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<![CDATA[Analisis Ketepatan Kode Diagnosis Typhoid Fever Pada Rekam Medis Rawat Inap di Rumah Sakit Islam Karawang Tahun 2020 ]]>
<![CDATA[Nurfena, Deta Nurfena]]>;
<![CDATA[Indawati, Laela]]>;
<![CDATA[Dewi, Deasy Rosmala]]>;
<![CDATA[Fannya, Puteri]]>
<![CDATA[ Cerdika: Jurnal Ilmiah Indonesia Vol. 2 No. 4 (2022): Cerdika: Jurnal Ilmiah Indonesia ]]>
Publisher : <![CDATA[Publikasi Indonesia ]]>
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DOI: 10.59141/cerdika.v2i4.363
<![CDATA[Medical record is a file containing records and documents regarding patient identity, examination, treatment, actions and other services that have been provided to patients. where one of the services provided is the management of patient medical record documents that contain coding of diagnoses and actions given to patients. The implementation of coding disease diagnoses in hospitals is a very important activity, namely by classifying disease diagnoses into several groups for the benefit of reports that the hospital does every month, both for internal reports and external reports and plays an important role in the financing system at the hospital itself. The purpose of this study was to determine the accuracy of the diagnosis code for typhoid fever in inpatients at the Karawang Islamic Hospital. The research methodology was carried out using quantitative descriptive methods, the population was 200 medical records of typhoid fever patients in 2020, with a total sample of 67 samples. The sampling technique used is simple random sampling. How to collect data is done by direct observation. The accuracy of the code obtained is 31 (46%) correct codes and 36 (54%) incorrect codes, the inaccuracy of the code is caused by the medical record professional staff in charge of the coding section who are still not focused and not careful with laboratory results to determine the results of the coding. It is correct and only codes for the H titer, while in determining the diagnosis of typhoid fever, it is seen from the O titer. Suggestions for coding the diagnosis carried out at the Karawang Islamic Hospital are expected that the coding is carried out correctly according to the diagnosis, history, and laboratory results.]]>
<![CDATA[Tinjauan Kelengkapan Pengisian Formulir Assesment Awal Poli Klinik Pasien Rawat Jalan Menggunakan Metode IAR ]]>
<![CDATA[Safitri, Dinda Melani]]>;
<![CDATA[Fannya, Puteri]]>;
<![CDATA[Indawati, Laela]]>;
<![CDATA[Rosmala Dewi, Deasy]]>
<![CDATA[ Cerdika: Jurnal Ilmiah Indonesia Vol. 2 No. 4 (2022): Cerdika: Jurnal Ilmiah Indonesia ]]>
Publisher : <![CDATA[Publikasi Indonesia ]]>
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DOI: 10.59141/cerdika.v2i4.371
<![CDATA[The hospital is one of the health care facilities with various services helping people who have health probems. Medical record is a file that contains records and data related to patient identity, examination results, treatment history that has been given, other actions and services that have been carried out to patients. This study aimed to describe the completeness of filling the initial polyclinic assessment form. The methode of this study was descriptive analysis. The population of this study were the initial assessment of the physiotherapy clinic 312 medical records, surgery poly 177 medical records, and internal medicine clinic 457 medical records. And the sample of this research is 91 medical records. The results showed that from 91 medical records, 70 (77%) of forms is complete and 21 (23%) of forms is incomplete, which consisted of complete patient identification 80 (88%) and incomplete 11 (12%), completeness of important reports/notes 54 (59%) and incomplete 37 (41%), completeness of author authentication 73 (80%) and incomplete 18 (20%), and completeness of good records 72 (79%) and incomplete 19 ( 21%).]]>
<![CDATA[Tinjauan Ketepatan Pengodean Diagnosis Penyebab Dasar Kematian pada Pasien Diabetes Mellitus di RSU UKI Jakarta ]]>
