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Akbar, Prima Soultoni
Politeknik Kesehatan Kemenkes Malang
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ANALISIS KEBUTUHAN RAK PENYIMPANAN DOKUMEN REKAM MEDIS AKTIF DI PUSKESMAS KENDALKEREP MALANG Prima Soultoni Akbar; Tsalits Maulidah Hariez
Jurnal Rekam Medis dan Informasi Kesehatan Indonesia Vol. 3 No. 1 (2023): Jurnal Rekam Medis dan Informasi Kesehatan Indonesia
Publisher : program studi Rekam Medis dan Infomasi Kesehatan ITSK RS dr Soepraoen Malang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.62951/jurmiki.v3i1.45

Abstract

Medical record should be kept in store shelves that kept confidential, to avoid damage and officers in the medical record and return.So that this be effective and efficient store needs planning needs to be sufficient to keep within a certain period of time to the time will come and facilitate the back by officers.in storage of Puskesmas Kendalkerep record, not optimal because there are still kept are right on top in addition to store shelves triggered by the lack of store shelves so that it difficult to find the medical record can slow the documents and the medical record not yet destroyed had to be destroyed.Puskesmas kendalkerep also have not just calculate the store shelves. The research is descriptive qualitative research,  observing and analyzing the documents record store shelves puskesmas kendalkerep.The way the collection of data using observation and interview.The observation is made by means of observing, noted, and measuring the amount of patient visits, the thickness of the medical record, size store shelves and calculate the store shelves with watson and trend analysis method.The number of active medical record store shelves documents required to 5 years woultd go to 9 unit so it needs additional 4 shelf unit
Tinjauan Pelaksanaan Sistem Penyimpanan Rekam Medis di Rumah Sakit Prima Soultoni Akbar; Santy Irene Putri
Jurnal Penelitian Kesehatan SUARA FORIKES 2022
Publisher : FORIKES

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33846/sf13nk308

Abstract

Storage of medical record files has the objective of protecting documents from being physically damaged and protecting the contents of the medical record files. Systematic document storage is the key to successful management of a service. This must also be supported by a good system, quality human resources and appropriate storage facilities. Therefore it is very important to review the implementation of the medical record file storage system. This study was conducted to review the implementation of the medical record file storage system in hospitals. By using the keyword "Implementation Review" OR "Medical Record File Storage System" OR "Hospital" in the database to search for literature reviews. 202 articles were selected from the Google Scholar database and 5 articles were found that met the inclusion and exclusion criteria. Articles are taken from reputable or accredited databases. The selection was taken by taking into account the PICO framework, then the articles were analyzed one by one. Implementation of a document storage system should add facilities and infrastructure such as shelves and expand the medical record file storage space so that it can be arranged systematically. We recommend that the medical record file storage system is carried out according to the SOP and the SOP should be updated according to conditions in the work environment. Identification of constraints on the medical record file storage system caused by a lack of storage racks, lack of room size, SOP, lack of use of tracers, inadequate knowledge and skills and limited human resourcesKeywords: storage system; medical records; systematic review ABSTRAK Penyimpanan berkas rekam medis memiliki tujuan untuk melindungi dokumen agar tidak rusak secara fisik serta melindungi isi dari berkas rekam medis tersebut. Penyimpanan dokumen yang sistematis merupakan kunci kesuksesan manajemen dari suatu pelayanan. Hal ini juga harus di dukung dengan sisitem yang baik, sumber daya manusia yang berkualitas serta fasilitas penyimpanan yang sesuai. Maka dari itu penting sekali meninjau implementasi sistem penyimpanan berkas rekam medis. Studi ini dilakukan untuk meninjau implementasi sistem penyimpanan berkas rekam medis di rumah sakit. Dengan menggunakan keyword “Tinjauan Pelaksanaan” OR “Sistem Penyimpanan Berkas Rekam Medis” OR “Rumah Sakit” dalam database untuk mencari literature review. Dilakukan seleksi terhadap 202 artikel dari database Google Scholar dan ditemukan 5 artikel yang sesuai kriteria inklusi dan eksklusi. Artikel diambil dari database bereputasi maupun terakreditasi. Penyeleksian diambil dengan memperhatikan PICO framework, kemudian artikel dianalisis satu persatu. Pelaksanaan sistem penyimpanan dokumen sebaiknya menambahkan sarana dan prasarana seperti rak dan memperluas ruangan penyimpanan berkas rekam medis dapat tertata secara sistematis. Sebaiknya sistem penyimpanan berkas rekam medis di lakukan sesuai SOP dan SOP sebaiknya di perbarui sesuai dengan keadaan di lingkungan kerja. Identifikasi kendala sistem penyimpanan berkas rekam medis disebabkan oleh kurangnya rak penyimpanan, kurang luasnya ruangan, SOP, kurangnya penggunaan tracer, pengetahuan dan ketrampilan belum memadai dan terbatasnya SDMKata kunci: sistem penyimpanan; rekam medis; tinjauan sistematis
Edukasi Penyakit Tidak Menular dan Pelatihan Pengelolaan Web Profil di Panti Asuhan Al-Ikhlas Wijaya, Avid; Akbar, Prima Soultoni; Zein, Eiska Rohmania
JPP IPTEK (Jurnal Pengabdian dan Penerapan IPTEK) Vol 9, No 1 (2025): Mei
Publisher : Institut Teknologi Adhi Tama Surabaya

