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Hubungan Kondisi Institusional dengan Niat Petugas untuk Menggunakan Rekam Medis Elektronik di Rumah Sakit X Adinda Mentari Nursya’bani; Daniel Happy Putra; Dina Sonia; Muhammad Fuad Iqbal
An-Najat Vol. 2 No. 3 (2024): AGUSTUS - An-Najat: Jurnal Ilmu Farmasi dan Kesehatan
Publisher : STIKes Ibnu Sina Ajibarang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.59841/an-najat.v2i3.1625

Abstract

The implementation of electronic medical record (EMR) in institutions that are ready will have a positive impact on its execution. Institutional readiness should be comprehensively assessed across various aspects, including human resources. Users are a key factor in determining the success of an information system. User feedback can serve as a consideration to maximize EMR implementation. However, this can sometimes be unpredictable due to numerous influencing factors, including institutional conditions. To explore the relationship between institutional conditions and the intention of healthcare providers to use EMR, a quantitative inferential study with a cross-sectional design was conducted at Hospital X. The study population consisted of 129 healthcare providers, with 91 data points processed as samples. Data were analysed using univariate and bivariate analyses with the Chi-Square test. Among the 91 analysed data points, institutional conditions were categorized as good (56%), intention to use EMR was high (56%), and use behaviour was high (82,4%). There was a significant relationship between institutional conditions and healthcare providers’ intention to use EMR, with a p-value of 0,001 < 0,05 and an Odds Ratio of 4,908.
Analisis Kualitatif Konsistensi Pencatatan Rekam Medis Rawat Inap Kasus Penyakit Dalam di Rumah Sakit Pelabuhan Jakarta Putri Nurindahsari; Dina Sonia; Lily Widjaja; Daniel Happy Putra
SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat Vol. 2 No. 4 (2023): Oktober 2023
Publisher : Yayasan Literasi Sains Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.55123/sehatmas.v2i4.2352

Abstract

Qualitative analysis is an activity that examines the filling of medical records for inconsistent and incomplete contents, which indicates that the medical records are inaccurate and incomplete. The purpose of this study was to find out a qualitative analysis of the reliability of recording medical records of inpatient cases of internal medicine for the year 2022. This type of research uses a descriptive method with a quantitative approach and data collection by observation and interviews. Of the 99 medical records, the results obtained were 96% consistent and 4% inconsistent. And the results of the 4 subcomponents include: At the time of admission, namely the consistency of the initial assessment of nurses and inpatient doctors, the results were 98% consistent. On the subcomponent during hospitalization, namely the consistency of progress notes between doctors and nurses, obtaining results of 99% consistency, Consistency of Doctor's Instructions with delivery notes the drug gets 93% consistent results, when going home, namely the consistency of the doctor's return summary and the nurse gets 94% consistency results. Of the 4 sub-components that have the highest consistency, the consistency between the doctor's and nurse's developmental records obtains 99% consistent results. While the lowest was the consistency of the Doctor's Instructions with a record of drug administration obtaining 93% consistent results. The conclusion is that the qualitative analysis of medical record recording is not 100% consistent. It is recommended that the Jakarta Harbor Hospital make standard operating procedures and implement related qualitative analysis of medical records.
Tinjauan Kelengkapan Rekam Medis Rawat Inap di Rumah Sakit Umum Daerah Kembangan Nabilah Khairunisa; Dina Sonia; Puteri Fannya; Noor Yulia
SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat Vol. 2 No. 4 (2023): Oktober 2023
Publisher : Yayasan Literasi Sains Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.55123/sehatmas.v2i4.2403

Abstract

The completeness of filling in the medical record can be checked using a documentation audit, one of which is quantitative analysis by reviewing certain parts of the contents of the medical record with the intention of finding deficiencies, especially those related to medical record documentation. The purpose of this study was to get an overview of the completeness of filling out inpatient medical records at the Kembangan Regional General Hospital. This research method uses a descriptive method with a quantitative approach. The population in this study were inpatient medical records at the Kembangan Regional General Hospital with a sample of 89 medical records. Based on the results of calculations using quantitative analysis obtained an average completeness of 82%, the highest completeness is the patient identification component of 87% and the lowest completeness is the important reporting component of 76%. Based on the research that has been done, it can be concluded that filling in the medical record at the Kembangan Regional General Hospital is not complete, this is due to the lack of awareness of health workers to complete filling in the medical record so that it has an impact on incomplete filling in medical record files
Tinjauan Penyebab Pengembalian Berkas Klaim Biaya Pelayanan Pasien Rawat Inap BPJS Kesehatan di Rumah Sakit Pelabuhan Jakarta Tahun 2022 Siti Rahmawati Handayani; Lily Widjaja; Daniel Happy Putra; Dina Sonia
SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat Vol. 2 No. 4 (2023): Oktober 2023
Publisher : Yayasan Literasi Sains Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.55123/sehatmas.v2i4.2617