<![CDATA[Nurmalasari, Dinda]]>;
<![CDATA[Widjaja, Lily]]>;
<![CDATA[Rosmala Dewi, Deasy]]>;
<![CDATA[Indawati, Laela]]>
<![CDATA[ Cerdika: Jurnal Ilmiah Indonesia Vol. 2 No. 4 (2022): Cerdika: Jurnal Ilmiah Indonesia ]]>
Publisher : <![CDATA[Publikasi Indonesia ]]>
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DOI: 10.59141/cerdika.v2i4.374
<![CDATA[Determination is a precaution and the accuracy of disease codes can be easily identified into correct and incorrect codes, Correct codes are adjusted in ICD-10 then incorrect codes are inappropriate codes in ICD-0. The cause of death was hospital reporting. The uncertainty of the diagnostic code consists of 5m (man, money, method, machine, material) based on the interview of the coding officer that the precision of the cause of death in the diabetes mellitus diabetes is not optimum because of poor doctors' writing, the use of abbreviations in the diagnosis, the lack of human resources in rmic education, no charge in coding, The method of conducting a death certificate from the medical certificate form is the cause of death at the point of immediate cause, the cause between and the underlying cause and the absence of a specialized chamber. Hence, the authors conducted a study on the correctness of the causes of death in diabetes patients mellitus according to the icd-10. The purpose of this study was to understand the precision of the diagnosis of the causes of death in the diabetes patient mellitus in Jakarta general hospital. Based on a study of the 72 medical records of patients dying of the precision of the cause of death in diabetes patients mellitus in Jakarta general in 2017-2020.]]>
<![CDATA[Tinjauan Kebutuhan Rak Penyimpanan Rekam Medis di Rumah Sakit Annisa Bogor Tahun 2022 ]]>
<![CDATA[Salsabila, Annisa Nur]]>;
<![CDATA[Viatiningsih, Wiwik]]>;
<![CDATA[Widjaja, Lily]]>;
<![CDATA[Indawati, Laela]]>
<![CDATA[ Cerdika: Jurnal Ilmiah Indonesia Vol. 2 No. 7 (2022): Cerdika: Jurnal Ilmiah Indonesia ]]>
Publisher : <![CDATA[Publikasi Indonesia ]]>
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DOI: 10.59141/cerdika.v2i7.436
<![CDATA[Hospital is a health service institution by providing outpatient and inpatient services. Each hospital also has an obligation to have a Medical Record Unit. Medical records are files that contain records or documents such as patient identities, results of diagnoses, actions, and treatments as well as services that have been provided to patients. In the context of administering medical records, health service facilities are required to provide the necessary facilities. One of them is a medical record storage rack to store medical records. Based on the results of research at the Medical Record Unit of the Annisa Hospital, Bogor, it was found that the medical record storage rack was inadequate and some medical records were piled on the floor, making it difficult for officers to find medical records when needed and services at the polyclinic became hampered. The purpose of this study was to determine the need for medical record storage racks for the next 5 years at Annisa Hospital Bogor in 2022. The study was conducted using a quantitative descriptive method, using a non-random sampling method with saturated sampling technique. From the results of the study, the Annisa Bogor Hospital still lacks medical record storage rack facilities which currently have 12 wooden shelves and 3 Roll O'packs, an additional rack of 9 Roll O'packs is needed. The storage area at Annisa Hospital Bogor is sufficient because the area needed for the next 5 years is 61.3 m2. Meanwhile, the current room area is 120 m2 combined with the medical record officer's workspace.]]>
<![CDATA[Tinjauan Pelaksanaan Penyusutan Rekam Medis Inaktif di Rumah Sakit Islam Jakarta Cempaka Putih Tahun 2021 ]]>
<![CDATA[Kurnia, Hanum Milla]]>;
<![CDATA[Indawati, Laela]]>;
<![CDATA[Rumana, Nanda Aula]]>;
<![CDATA[Siswati, Siswati]]>
<![CDATA[ Cerdika: Jurnal Ilmiah Indonesia Vol. 2 No. 9 (2022): Cerdika: Jurnal Ilmiah Indonesia ]]>