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31284/j.jpp-iptek.2025.v9i1.6771

Abstract

Penyakit tidak menular (PTM) menjadi masalah kesehatan yang signifikan, tidak hanya di tingkat individu, tetapi juga di berbagai kelompok masyarakat, termasuk di panti asuhan. Panti asuhan sering kali menghadapi tantangan dalam meningkatkan pemahaman kesehatan bagi penghuninya, terutama mengenai pencegahan PTM. Oleh karena itu, pengabdian masyarakat ini bertujuan untuk meningkatkan literasi kesehatan mengenai PTM di Panti Asuhan Al-Ikhlas, Wagir, Kabupaten Malang, Indonesia, melalui pengembangan dan penerapan web profil kesehatan. Kegiatan ini dilaksanakan dalam tiga tahapan, yaitu pra-kegiatan, kegiatan inti, dan pasca-kegiatan. Pada tahap pra-kegiatan, dilakukan koordinasi dan sosialisasi dengan pihak panti asuhan mengenai konsep web dan materi edukasi PTM. Kegiatan inti terdiri dari edukasi langsung mengenai PTM, pelatihan interaktif terkait faktor risiko, pencegahan, serta pentingnya gaya hidup sehat, serta pelatihan tentang pembuatan dan pengoperasian konten PTM di dalam platform web. Pada tahap pasca-kegiatan, tim melakukan monitoring dan evaluasi untuk menilai efektivitas web profil dalam meningkatkan literasi kesehatan serta mengidentifikasi kendala yang dihadapi selama penggunaan web profil. Hasil dari kegiatan ini menunjukkan bahwa web profil kesehatan efektif dalam meningkatkan pemahaman penghuni panti asuhan mengenai PTM. Pelatihan yang diberikan kepada pengurus dan penghuni panti asuhan juga berhasil memperkuat kemampuan mereka dalam mengelola dan memperbarui konten web profil. Evaluasi yang dilakukan mengidentifikasi beberapa kendala teknis yang kemudian berhasil diatasi dengan solusi yang relevan. Dengan dukungan berkelanjutan dari pihak panti asuhan dan mitra pendanaan, web profil ini diharapkan dapat terus memberikan manfaat dalam edukasi kesehatan yang berkelanjutan bagi penghuni panti asuhan.
Analysis of the Accuracy of Diagnosis Codes on the Return of BPJS Claim Files at TNI-AD Bhirawa Bhakti Hospital Malang: Analisis Keakuratan Kode Diagnosis Terhadap Pengembalian Berkas Klaim BPJS di RS TNI-AD Bhirawa Bhakti Malang Bella Artamevia, Fifi; Akbar, Prima Soultoni; Nurhadi, Nurhadi
JOURNAL OF MEDICAL AND HEALTH SCIENCE Vol. 2 No. 2 (2024): December
Publisher : Universitas Muhammadiyah Sidaorjo

