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All Journal Jurnal Manajemen Pendidikan Indonesian of Health Information Management Journal (INOHIM) Surya Medika: Jurnal Ilmiah Ilmu Keperawatan dan Ilmu Kesehatan Masyarakat Jurnal Kesehatan Tambusai Interdisciplinary Social Studies Edu Cendikia: Jurnal Ilmiah Kependidikan International Archives of Medical Sciences and Public Health International Archives of Medical Sciences and Public Health Journal of Comprehensive Science Cerdika: Jurnal Ilmiah Indonesia Klinik: Jurnal Ilmiah Kedokteran dan Kesehatan Mutiara: Multidiciplinary Scientifict Journal Jurnal Rekam Medic
Fannya, Puteri
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Journal : Cerdika: Jurnal Ilmiah Indonesia

 1 
Analisis Ketepatan Kode Diagnosis Typhoid Fever Pada Rekam Medis Rawat Inap di Rumah Sakit Islam Karawang Tahun 2020 Nurfena, Deta Nurfena; Indawati, Laela; Dewi, Deasy Rosmala; Fannya, Puteri
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.v2i4.363

Abstract

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.
Tinjauan Kelengkapan Pengisian Formulir Assesment Awal Poli Klinik Pasien Rawat Jalan Menggunakan Metode IAR Safitri, Dinda Melani; Fannya, Puteri; Indawati, Laela; Rosmala Dewi, Deasy
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.v2i4.371

Abstract

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%).
Tinjauan Tata Ruang Unit Rekam Medis dalam Menjaga Keamanan dan Kerahasiaan Rekam Medis di RSUD Kembangan Tri Putra, Iqbal; Fannya, Puteri; Widjaya, Lily; Muniroh, Muniroh
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.v2i4.372

Abstract

In the Medical Record Unit of the Kembangan Regional General Hospital, the work space of the medical record unit is directly related to the active medical record storage room, the door of the medical record unit at the Kembangan Regional General Hospital does not yet have a secret key or additional security such as a fingerprint. The purpose of this study was to determine the layout of the medical record unit in maintaining the security and confidentiality of medical records at the Kembangan Regional General Hospital. This study used quantitative descriptive methods with observation and interview data collection techniques, as well as direct measurements in the workspace and storage of the medical record unit of the Kembangan Regional General Hospital using a measuring instrument in the form of a building meter, then to determine the need for storage space obtained from the calculation of shelf requirements. medical record storage using the formula according to the International Federation of Health Information Management Associations. The results of the research are in the medical record unit of the Kembangan Regional General Hospital already have standard operating procedures related to the security and confidentiality of medical records but in practice it has not been implemented optimally. Inadequate facilities and infrastructure can be seen from the current work area of 10.27 m3, it should takes 15 m3, the storage space is still minimally lit and does not meet the standards. Suggestion: it is better if standard operating procedures have not been implemented to be implemented immediately.
Tinjauan Prosedur Pendaftaran Pasien Rawat Inap di RSU Bhakti Asih Tangerang Fandhika, Lilin Tata; Fannya, Puteri; Rumana, Nanda Aula; Yulia, Noor
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.v2i4.375

Abstract

The inpatient registration procedure contains a collection of patient data that is admitted per day, from the existing data registered for inpatient registration, it can be seen the number of patients admitted per day, the number of patients admitted per treatment room. The purpose of this study was to determine the procedure for registering inpatients at Bhakti Asih General Hospital, Tangerang. This type of research uses a qualitative descriptive method. Data collection techniques used are observation and interviews. The results of this study are related to the implementation of inpatient registration procedures, there are obstacles regarding incomplete requirements at the time of registration such as personal identity cards (KTP/KK), patient referral letters and the lack of registration officers so that there is a buildup during inpatient registration. the lack of completeness in the patient identity requirements as a condition for patient registration, therefore the officer must educate the patient to make a statement letter for files that are left behind 2 X 24 hours or before the patient goes home. to be brought as terms and procedures of patient registration at the hospital.
Gambaran Prosedur Klaim Peserta Rawat Inap Bpjs Kesehatan Di Rspad Gatot Subroto Tahun 2022 Amalia, Isnaini; Fannya, Puteri; Viatiningsih, Wiwik; Aula Rumana, Nanda
Cerdika: Jurnal Ilmiah Indonesia Vol. 3 No. 4 (2023): Cerdika : Jurnal Ilmiah Indonesia
Publisher : Publikasi Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.59141/cerdika.v3i4.578

Abstract

Jaminan kesehatan yang dilaksanakan memiliki prosedur dan kebijakan. Prosedur dan kebijakan tersebut merupakan penjelasan fasilitas kesehatan diharuskan mengajukan klaim secara rutin yaitu maksimal tanggal 10 bulan berikutnya. Dalam prosedur dan kebijakan tersebut BPJS Kesehatan memiliki sebuah sistem yang digunakan untuk mengajukan klaim dengan pola pembayaran Indonesian Case Base Groups (INA-CBG’s) pada tarif pelayanan kesehatan tingkat lanjut. Sebelum mengajukan klaim, pihak rumah sakit melakukan verifikasi administrasi dengan dokumen yang dibutuhkan. Penelitian ini menggunakan metode penelitian analisis deskriptif dengan pendekatan kualitatif melalui observasi dan wawancara. SPO dalam pengajuan klaim sejak dibuat tahun 2016 belum memiliki perubahan. Isi dari SPO itu tetap sama dengan memiliki 16 poin yang menjadi pedoman dalam pengajuan klaim. Pengajuan klaim memiliki 4 tahapan yaitu verfikasi JKN, grouper JKN, verifikasi BPJS Kesehatan dan pembayaran. Pada pelaksanaannya masih terdapat kendala dalam proses pengajuan klaim yaitu masih terdapatnya kode yang salah, tidak lengkapnya berkas yang dibutuhkan, serta sistem yang terkadang bermasalah. Maka dari itu petugas diharapkan agar memperhatikan kembali SPO yang ada apakah SPO tersebut memerlukan perubahan atau tidak. Dan petugas agar lebih teliti lagi dalam proses koding dan mengumpulkan berkas yang diperlukan.
Co-Authors Adham, Yunan Amalia, Isnaini Athiyyah, Hanifatul Daniel Happy Putra Dewi, Deasy Rosmala Faiha, Hana Fandhika, Lilin Tata Happy Putra , Daniel Indawati, Laela Luthfiah Aulia Rachman Magdalena, Selvy Mufida, Melani Aulia Muniroh, Muniroh Nur Mawaddah, Nur Nurfena, Deta Nurfena Rahmawati, Rena Maulina Ramadhana, Nur Fatihah Adlia Rosita, Annida Ulfiar Rosmala Dewi, Deasy Rumana, Nanda Sabina, Diva Safitri, Dinda Melani Seastama, Komang Cyntia Noviari Sonia, Dina Surlialy, Dewi Tri Putra, Iqbal Trideswira Usman, Nadia Salim Bin Viatiningsih, Wiwik Vitianingsih, Wiwik Widjaja, Lily Widjaya, Lily Yulia, Noor