Publisher : <![CDATA[Publikasi Indonesia ]]>
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DOI: 10.59141/cerdika.v2i9.443
<![CDATA[Depreciation is an activity to reduce medical records from storage shelves by moving active medical records to inactive medical records. Depreciation of medical records needs to be done and considered, if the depreciation is not carried out with the addition of medical records that continues to increase, it will cause a buildup of medical record archives. This study aims to determine how the implementation of inactive medical record shrinkage at the Islamic Hospital Jakarta Cempaka Putih. This research method uses a descriptive method with a qualitative approach consisting of 3 informants, namely 1 head of medical records and 2 medical record officers. Based on the results of the study, it was found that the Islamic Hospital of Jakarta Cempaka Putih already had standard operating procedures related to shrinkage (retention) and destruction. The medical record unit depreciates medical records referring to the existing SOP. In carrying out the depreciation of the Jakarta Cempaka Putih Islamic Hospital, there were several things that had not been implemented, such as media transfer and extermination. The obstacle factors that occur in the implementation of depreciation are lack of human resources and there are still many medical records that accumulate because they have not been done entirely. Suggestions for the Islamic Hospital of Jakarta Cempaka Putih to make Standard Operating Procedures regarding the depreciation of inactive medical records, make decisions on medical records based on useful and not useful values, suggestions for Human Resources (HR) in the depreciation implementation section set a schedule so that the depreciation process can conducted.]]>
<![CDATA[Literature Review Ketepatan Pengodean ICD-10 External Cause di Rumah Sakit ]]>
<![CDATA[Harahap, Maulidiah Rizki]]>;
<![CDATA[Indawati, Laela]]>;
<![CDATA[Widjaja, Lily]]>
<![CDATA[ Cerdika: Jurnal Ilmiah Indonesia Vol. 2 No. 9 (2022): Cerdika: Jurnal Ilmiah Indonesia ]]>
Publisher : <![CDATA[Publikasi Indonesia ]]>
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DOI: 10.59141/cerdika.v2i9.445
<![CDATA[External cause is classifying disease with cases of injury, poisoning, and accidents, from external causes. Therefore, medical officers must be competent in coding according to ICD-10 and are required to provide precise and accurate codes. The purpose of this study was to determine the percentage accuracy of the external cause ICD-10 coding and to find out the obstacles to the inaccuracy of external cause coding. using the literature review method. The results of a literature review of 12 journals related to the coding accuracy of ICD-10 external causes in several hospitals found that the highest percentage of code accuracy was 82% with the lowest percentage of code accuracy being 0%, while the highest percentage of coding inaccuracy was 100% and for the percentage of inaccuracy. the lowest code as much as 18 %. The 10 journals above use 5M elements, namely the obstacles that are often obtained from the Man factor which consists of coders who are not careful in determining the code, the competence of medical recorders needs to be honed, and lack of effective communication between coders and officers regarding the contents. medical records. It is recommended for coders who do not understand coding to conduct seminars to learn how to do good coding, so that the percentage of inaccuracies in the hospital is reduced to a lower level.]]>
<![CDATA[Tinjauan Ketepatan Kode Diagnosis Pada Kasus Bedah Pasien Rawat Inap di RSKD Duren Sawit ]]>
<![CDATA[Rahayu, Ririn]]>;
<![CDATA[Indawati, Laela]]>;
<![CDATA[Widjaja, Lily]]>;
<![CDATA[Rumana, Nanda Aula]]>
<![CDATA[ Cerdika: Jurnal Ilmiah Indonesia Vol. 2 No. 11 (2022): Cerdika: Jurnal Ilmiah Indonesia ]]>
Publisher : <![CDATA[Publikasi Indonesia ]]>
