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All Journal Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Jurnal Kesehatan Tambusai Jurnal Pengabdian Masyarakat (ABDIRA) Zadama: Jurnal Pengabdian Masyarakat Jurnal Ilmiah Pengabdian Kepada Masyarakat Pengabdian Kepada Masyarakat Indonesia SEAN (ABDIMAS SEAN) COVID-19 : Journal of Health, Medical Records and Pharmacy
Simanjuntak, Marta
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Aerospace Engineering Humanities Chemical Engineering, Chemistry & Bioengineering Chemistry Civil Engineering, Building, Construction & Architecture Computer Science & IT Dentistry Economics, Econometrics & Finance Education Health Professions Immunology & microbiology Languange, Linguistic, Communication & Media Medicine & Pharmacology Nursing Public Health Social Sciences Other

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Review of the Completeness of the Medical Resume Form Based on the Assessment Elements of Mirm 15 National Hospital Accreditation Standards (SNARS) at Imelda Pekerja Indonesia Hospital Medan 2021 Liem, John Barker; Rifhan, Zanurul; Simanjuntak, Marta; Sitorus, Mei Sryendang; Alna, Jihan
COVID-19 : Journal of Health, Medical Records and Pharmacy Vol. 2 No. 01 (2024): COVID-19 : Journal of Health, Medical Records and Pharmacy
Publisher : CV. Devitara

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

Abstract

Incompleteness in filling out a medical resume will greatly affect the hospital's accreditation assessment listed in the MIRM 15 SNARS standard sub-group Issue 1.1. This study aims to determine the completeness of filling out the resume form based on the assessment elements of MIRM 15 SNARS Edition 1.1 at Imelda Pekerja Indonesia Hospital in Medan. This study uses quantitative and qualitative methods, with a population of 1,355 medical resume forms at Imelda Pekerja Indonesia Hospital Medan in November-December 2021 and a sample of 93 medical resumes which are completed into 100 medical resume forms. Based on the results of the study, it was found that 76 medical resume forms were filled (70%) and 30 medical resume forms were incomplete (30%). score Based on the assessment of SNARS Edition 1.1, the number of complete medical resume forms was 76% with a score of 5 (partially fulfilled) because the achievement range was 29%-79%. The highest completeness on the medical resume form at Imelda Pekerja Indonesia Hospital is found in the patient history component, diagnostic examination, therapeutic procedures and actions, drugs given and drugs when the patient leaves the hospital, the patient's health condition (current status) and follow-up instructions (100% ) Medical resume forms and the lowest completeness were found on physical examination (15%) indication of patients being treated (6%), comorbidities (12) and patient/family signatures (24%) of medical resume forms. Researchers suggest that there is a need for socialization that continuously increases knowledge to medical officers about filling out the complete medical resume form according to SNARS at Imelda Pekerja Indonesia Hospital in Medan.
Tahapan Audit Koding Rekam Medis dengan Menggunakan Analisa Kualitatif pada Pasien Rawat Inap di RS Khusus Mata SMEC Tahun 2025 Hutasoit, Theresia; Daeli, Cosmas Samuel; Sitorus, Mei Sryendang; Simanjuntak, Marta; Rotonga, Zulham Andi; Hasibuan, Ali Sabela; Liem, John Barker; Valentina, Valentina; Zulfahmi, Zulfahmi; Sitompul, Osayku Inesa
Jurnal Pengabdian Masyarakat (ABDIRA) Vol 6, No 1 (2026): Abdira, Januari
Publisher : Universitas Pahlawan Tuanku Tambusai

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31004/abdira.v6i1.1278

Abstract

Medical records are crucial documents that document all healthcare services. Accurate coding forms the basis for claims billing, research, and clinical decision-making. However, incomplete and inaccurate recording often presents obstacles, necessitating a coding audit. This Community Service project aimed to identify the stages of a coding audit using qualitative analysis of inpatients. The audit was conducted on four cases. The analysis used six review components: consistency of diagnosis and treatment, clinical recording, treatment justification, informed consent, documentation practices, and potential for compensation. The results of the medical record coding audit indicated that most components were consistent and met standards, including diagnosis, treatment, clinical recording, and completion of informed consent. However, inconsistencies were still found in instructions for discontinuing or replacing medications. There were no incidents that could potentially result in compensation. However, improvements are still needed in the documentation of instructions for discontinuing or replacing medications. The results emphasize the importance of ongoing socialization and monitoring to optimize the quality of medical records.
Hubungan Kelengkapan Resume Medis Rawat Inap BPJS Dengan Persetujuan Klaim BPJS Di RS Advent Medan 2024 Christy, Johanna; Simanjuntak, Marta; Hutasoit, Theresia; Erlindai, Erlindai; Lase, Siji Valentine
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Vol. 11 No. 1 (2026): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Februari
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v11i1.1891

Abstract

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.
Co-Authors Alna, Jihan Azhar, Anja Berutu, Novita Sari Christy, Johana Christy, Johanna Cosmas Samuel Daeli Dawolo, Fitra Christin Erlindai, Erlindai Gusla Nengsih, Yeyi Hutauruk, Puput Melati Lase, Chrisman Lase, Siji Valentine Liem, John Barker Lubis, Siti Permata Sari Nababan, Edward Ramos Nila Sari Octaviana Caisara, Dewi Rifhan, Zanurul Ritonga, Zulham Andi Rotonga, Zulham Andi Sabela Hasibuan, Ali Sarlina , Eti Siallagan, Happy Sihite , Geovani Arta Sihite, Geovani Arta Simanjuntak, Esraida Sitompul, Osayku Inesa Sitorus, Mei Sryendang Theresia Hutasoit Valentina Valentina, Valentina Zebua, Berlian Oktarianis Zulfahmi Zulfahmi