Abstract

In the process of submitting a BPJS Health Claim, some requirements must be completed by the Health Facility. Of these requirements, the BPJS Health party will know that the claim submission can be paid or returned/delayed. This research was conducted to find out the reasons for returning the claim file for BPJS Kesehatan inpatient care at the Jakarta Harbor Hospital in 2022. The method in this study used descriptive research with a quantitative approach. The results of the study were 118 samples (6.7%) of 1,762 files, the highest returned cause was an inaccuracy in the coding of diagnoses/actions of 49 (42%), and the second highest was not fulfilling inpatient administration 18 (15%), other causes - others as much as 51 (43%). 3 factors from 5M are the cause of returning claim files, namely the human factor: casemix officers who are not diligent, lack of coder understanding/knowledge, and lack of accuracy in the filing department so that files are missed/left behind, machine: there is an upgrade to the latest version of the INA-application CBGs and V-Claim are also the Ministry of Health's newest program which requires TB patients to be inputted into the SITB application, Material: incomplete claim requirements files. While the money and method factors are not an obstacle or a cause for returning claim files. It is recommended to evaluate and re-socialize the reasons for returning BPJS Health claims so that the process of submitting BPJS Health claims is carried out properly and is 100% accepted.
Tinjauan Ketepatan Kode Diganosis Tuberkulosis Paru Pasien Rawat Jalan di Rumah Sakit SHL Pandeglang Rahelia Putri; Lily Widjaja; Dina Sonia; Daniel Happy Putra
SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat Vol. 3 No. 2 (2024): April 2024
Publisher : Yayasan Literasi Sains Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.55123/sehatmas.v3i2.3423

Abstract

In coding activities, medical recorders and health information are needed who master how to give disease codes according to ICD-10 and actions according to ICD-9 CM so that the resulting code has accuracy according to the diagnosis or action given. One of the most frequently used coding accuracy is accuracy in coding for Pulmonary Tuberculosis. One of the important things is how to describe the accuracy of the Outpatient Pulmonary Tuberculosis diagnosis code at SHL Pandeglang Hospital. This study was shown to determine the accuracy of the diagnosis code for Outpatient Pulmonary Tuberculosis at SHL Pandeglang Hospital. This research method uses a descriptive method with a quantitative approach. The sample of this study was taken by saturated sampling technique. Data were taken using interviews and observations. The results of the study of 122 medical records obtained accuracy of 93 (76.2%) files and inaccuracy of 29 (23.8%) files. Based on the identification of factors causing the inaccuracy of the diagnosis code, there are 4 factors, namely the man factor: occurs due to the lack of accuracy of the coder in coding, the workload of the coder, and the lack of training for coders with non-RMIK backgrounds. Material factors: the unavailability of the Medical Dictionary (Dictionary of Medical Terminology) and the absence of an abbreviated list of diagnoses (standard). Machine factors: damage to the computer, software hangs, and computers that are too old. Method factor: incomplete SPO diagnosis coding.
KINERJA KARYAWAN DAN KEPEMIMPINAN: SUATU STUDI LITERATUR Anisa Nurjulaeni; Chika Putri Nur Adila; Danang Nugroho; Dina Sonia; I made Dharma Farellio; Mochamad Ladi Maulana
JURNAL RUMPUN MANAJEMEN DAN EKONOMI Vol. 1 No. 2 (2024): Mei
Publisher : CV. KAMPUS AKADEMIK PUBLISHING