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.21070/anamnetic.v2i2.1601

Abstract

Coding accuracy is the accuracy and suitability of codes for both diagnoses and actions carried out by coding officers based on applicable provisions, namely ICD 10 version 2010 and ICD 9 CM. The accuracy of diagnostic data is very important in the field of clinical data management, BPJS health billing, and other issues related to health services. said to be accurate, if the files (Individual Patient Report, Coding Confirmation, Supporting Report, medical resume, and operation report) are consistent with each other. It is said to be inaccurate if one or several files do not show consistency. The aim of this research is to determine the analysis of the accuracy of diagnosis codes on the return of BPJS claim files at the TNI-AD Bhirawa Bhakti Hospital, Malang. The type of research used is quantitative, collecting data through interviews. The research subjects were 45 medical records. The research results show that the average return of claim files is 12% of the total claim files submitted each month. The return of claim files was due to the coding officer's lack of understanding of coding rules, incomplete files, the coding officer's background not meeting medical recorder competency standards and the absence of regular meetings related to coding training being held. From the results of this research, it can be concluded that there is a return of claim files due to incompleteness and carelessness of officers. Based on this conclusion, the author suggests holding regular meetings to discuss the accuracy of codification and completeness of medical records as well as additional human resources so that hospitals can minimize refunds of claim costs by parties. BPJS Health. Suggestions for future researchers, when this suggestion is implemented by hospitals, will there be a good influence on the accuracy of the codification and claims return process by BPJS Health.
ANALISIS FAKTOR YANG MEMPENGARUHI KEAKURATAN KODE DIAGNOSIS PASIEN RAWAT INAP DI RS X KOTA MALANG Akbar, Prima Soultoni
Jurnal Informasi Kesehatan Indonesia (JIKI) Vol. 11 No. 1 (2025): Jurnal Informasi Kesehatan Indonesia
Publisher : Politeknik Kesehatan Kemenkes Malang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31290/jiki.v11i1.5427

Abstract

Salah satu aspek terpenting dalam pelayanan rekam medis adalah kegiatan klasifikasi dan kodefikasi diagnosis serta tindakan. Dalam melakukan pemberian kode diagnosis pasien masih ditemukan menggunakan sistem komputerisasi dengan dokter sebagai pemberi kode diagnosis. Tujuan penelitian ini adalah mengalisis faktor yang mempengaruhi keakuratan kode diagnosis pasien rawat inap di RS X Kota Malang. Jenis penelitian ini adalah metode campuran (mixed method) dengan pendekatan kuantitatif untuk menganalisis tingkat keakuratan dan pendekatan kualitatif dengan metode wawancara, serta instrumen penelitian menggunakan lembar checklist. Teknik pengumpulan data yang digunakan dalam penelitian ini dengan menggunakan metode observasi dan wawancara. Populasi yang digunakan adalah rekam medis pasien rawat inap pada bulan September 2024. Sampel diambil secara acak yang berjumlah 98 berkas rekam medis. Informan dalam penelitian ini adalah kepala rekam medis dan petugas koding rawat inap di RS X Kota Malang, Hasil penelitian menunjukkan bahwa 18% kode diagnosis penyakit diberikan secara tidak tepat, dan 82% kode diagnosis penyakit diberikan secara tepat dari 98 berkas sampel. Faktor-faktor yang mempengaruhi keakuratan kode diagnosis pasien rawat inap di RS X Kota Malang adalah kompetensi sumber daya manusia, pelatihan, penggunaan SOP yang ditetapkan oleh rumah sakit, dan penerapan sistem reward dan punishment bagi seluruh petugas, khususnya petugas koding.
The Relationship between Completeness of Medical Information and the Accuracy of Diagnosis Codes for BPJS Inpatients at Hospital X Malang City : Hubungan Kelengkapan Informasi Medis Terhadap Keakuratan Kode Diagnosis Pasien BPJS Rawat Inap RS X Kota Malang Annisa, Nadia Salma; Akbar, Prima Soultoni
JOURNAL OF MEDICAL AND HEALTH SCIENCE Vol. 3 No. 1 (2025): Juli
Publisher : Universitas Muhammadiyah Sidaorjo

