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Indawati, Laela
Universitas Esa Unggul
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Tinjauan Ketepatan Pengodean Diagnosis Penyebab Dasar Kematian pada Pasien Diabetes Mellitus di RSU UKI Jakarta Nurmalasari, Dinda; Widjaja, Lily; Rosmala Dewi, Deasy; Indawati, Laela
Cerdika: Jurnal Ilmiah Indonesia Vol. 2 No. 4 (2022): Cerdika: Jurnal Ilmiah Indonesia
Publisher : Publikasi Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.59141/cerdika.v2i4.374

Abstract

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.
Tinjauan Kebutuhan Rak Penyimpanan Rekam Medis di Rumah Sakit Annisa Bogor Tahun 2022 Salsabila, Annisa Nur; Viatiningsih, Wiwik; Widjaja, Lily; Indawati, Laela
Cerdika: Jurnal Ilmiah Indonesia Vol. 2 No. 7 (2022): Cerdika: Jurnal Ilmiah Indonesia
Publisher : Publikasi Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.59141/cerdika.v2i7.436

Abstract

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.
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.
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 Aprilia Anisa Dewi Wahyuni Anisa Dyah Irawati Annida Ariyani Annisa Nur Salsabila Aqshal Hidayatullah Arip Budiana Ariyani, Annida Athirah Iwani Rahman Athiyyah, Hanifatul Ayu Hardianti Azhar Muttaqin Azhar Muttaqin Bagas Saputra Bahlani Bangga Agung Satrya Bayu Fajar Ilhami Carono 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 Endika Rachmad Erviana, Erviana 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 Intan Rusdiana Dewi Iqbal, Muhammad Fuad 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 Muammar Dzachwani Muhamad Endra Suriatno Muhamad Fazriyansah Muniroh Muniroh Muniroh, Muniroh Nadia Sintia Nanda Aula Romana Nanda Aula Rumana Nur Mawaddah, Nur 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 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 Zharifah, Naurah