 1,3 juta setiap tahunnya dengan prevalensi sebesar 5,5% dari jumlah penduduk yang berkisar 238 juta. Pada pengodean kasus fracture masih ditemukan ketidaktepatan, penyebab ketidaktepatan tersebut terjadi karena tidak menambahkan kode karakter-5. Sehingga tujuan penelitian ini adalah untuk mengetahui hubungan kelengkapan resume medis dengan ketepatan kode diagnosis fracture dan injury di RSUD Kota Tangerang. Jenis penelitian ini adalah kuantitatif dengan menggunakan desain cross sectional. Teknik pengambilan sampel dalam penelitian ini menggunakan teknik sampling jenuh, dimana semua populasi dalam penelitian ini dijadikan sampel, sampel dalam penelitian ini sebanyak 68 resume medis pasien fracture dan injury. Analisis data dilakukan dengan analisis univariat dan analisis bivariat dengan uji analisis Chi-Square (X2). Hasil penelitian menunjukkan bahwa resume medis yang tidak lengkap sebanyak 29 (42.6%) dan resume yang lengkap sebanyak 39 (57.4%). Sedangkan ketepatan kode diagnosis fracture dan injury yang tidak tepat sebanyak 53 (77.9%) dan ketepatan kode diagnosis fracture dan injury yang tepat sebanyak 15 (22.1%). Nilai p-value = 0,000 (0,000 < 0,05) sehingga ada hubungan kelengkapan resume medis dengan ketepatan kode diagnosis fracture dan injury di RSUD Kota Tangerang. Kata kunci: Resume Medis, Ketepatan Kode Diagnosis, Fracture Dan Injury
Co-Authors Ade Rizqa Rahayu Alfian Aroododo Ambarwati Angelia Dyah Sukmarini Avenia Dionisia Menna Ayuningtyas, Meta Bambela, Innes Dewi Noviany Darmawan, Lusiana Desmayanti Br Subakti Dewi, Deasy Rosmala Ersa Shamira A nom Hosizah Hosizah Husni Abdul Muchlis Ikaningsih, Kurnia Tisna Lestari, Jayanti Loli Adriani Lusiana Darmawan Melani Nurbaiti Hasanah Meo, maria Hiasinta Nanda Dina Cahya nom, Ersa Shamira A Nurhasanah, Raden Nurmalasari, Mieke Oktavianti, Putri Peter Herey Peter Herey Rachmad Hidayat Rahayu, Ade Rizqa Ryo Hikmah Tiyardi Seiswati, Siswati Silvia Ni&#039;matul Maula Suprobowati Suprobowati Susi Arianti Tiyardi, Ryo Hikmah Tria Saras Pertiwi Witri Zuama Qomarania Wittri, Zalipa