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DOI: 10.59141/cerdika.v2i11.455
<![CDATA[Based on Kenmenkes RI in 2014, it explains about coding which has the meaning as an activity of providing main diagnosis codes and secondary diagnoses in accordance with ICD-10 and providing procedure codes in accordance with ICD-9CM. Coding inaccuracies can affect the financing of health services, this study was conducted to see the accuracy of the main and secondary diagnosis codes of surgical cases of inpatients at Duren Sawit Hospital using descriptive research methods with a quantitative approach, namely writing aims to describe the results obtained on the accuracy of diagnosis codification. Informants in this study were inpatient coders at RSKD Duren Sawit, data collection in this study using interviews and observation methods. The results of this study indicate that the coding SPO uses the latest procedures based on an electronic system, the educational background of the coder at RSKD Duren Sawit has an important role in the quality of the correct code. The competence of the coder at RSKD Duren Sawit still has to undergo deeper learning, in the results of coding research on surgical cases of inpatients, it was found that the average dignosis code that had accuracy was 58 (63.74%) and 33 (36.26%) were inappropriate, and it was also found that the results of the accuracy of the secondary diagnosis were 84 (92.30%) and 7 (7.70%) were inappropriate. Based on the 4 characters, the inaccuracy occurred in the main diagnosis of the majority in the 4th character as many as 31 (34.7%). There are factors that become obstacles to the identification of 5M, namely the man factor, the lack of accuracy of doctors in inputting diagnoses and the lack of accuracy of officers in re-examining incorrect diagnosis codes and having to undergo learning related to coding more deeply for diagnosis coding officers who are not from academic graduates of medical records.]]>
<![CDATA[Tinjauan Aspek Keamanan dan Kerahasiaan di Ruang Penyimpanan Rekam Medis di RSUD Kota Depok ]]>
<![CDATA[Salsabillah, Shania]]>;
<![CDATA[Happy Putra, Daniel]]>;
<![CDATA[Indawati, Laela]]>;
<![CDATA[Rumana, Nanda Aula]]>
<![CDATA[ Cerdika: Jurnal Ilmiah Indonesia Vol. 2 No. 10 (2022): Cerdika: Jurnal Ilmiah Indonesia ]]>
Publisher : <![CDATA[Publikasi Indonesia ]]>
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DOI: 10.59141/cerdika.v2i10.463
<![CDATA[Security and confidentiality of medical records in the storage room is one of the supporting factors for the creation of confidentiality of patient medical record information, to get the expected results it is necessary to have medical records officers, medical records, storage rooms, SOP (Standard Operating Procedures) security and confidentiality in the medical record room, as well as facilities and facilities in the storage room. This research was conducted in the Medical Record Unit of the Depok City Hospital. This study aims to determine the aspects of security and confidentiality in the medical record storage room. This study uses descriptive analysis method with a qualitative approach by conducting interviews and observations. The research results obtained at the Depok City Hospital already have 2 standard operating procedures, namely regarding security and confidentiality and standard procedures for storing medical records. However, the implementation of the work has not been carried out optimally. There are medical records whose covers are damaged, not replaced with new ones, the medical record storage room still uses a manual door which in the standard procedure must use a coded key. This makes the implementation of work at the Depok City Hospital has not been carried out according to existing standard operating procedures. Supporting facilities in the storage room are also inadequate, especially for the second storage room which only has 1 air conditioner, does not have good ventilation for air exchange so that there is no air between stored medical records, does not have a temperature and humidity control device.]]>
