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Indawati, Laela
Universitas Esa Unggul
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Tinjauan Pelaksanaan Penyusutan Rekam Medis Inaktif di Rumah Sakit Islam Jakarta Cempaka Putih Tahun 2021 Kurnia, Hanum Milla; Indawati, Laela; Rumana, Nanda Aula; Siswati, Siswati
Cerdika: Jurnal Ilmiah Indonesia Vol. 2 No. 9 (2022): Cerdika: Jurnal Ilmiah Indonesia
Publisher : Publikasi Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.59141/cerdika.v2i9.443

Abstract

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.
Literature Review Ketepatan Pengodean ICD-10 External Cause di Rumah Sakit Harahap, Maulidiah Rizki; Indawati, Laela; Widjaja, Lily
Cerdika: Jurnal Ilmiah Indonesia Vol. 2 No. 9 (2022): Cerdika: Jurnal Ilmiah Indonesia
Publisher : Publikasi Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.59141/cerdika.v2i9.445

Abstract

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.
Tinjauan Ketepatan Kode Diagnosis Pada Kasus Bedah Pasien Rawat Inap di RSKD Duren Sawit Rahayu, Ririn; Indawati, Laela; Widjaja, Lily; Rumana, Nanda Aula
Cerdika: Jurnal Ilmiah Indonesia Vol. 2 No. 11 (2022): Cerdika: Jurnal Ilmiah Indonesia
Publisher : Publikasi Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.59141/cerdika.v2i11.455

Abstract

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.
Tinjauan Aspek Keamanan dan Kerahasiaan di Ruang Penyimpanan Rekam Medis di RSUD Kota Depok Salsabillah, Shania; Happy Putra, Daniel; Indawati, Laela; Rumana, Nanda Aula
Cerdika: Jurnal Ilmiah Indonesia Vol. 2 No. 10 (2022): Cerdika: Jurnal Ilmiah Indonesia
Publisher : Publikasi Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.59141/cerdika.v2i10.463

Abstract

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.
Tinjauan Aspek Keamanan dan Kerahasiaan Di Ruang Penyimpanan Rekam Medis Di RSUD Kota Depok Salsabillah, Shania; Happy Putra, Daniel; Indawati, Laela; Aula Rumana, Nanda
Cerdika: Jurnal Ilmiah Indonesia Vol. 3 No. 1 (2023): Cerdika: Jurnal Ilmiah Indonesia
Publisher : Publikasi Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.59141/cerdika.v3i1.504

Abstract

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.
Analisis Ketepatan Kode Diagnosis Kasus Persalinan Secara Sectio Caesarea Di Rumah Sakit Pelabuhan Jakarta Anggraini, Adelia; Widjaja, Lily; Indawati, Laela; Rosmala Dewi , Deasy
Cerdika: Jurnal Ilmiah Indonesia Vol. 3 No. 1 (2023): Cerdika: Jurnal Ilmiah Indonesia
Publisher : Publikasi Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.59141/cerdika.v3i1.505

Abstract

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.
Tinjauan Ketepatan Kode Diagnosis pada Kasus Neoplasma di RSIJ Cempaka Putih Kamalia, Farhah; Indawati, Laela
Jurnal Ilmiah Wahana Pendidikan Vol 10 No 7 (2024): Jurnal Ilmiah Wahana Pendidikan
Publisher : Peneliti.net

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.5281/zenodo.11083581

Abstract

Keakuratan kode diagnosis secara signifikan mempengaruhi informasi yang diperoleh dari laporan morbiditas dan mortalitas, tagihan biaya layanan, dan kualitas rumah sakit secara keseluruhan. Tujuan penelitian ini adalah untuk mengidentifikasi keakuratan kode diagnosis kasus neoplasma pada pasien rawat inap di RSIJ Cempaka Putih. Metode penelitian yang digunakan adalah metode deskriptif dengan pendekatan kuantitatif. Besar sampel terdiri dari 96 rekam medis yang dipilih dari populasi sebanyak 703 rekam medis, dengan menggunakan rumus Slovin dan metode simple random sampling. Hasil penelitian: SPO untuk pengkodean diagnosis secara umum telah berjalan, namun belum ada SPO khusus mengenai pemberian kode diagnosis pada kasus neoplasma. Hasil keakuratan kode diagnosis diperoleh kode topografi 54 rekam medis (56,52%) akurat dan 42 rekam medis (43,75%) tidak akurat. Rumah sakit belum menerapkan kode morfologi neoplasma. Ketidaktepatan kode diagnosis neoplasma disebabkan oleh ketidakakuratan pengkode, kurangnya informasi terkait diagnosis, dan belum adanya SPO khusus yang mengatur tata cara pengkodean diagnosis neoplasma. Untuk meningkatkan keakuratan kode yang dihasilkan, perlu dilakukan evaluasi terhadap prosedur pengkodean diagnosis neoplasma. Dengan demikian, kualitas data dan keandalan laporan morbiditas dan mortalitas rumah sakit, penagihan layanan, dan penilaian kualitas dapat ditingkatkan.
Overview of the Accuracy of Fracture Main Diagnostic Codes in Inpatients at Gatot Soebroto Army Hospital Carono; Siswati; Deasy Rosmala Dewi; Laela Indawati
Open Access Indonesian Journal of Medical Reviews Vol. 2 No. 3 (2022): Open Access Indonesian Journal of Medical Reviews
Publisher : HM Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37275/oaijmr.v2i3.194