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.21070/anamnetic.v3i1.1603

Abstract

Background: Completeness of medical information is critical in ensuring diagnosis code accuracy. The purpose of this study is to look at the relationship between medical information completeness and diagnosis code correctness in BPJS Patient Inpatient Medical Record Documents. Subjects and Methods: This form of research employs both quantitative and correlational methodologies. The sample consisted of 83 documents chosen at random. Chi-square was employed to analyse the data. Results: The ratio of complete medical information is 60%, whereas incomplete medical information is 40%. Medical resumes with 19 papers had the highest percentage of incompleteness (23%). The accuracy of hospital record diagnostic codes is 40%, while inaccuracies are 60%. Inaccuracies in diagnosis codes are generated by a variety of circumstances, including wrongly defining the major diagnosis, officers being less cautious, and providing inadequate support. The chi square statistical test results in p = 0.0019. Conclusion: there is a correlation between the completeness of medical information and the accuracy of diagnosis codes in BPJS patient inpatient records. The author recommends that health professionals be more attentive when entering medical information, coders follow fundamental ICD 10 rules, and institutions provide coder training to ensure that coding activities operate smoothly.
FAKTOR PENYEBAB PENDING KLAIM BPJS RAWAT INAP DENGAN PENERAPAN REKAM MEDIS ELEKTRONIK DI RSUD DR. MOEWARDI SURAKARTA Utami, Yeni Tri; Akbar, Prima Soultoni; Amelia, Reza; Sari, Sella Yulia
Prosiding Seminar Informasi Kesehatan Nasional 2024: SIKesNas 2024
Publisher : Fakultas Ilmu Kesehatan Universitas Duta Bangsa Surakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.47701/sikenas.vi.3939

Abstract

Berdasarkan hasil survei di RSUD dr. Moewardi jumlah klaim BPJS rawat inap yang mengalami pending sebanyak 4878 berkas (16,29%). Penelitian ini bertujuan untuk mengetahui faktor penyebab pending klaim BPJS rawat inap pada penerapan rekam medis elektronik di RSUD dr. Moewardi Surakarta. Metode penelitian menggunakan deskriptif dengan pendekatan retrospektif. Populasi dan Sampel yang digunakan adalah seluruh berkas klaim BPJS rawat inap yang mengalami pending tahun 2023. Metode pengumpulan data dengan observasi dan wawancara. Pelaksanaan klaim BPJS rawat inap telah dilaksanakan sesuai dengan Standar Operasional Prosedur. Faktor penyebab pending klaim diklasifikasikan menjadi 4 faktor yaitu berkas tidak lengkap sebanyak 2995 berkas (61,39 %), ketidaklengkapan berkas penunjang pasien sebanyak 1031 berkas (21,13 %), ketidaktepatan pengodean sebanyak 457 berkas (9,36 %), dan reseleksi diagnosis dan kode yang tidak sesuai dengan kriteria BPJS sebanyak 395 berkas (8,09 %). Dampak dari kasus pending klaim yaitu terjadinya cash flow rumah sakit yang terganggu dan penambahan beban kerja petugas. Upaya dalam mengatasi pending klaim dengan merevisi atau konfirmasi penyebab pending klaim kemudian menelaah kembali dan apabila diperlukan melakukan konfirmasi dengan unit terkait. Sebaiknya RSUD dr. Moewardi melakukan peningkatan koordinasi dengan unit-unit yang terkait mengenai syarat kelengkapan pengajuan klaim sehingga dapat meminimalisir terjadinya pending klaim pada bulan-bulan berikutnya.
Peningkatan Literasi Digital Kesehatan bagi Masyarakat dalam Mengakses Informasi Medis yang Akurat melalui Pemanfaatan Sistem Informasi Kesehatan Putri, Santy Irene; Widiyanto, Aris; Ummah, Wiqodatul; Supriyono, Nisa'i Daramita; Prisusanti, Retno Dewi; Akbar, Prima Soultoni; Widiatrilupi, Raden Maria Veronika; Purwanti, Anik; Abdullah, Ikhwan; Wardoyo, Puspo; Gamar, No’o
Darmabakti : Jurnal Pengabdian dan Pemberdayaan Masyarakat Vol 6 No 02 (2025): Darmabakti : Junal Pengabdian dan Pemberdayaan Masyarakat
Publisher : Lembaga Peneliian dan Pengabdian Masyarakat (LPPM) Universitas Islam Madura (UIM)

