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FAKTOR – FAKTOR PENENTU KETEPATAN KODE DIAGNOSA CHRONIC KIDNEY DISEASE (CKD) PASIEN RAWAT INAP DI RUMAH SAKIT UMUM IMELDA PEKERJA INDONESIA TAHUN 2023 Hutasoit, Theresia; Sitorus, Mei Sryendang; Erlindai, Erlindai; Christy, Johanna; Syahputri, Melati Adila
Jurnal Kesehatan Tambusai Vol. 5 No. 4 (2024): DESEMBER 2024
Publisher : Universitas Pahlawan Tuanku Tambusai

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31004/jkt.v5i4.37033

Abstract

Ketepatan dalam pemberian kode diagnosis merupakan hal yang harus diperhatikan oleh perekam medis khususnya coder. Salah satu kompetensi yang harus dimiliki oleh seorang perekam medis adalah kodefikasi penyakit dan tindakan medis. Ketepatan kode diagnosis pada penyakit CKD sangat dipengaruhi oleh kelengkapan rekam medis. Berdasarkan hasil survei awal yang dilakukan terdapat 37 rekam medis yang lengkap yaitu (60,65%) kode diagnosis pada penyakit CKD sesuai dengan ICD-10 dan terdapat 24 rekam medis yang tidak lengkap yaitu (39,34%).  Bertujuan untuk mengetahui apa saja faktor penentu ketepatan kode diagnosa CKD pada pasien rawat inap. Jenis penelitian ini adalah deksriptif dengan pendekatan kualitatif yaitu mendeksripsikan dan menggambarkan secara rinci permasalahan yang diteliti dengan mempelajari semaksimal mungkin suatu kejadian. Populasinya yaitu petugas koding rawat inap yang berjumlah 5 orang. Jumlah sampel yang digunakan sebanyak 31 rekam medis CKD rawat inap. Cara pengumpulan data dengan menggunakan observasi dan wawancara. Hasil yang diperoleh dari penelitian ini, dari 31 rekam medis CKD rawat inap terdapat 12 rekam medis yang memiliki kode kurang tepat (38,70%) dan 19 rekam medis yang tepat (61,30%). Faktor penentu ketepatan kode seperti Man kurang telitinya petugas dalam kelengkapan pengisian berkas rekam medis, Material ketidaklengkapan pengisian dan tidak ditulisnya diagnosis penyakit, Method masih ditemukannya petugas yang kurang memahami SPO, dan Machine gangguan jaringan komputer. Berdasarkan hasil penelitian, diharapakan untuk diberikannya pelatihan coding terkait tatacara mengkode yang tepat sesuai panduan SPO, ICD-10 dan perlu ditingkatkan komunikasi antar petugas coding dan dokter yang memberi diagnosis serta melengkapi bagian pemeriksaan penunjang agar dapat menghasilkan kode yang tepat.
GWANCANA (Women's Movement to Prevent Anemia) in Improving Adolescent Health Independence at PAB 8 Middle School Sampali Medan: GWANCANA (Gerakan Wanita Cegah Anemia) Dalam Peningkatan Kemandirian Kesehatan Remaja di SMP PAB 8 Sampali Medan Warnelis Sinaga, Elvalini; Gultom, Risatantry; Samgryce Siagian, Hartika; Christy, Johanna; Veronika, Ida; Priscillia, Prilly
Jukeshum: Jurnal Pengabdian Masyarakat Vol. 5 No. 1 (2025): Edisi Januari 2025
Publisher : Universitas Haji Sumatera Utara

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.51771/jukeshum.v5i1.1200

Abstract

One of the nutritional problems faced by adolescents is anemia. Anemia is defined as a decrease in blood hemoglobin (Hb) levels below normal values for age and gender. Common Hb values are <13.5 g/dL in adult men and <11.5 g/dL in adult women. Several factors that influence adolescents to experience anemia are unhealthy eating patterns, limited sources of knowledge and skills, lack of commitment from the school, and lack of student understanding of the dangers of anemia. The implementation of the GWANCANA program is to increase the independence of adolescent girls in preventing anemia by utilizing and reactivating the School Health Unit by forming a women's movement to prevent anemia. The target of community service counseling is adolescent girls at SMP PAB 8 SAMPALI Junior High School, Jl. Pasar Hitam No.69, Percut Sei Tuan District, Deli Serdang Regency, Sumatra Province, this aims to increase the independence of adolescent girls in preventing anemia by utilizing and reactivating the School Health Unit by forming a women's movement to prevent anemia (GWANCANA). Respondents from the counseling activities were all 124 young women. The method used was to measure knowledge first to see the increase in knowledge before and after the counseling was carried out using several media such as: questionnaires, posters, ppt and leaflets to attract the attention of female students of SMP PAB 8 SAMPALI. The knowledge of young women where the average previous knowledge value was 45.2 and after being given counseling increased to 89.1 This women's movement to prevent anemia plays a very important role in increasing the independence of young women in improving their health.
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.
Sosialisasi Pemanfaatan Sistem Informasi Manajemen Rumah Sakit (SIMRS) terhadap Pengolahan Data pada Laporan Eksternal dan Internal di RSU Imelda Pekerja Indonesia Medan Tahun 2025 Sitorus, Mei Sryendang; Valentina, Valentina; Liem, John Barker; Ardanta, Yanda; Hutasoit, Theresia; Daeli, Cosmas Samuel; Hasibuan, Ali Sabela; Ritonga, Zulham Andi; Erlindai, Erlindai; Christy, Johanna
Jurnal Pengabdian Masyarakat (ABDIRA) Vol 6, No 2 (2026): Abdira
Publisher : Universitas Pahlawan Tuanku Tambusai

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31004/abdira.v6i2.1951

Abstract

Hospital Management Information System (HMIS) at Imelda Pekerja Indonesia General Hospital has been in place since 2015; however, the system has not yet been utilized as the primary source for data processing.Reporting staff sometimes still process data manually collected from each service unit.External reports are mandatory reports submitted by every hospital to the Health Office. Internal reports are used for the hospital’s internal purposes.The implementation method of this community service activity consisted of socialization on the utilization of SIRS for data processing, reviewing the Standard Operating Procedure (SOP) for Reporting and creating a checklist of data requirements for reports.The socialization was provided to all 16 medical record officers in the Medical Records Unit using discussion, lecture, and question-and-answer methods. The results of this activity are expected to improve the staff’s knowledge regarding the utilization of HMIS for data processing in reports at hospital.This activity was successfully carried out due to the cooperation and support of all implementing team members and hospital team.However, the common obstacles faced by staff include network and application disruptions, which hinder the data processing for hospital reporting. Therefore, improving network stability within the system is necessary to ensure that the reporting process can run more effectively and efficiently.