Abstract

Coding activities include the coding of diagnosis and the coding of medical treatment. The important thing that must be considered by medical recorders is the accuracy in giving the diagnosis code. This study aims to determine the accuracy of the main diagnostic code for fractures in inpatients at Gatot Soebroto Army Hospital using ICD-10. This research is an observational study with a descriptive method. The study was conducted at the medical record unit of the Gatot Soebroto Army Central Hospital from October to December 2020. Sampling in this study was carried out using a systematic random sampling technique. The sample in this study was the medical record of patients with a fracture diagnosis at Gatot Soebroto Army Hospital. This study found that standard operating procedures (SOPs) for giving diagnosis codes in general according to ICD-10 at Gatot Soebroto Army Hospital already exist. However, the SOP code for fracture diagnosis is not yet available. Most of the documents (72.88%) had a diagnosis code that did not match the ICD-10. In conclusion, Gatot Soebroto Army Hospital does not yet have a special SOP regarding the diagnosis code for fracture cases. Most fracture diagnosis codes in medical record documents are incorrect. This is probably due to the lack of accuracy of the coder in coding the diagnosis, the absence of an evaluation or audit of the diagnosis coding for fracture cases, and the writing of the diagnosis by doctors being unclear and illegible.
Ketepatan Pengodean Diagnosis dan Tindakan Medis 10 Penyakit Terbanyak Putri, Sisilia; Yulia, Noor; Indawati, Laela; Dewi, Deasy Rosmala
Surya Medika: Jurnal Ilmiah Ilmu Keperawatan dan Ilmu Kesehatan Masyarakat Vol. 19 No. 2 (2024)
Publisher : STIKes Surya Global Yogyakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.32504/sm.v19i2.1017

Abstract

Latar Belakang: Keakuratan pengkodean diagnosis dan prosedur medis sangat penting bagi rumah sakit untuk memudahkan penyajian informasi data dan sebagai penentu pembiayaan. Tujuan dari penelitian ini adalah untuk menganalisis keakuratan pengkodean diagnosis dan prosedur medis 10 penyakit terbanyak pada bulan Februari 2023 di RSUD Kembangan.   Metode : Metode penelitian menggunakan metode deskriptif dengan pendekatan analisis kuantitatif. sampel dengan jumlah 55 rekam medis yang diambil dengan teknik simple random sampling.   Hasil : Rumah sakit belum memiliki SPO khusus untuk pengodean dan prosedur medis, dari 55 sampel didapatkan hasil yang akurat untuk pengodean diagnosa 10 penyakit pada bulan Februari 2023, sebanyak 28 sampel tepat (51%) dan 25 sampel tidak tepat (49%), atau memiliki pengodean prosedur medis sebesar (66%) dan tidak tepat sebesar (34%).   Kesimpulan : Masih banyak terjadi ketidaktepatan pengkodean diagnosis dan prosedur medis di RSUD Kembangan yang mengakibatkan ketepatan diagnosis dan tindakan medis tidak mencapai 100%. Hal ini kemungkinan disebabkan karena belum adanya SPO khusus untuk diagnosis dan tindakan medis serta belum adanya petugas koding yang ahli dalam bidang koding.   Kata Kunci : Akurasi Koding; 10 Penyakit Terbanyak
Pengaruh Aktivitas Organisasi, Prestasi Belajar, Jiwa Kewirausahaan, dan Jenis Kelamin Terhadap Kesiapan Kerja Alumni Karim, Hidayat Ramadhani Nuzulul; Rumana, Nanda Aula; Indawati, Laela; Satrya, Bangga Agung
Jurnal Manajemen Informasi dan Administrasi Kesehatan Vol. 8 No. 2 (2025): JMIAK
Publisher : Program Studi D3 Rekam Medis dan Informasi Kesehatan