<![CDATA[Tinjauan Aspek Keamanan dan Kerahasiaan Di Ruang Penyimpanan Rekam Medis Di RSUD Kota Depok ]]>
<![CDATA[Salsabillah, Shania]]>;
<![CDATA[Happy Putra, Daniel]]>;
<![CDATA[Indawati, Laela]]>;
<![CDATA[Aula Rumana, Nanda]]>
<![CDATA[ Cerdika: Jurnal Ilmiah Indonesia Vol. 3 No. 1 (2023): Cerdika: Jurnal Ilmiah Indonesia ]]>
Publisher : <![CDATA[Publikasi Indonesia ]]>
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DOI: 10.59141/cerdika.v3i1.504
<![CDATA[Keamanan dan kerahasiaan rekam medis di ruang penyimpanan merupakan salah satu faktor pendukung terciptanya kerahasiaan informasi rekam medis pasien, untuk mendapatkan hasil yang diharapkan maka diperlukan petugas rekam medis, rekam medis, ruang penyimpanan, SPO (Standar Prosedur Operasional) keamanan dan kerahasiaan di ruang rekam medis, serta fasilitas dan sarana di ruang penyimpanan. Penelitian ini dilaksanakan di Unit Rekam Medis RSUD Kota Depok. Penelitian ini bertujuan untuk mengetahui aspek keamanan dan kerahasiaan di ruang penyimpanan rekam medis. Penelitian ini menggunakan metode analisis deskriptif dengan pendekatan kualitatif dengan melakukan wawancara dan observasi. Hasil penelitian yang didapatkan di RSUD Kota Depok ini telah memiliki 2 standar prosedur operasional yaitu mengenai keamanan dan kerahasiaan serta standar prosedur ruang penyimpanan rekam medis. Tetapi, untuk pelaksanaan pekerjaannya belum terlaksana dengan maksimal. Terdapat rekam medis yang sampulnya mengalami kerusakan, tidak diganti dengan yang baru, ruang penyimpanan rekam medis masih menggunakan pintu manual yang dimana di dalam standar Prosedur harus menggunakan kunci berkode. Hal ini menjadikan pelaksanaan pekerjaan di RSUD Kota Depok belum dijalankan sesuai standar prosedur operasional yang ada. Fasilitas pendukung yang berada di ruang penyimpanan pun kurang memadai khususnya untuk ruang penyimpanan kedua hanya memiliki 1 AC, tidak memiliki ventilasi yang baik untuk pertukaran udara sehingga tidak ada udara diantara rekam medis yang disimpan, tidak memiliki alat pengatur suhu dan kelembapan.]]>
<![CDATA[Analisis Ketepatan Kode Diagnosis Kasus Persalinan Secara Sectio Caesarea Di Rumah Sakit Pelabuhan Jakarta ]]>
<![CDATA[Anggraini, Adelia]]>;
<![CDATA[Widjaja, Lily]]>;
<![CDATA[Indawati, Laela]]>;
<![CDATA[Rosmala Dewi , Deasy]]>
<![CDATA[ Cerdika: Jurnal Ilmiah Indonesia Vol. 3 No. 1 (2023): Cerdika: Jurnal Ilmiah Indonesia ]]>
Publisher : <![CDATA[Publikasi Indonesia ]]>
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DOI: 10.59141/cerdika.v3i1.505
<![CDATA[Salah satu aspek terpenting dalam pelayanan rekam medis adalah kegiatan klasifikasi dan kodefikasi diagnosis serta tindakan. Dalam melakukan pemberian kode diagnosis pasien, petugas koding mengacu pada aturan ICD-10. Berdasarkan aturan ICD-10 kasus persalinan terdiri atas tiga komponen yaitu kondisi atau penyulit (O00-O99), metode persalinan (O80-O84), dan outcome of delivery (Z37.-) yang digunakan sebagai kode tambahan untuk mengetahui hasil persalinan. Tujuan dalam penelitian yaitu untuk mengetahui ketepatan kode diagnosis kasus persalinan secara sectio caeasrea di Rumah Sakit Pelabuhan Jakarta. Penelitian menggunakan analisis deskriptif dengan pendekatan kuantitatif. Dengan sampel sebanyak 70 rekam medis kasus persalinan secara sectio caesarea di Rumah Sakit Pelabuhan Jakarta. Pada penelitian ini didapati hasil komponen atau penyulit ibu dengan ketepatan 90% (63 RM), lalu metode persalinan dengan ketepatan 11,43% (8 RM). Serta outcome of delivery yang memiliki ketepatan 0% (70 RM). Berdasarkan hasil wawancara dan observasi terhadap kepala rekam medis dan koder bahwa ketepatan pengodean dapat dipengaruhi oleh faktor 5M (man, money, material, method, machine), yaitu ketelitian koder dalam melakukan pengodean, kejelasan pada tulisan dokter, serta tersedianya SPO yang memiliki catatan khusus mengenai pengodean kasus persalinan sehingga proses pengodean dapat terstruktur dengan baik.]]>