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31102/darmabakti.2025.6.02.366-374

Abstract

The use of digital technology in the health sector is increasing, but public health digital literacy is still relatively low. This affects the public's ability to access accurate and reliable medical information. This service activity aims to improve public health digital literacy in using health information systems to find the right medical information. This program is carried out with preparation stages which include socialization to the community as well as the preparation of training materials and tools. The implementation of the activity consisted of a theory session by introducing digital technology and health information systems, followed by a practicum session where participants were trained using health applications and digital medical platforms. The evaluation was conducted by collecting feedback from participants to assess their improvement in knowledge and skills in accessing medical information digitally. The results of the evaluation showed that the majority of participants felt more confident in using technology to obtain accurate medical information after participating in this training.
Analysis of the Causes of Medical Records Document Misfiling at Makassar City Regional General Hospital Suhenda, Andi; Barsasella, Diana; Sukawan, Ari; Setiadi, Dedi; Sugiharto, Sugiharto; Akbar, Prima Soultoni
Poltekita: Jurnal Ilmu Kesehatan Vol. 19 No. 2 (2025)
Publisher : Poltekkes Kemenkes Palu

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33860/jik.v19i2.4283

Abstract

The procedure for storing medical record documents (MRDs) involves sorting the records by their medical record numbers before returning them to the medical records department and placing them in storage. This process facilitates the retrieval of required records and streamlines storage operations, thereby preventing misfiling when the documents are needed for patient care. Delays in locating MRDs on the filing racks can result from storage or placement errors, commonly referred to as misfiling. Efficient storage of medical record documents (MRDs) requires proper sorting by medical record numbers before returning them to the filing system. This process ensures quick retrieval and minimizes errors. However, delays in locating MRDs often occur due to misfiling—typically caused by improper storage or placement. This study aims to identify factors contributing to misfiling, focusing on the storage system, alignment, numbering, and human resources. This study is quantitative research with a descriptive design. The analysis used is univariant analysis. The population comprises inpatient medical records returned from the care units after patient discharge during the period of January to December 2023. The sampling method employed is non-probability sampling, specifically using accidental sampling. Among 50 inpatient MRDs stored in the filing room at Makassar City Regional General Hospital, 15 (30%) were misfiled. The factors contributing to the misfiling of medical record documents in the filing room include incompetent medical record personnel, misalignment in the filing system, the absence of tracers, and the lack of an expedition logbook. Misfiling was associated with several factors, including untrained personnel, inconsistencies in the filing alignment, absence of tracers, and the lack of a delivery logbook (previously referred to as an “expedition logbook”) used to track the movement of documents. Addressing these issues may improve filing accuracy and support patient care efficiency.
Telehealth Usage During The Coronavirus Disease 2019 Pandemic: A Meta-Analysis Akbar, Prima Soultoni; Putri, Santy Irene; Widiyanto, Aris; Atmojo, Joko Tri; Prisusanti, Retno Dewi; Ramadhanti, Tarisa Aulia
Poltekita : Jurnal Ilmu Kesehatan Vol. 17 No. 3 (2023): November
Publisher : Poltekkes Kemenkes Palu