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.32585/jmiak.v8i2.7147

Abstract

Kesiapan kerja merupakan aspek penting yang harus dimiliki oleh lulusan perguruan tinggi untuk menghadapi dunia kerja yang semakin kompetitif. Penelitian ini bertujuan untuk menganalisis pengaruh aktivitas organisasi, prestasi belajar, dan jiwa kewirausahaan terhadap kesiapan kerja pada alumni Program Studi Rekam Medis dan Informasi Kesehatan Universitas Esa Unggul. Penelitian dilakukan pada alumni Program Studi Rekam Medis dan Informasi Kesehatan Universitas Esa Unggul yang telah dinyatakan lulus ujian kompetensi tahun 2024 dengan populasi sebanyak 65 orang dengan sampel yang digunakan sebanyak 51 orang melalui penyebaran kuesioner sebagai instrumen pengumpulan data. Metode yang digunakan adalah penelitian kuantitatif dengan pendekatan analisis inferensial dan pengujian hipotesis menggunakan uji chi-square. Variabel yang diteliti meliputi aktivitas organisasi, prestasi belajar, jiwa kewirausahaan, dan kesiapan kerja. Hasil penelitian ini menunjukkan bahwa tidak terdapat pengaruh aktivitas organisasi terhadap kesiapan kerja dengan hasil p-value 0,468 >0,05. Tidak terdapat pengaruh prestasi belajar terhadap kesiapan kerja dengan hasil p-value 0,547 >0,05. Terdapat pengaruh jiwa kewirausahaan terhadap kesiapan kerja dengan hasil p-value 0,004 <0,05. Tidak terdapat pengaruh jenis kelamin terhadap kesiapan kerja dengan hasil p-value 0,447 >0,05.
Co-Authors Abdul Rokim Adelia Anggraini Adi Widodo Adijaya, Nuryansyah Ahmad Ripki Alex Sander Alfi Shiddiq Syafrian Almahshunatul Hanifah Amirah Syafiqah Zahra Amnur, Alvina Salsabila Aneu Rosliana Anggi Alpiyani Anggraini, Adelia Anisa Anisa Anisa Anisa Anisa Aprilia Anisa Dewi Wahyuni Anisa Dyah Irawati Annida Ariyani Annisa Nur Salsabila Aqshal Hidayatullah Arip Budiana Athirah Iwani Rahman Athiyyah, Hanifatul Ayu Hardianti Azhar Muttaqin Azhar Muttaqin Bagas Saputra Bahlani Bangga Agung Satrya Bayu Fajar Ilhami Carono Chinta Fourdy Wantika Daniel Happy Putra Daniel Happy Putra Debbie Friscilla Carolina Manalu Della Rati Saputri della Dessy Safutri Deta Nurfena Nurfena Devi Angeliana Kusumaningtiar Dewi, Deasy Rosmal Dewi, Deasy Rosmala Diah putri Ayu Islammia Dian Nur Muslimah Dina Sonia Dinda Melani Safitri Diva Sabina Dwi Chandrarika Putri Aulia Dwijayanti, Risma Mei Elina Intan Apzari Elvira Xandra Ximenes Harum Emilia Karin Dwi Liani Endika Rachmad Erviana, Erviana Eza Nurkholifa Fani Nur Azizah Fannya, Puteri Fauzan Habibilah Fauziah Irfany Fiqih Nurhidayah Fitria, Annah Gilang Dasa Dwi Mahendra Hanif Andini Hanum Milla Kurnia Harahap, Maulidiah Rizki Ilhami, Bayu Fajar Ilma Aulia Rahma Intan Rusdiana Dewi Iqbal, Muhammad Fuad Ira Rizka Safia Jeillia Jihan Swaradwibhagia Junata, Ilfan Kamalia, Farhah Karim, Hidayat Ramadhani Nuzulul Kevin Handynata Kurnia, Hanum Milla Kusumapradja, Rokiah Laras Sitoayu Lasmaria Simorangkir Liani, Emilia Karin Dwi Listania Aisyah Putri Luthfiah Aulia Rachman Luviany Gouw Manalu, Debbie Friscilla Carolina Maria Ferawaty Parera Mariyam, Mutia Maulidiah Rizki Harahap Mei Nur Khasanah Muammar Dzachwani Muhamad Endra Suriatno Muhamad Fazriyansah Muhammad Rezal Muniroh Muniroh Muniroh, Muniroh Mutia Mariyam Nadia Sintia Nanda Aula Romana Nanda Aula Rumana Naurah Zharifah Nur Mawaddah, Nur Nur Ratri Annisa Putri Nurasiyah Nurfena, Deta Nurfena Nurkholifa, Eza Nurmalasari, Dinda Nurmalasari, Mieke Nusamina Pulungan Octa Rina Sari Putri Rafikasani Putri, Alifatul Aulia Sagita Putri, Listania Aisyah Putri, Nur Ratri Annisa Putri, Sisilia Rahayu, Ririn Rahmawati, Rena Maulina Regina Yulianti T. S Rezal, Muhammad Rianta Sari Gultom Rifda Ulfa Andini Rifqi Fauzan Ririn Rahayu Risma Ayu Fitriyani Rizal Ramadhan Rizky Alfiansyah ROKIM, ABDUL Rumana, Nanda Saarah Salsabila Putri Yadita Sabina, Diva Sadono Hadi Saputro Safitri, Dinda Melani Salsabila Putri Cahyani Salsabila, Annisa Nur Salsabillah, Shania Sansy Dua Lestari Selvi Dwi Lestari Shania Salsabillah Shania Salsabillah Silfa Haniasti Simorangkir, Lasmaria Siswati Siswati Siswati Siswati Siva Maulia Fauziah Sonaria Tambunan Sonia, Dina Sonia Tia Ivany Uli Shalatiya uli Viatiningsih, Wiwik Wantika, Chinta Fourdy Widjaja, Lily Widjaya, Lily Yulia, Noor Zalipa Wittri