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33860/jik.v17i3.2905

Abstract

The recent pandemic has increased telemedicine use tremendously, but it has also pronounced access gaps to telemedicine. This study aimed to investigate factors affecting patient use of telehealth during the Coronavirus Disease 2019 Pandemic. This article was created using a systematic review and meta-analysis study that searched for articles in electronic databases such as Science Direct, PubMed, and Google Scholar. Observational studies are included in full papers with a publication year until 2022 were searched for this study. The Review Manager 5.3 (RevMan) software was used to analyze the articles in this study. We observed heterogeneity with a random-effect model to analyze the effect size from each primary study, and the results were reported as an adjusted odds ratio (aOR) and corresponding 95 percent confidence interval (CI). A total of 9 articles reviewed in the meta-analysis (consisting of 4 articles in each variable) showed that patients whose primary language is non-English (aOR= 0.72; 95% CI= 0.59 to 0.87; p= 0.0008) and have Medicaid insurance English (aOR= 0.86; 95% CI= 0.77 to 0.97; p= 0.02) were less likely to use telemedicine compared to patients who speak English and utilize private insurance. Medication insurance and non-English as a preferred language reduced the likelihood of patients using telemedicine.
Co-Authors ACHMAD JAELANI RUSDI Ahmad Jaelani Rusdi Alvionita, Chyntia Vicky Amelia, Reza Angga Ferdianto Anggi Ardhiasti Annisa, Nadia Salma Aquanturi Tri Darmayanti Ardhiasti, Anggi Artha Budi Susila Duarsa Atmojo, Joko Tri Avid Wijaya Ayu Anulus Bella Artamevia, Fifi Bhisma Murti Citra Alifa Puspaningtyas Dahlia, Mustika Sinci Dedi Setiadi Devy Putri Nursanti Dewi, Cindy Shinta Eiska Rohmania Zein Endang Sri Dewi Endang Sri Dewi Hastuti Suryandari Fajriah, Asruria Sani Fatimah Azzahro Nur Firdausiyah Fiashriel Lundy Lundy Gamar, No’o Handayani, Rina Tri Hariez, Tsalits Maulidah Hartaty Sarma Sangkot Hendra Dwi Kurniawan Ikhwan Abdullah ingrum, Herlinda Dwi N Intan Putri Maharani Joko Tri Atmojo Joko Tri Atmojo Kadek Dwi Pramana Kumalasari, Eri Puji Maria Paula Marla Nahak Muhammad Ibnu Maulana Nabila Fardilan Nindita Arum Veibiani Nur Laili Qomariah Nurhadi Purwanti, Anik Raden Maria Veronika Widiatrilupi Ramadhanti, Tarisa Aulia Rashati, Dewi Retno Dewi Prisusanti Rina Tri Handayani Rita Adriani Benya Adriani S. Sugiharto Sangkot, Hartaty Sarma Santy Irene Putri Santy Irene Putri Saras Kuntari Sari, Sella Yulia Selvi Marcellia Silfia Angela N Halu Sri Lestari Suhenda, Andi Sukawan, Ari Supriyono, Nisa'i Daramita Suryani, Pudji Syahira, Nurfathina Syukma Ramadhani Faizal Nur Tsalits Maulidah Hariez Utami, Yeni Tri Wardoyo, Puspo Widiyanto, Aris Wiqodatul Ummah Zein, Eiska Rohmania