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.61722/jrme.v1i2.1225

Abstract

The role of a leader in influencing his subordinates through leadership supports the success of a company. If a leader cannot talk to his employees, it will have a negative impact on their performance and the company. As a result, critical messages will be less accepted by employees, the communication atmosphere will become more defensive, and ultimately will hinder organizational performance. Studies show that effective leadership drives organizational success because it can increase motivation, discipline and productivity. Leadership and employee performance are closely related. This includes that leadership that is able to protect employees while working is able to improve their performance in accordance with company goals.
Identifikasi Penyelenggaraan Rekam Medis Elektronik pada Klinik Penyakit Dalam di RSUD Kembangan Syahrul Dwi Ramadhani; Noor Yulia; Puteri Fannya; Dina Sonia
Quantum Wellness : Jurnal Ilmu Kesehatan Vol. 1 No. 2 (2024): Juni: Quantum Wellness : Jurnal Ilmu Kesehatan
Publisher : Lembaga Pengembangan Kinerja Dosen

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.62383/quwell.v1i2.251

Abstract

The rapid development of information technology has penetrated into various sectors of life, including in the health sector, which has also had an impact on the development of computer-based medical record systems. The purpose of this study was to determine the implementation of Electronic Medical Records at the Internal Medicine Clinic at Kembangan Hospital. The research method uses descriptive methods with qualitative analysis on 10 informants by means of observation and interviews which will provide an overview and see directly a situation when the use of electronic medical records is carried out. The results showed that the hospital already had an SOP for filling in electronic medical records, which was not implemented according to what the officers did. The use of Electronic Medical Records, especially in the Internal Medicine Polyclinic, has gone well. Constraints from 5M Factor, namely Man, there are still registration officers who are incomplete or incorrect in filling in patient identity data, PPA (Professional Caring Provider) is incomplete in filling in patient diagnoses, Internet network material is sometimes slow, and the server is sometimes down, user complaints include display is less efficient, when filling. It is suggested to the Medical Record Unit, IT team and hospital management to evaluate the SOP, revise and socialize it in order to reduce the human error factor. Kembangan Hospital needs to improve the appearance of SIMRS Khanza to make it more attractive so as to increase the enthusiasm of the officers in inputting medical record data at SIMRS. Kembangan Hospital should improve network quality in the hospital environment to improve the performance of SIMRS.
Pengaruh Kompetensi PMIK Terhadap Kinerja Petugas Rekam Medis Di Rumah Sakit Angkatan Udara Dr. Esnawan Antariksa Armila Astiyana Triadi; Dina Sonia; Puteri Fannya; Noor Yulia
Vitamin : Jurnal ilmu Kesehatan Umum Vol. 2 No. 2 (2024): April : Jurnal ilmu Kesehatan Umum
Publisher : Asosiasi Riset Ilmu Kesehatan Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.61132/vitamin.v2i2.362

Abstract

This research was conducted with the aim of determining the influence of PMIK (Medical Recorder and Health Information) professional competence on the performance of medical record officers at the Dr. Air Force Hospital. Esnawan Antariksa. The research method used is quantitative with inferential analysis. The data collection techniques used were observation, interviews and questionnaires. The sampling technique used a total saturated sampling technique of 14 people. Obtained from 7 PMIK competency standard indicators (Noble Professionalism, Ethics and Legal, Introspection and Personal Development, Effective Communication, Health Data and Information Management, Clinical classification skills, Disease coding and other Health Problems as well as Clinical Procedures, Health Statistics Applications, Basic Epidemiology, and Biomedicine, Management of Medical Records Services and Health Information, there are still 2 indicators in the percentage that are not good, and in the 5 performance indicators of medical record officers (Quality of Work, Quantity of Work, Supervision, Attendance, Conservation) there are still 2 indicators in the percentage not good. It was found that 3 officers had a D-III RMIK education and 11 officers still had a high school education. Based on the results of the T test, it was found that the Sig. value was 275. It could be concluded that there was no influence of PMIK competency on the performance of medical records officers.
Analisis Ketepatan Kode Diagnosis Penyakit Tuberkulosis Paru Pasien Rawat Inap Di RSIJ Cempaka Putih Elsa Chandra Gita; Lily Widjaja; Daniel Happy Putra; Dina Sonia
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.11070313

Abstract

Dampak dari ketidakakuratan kode diagnosis adalah menurunnya kualitas pelayanan rumah sakit, pembayaran klaim tarif INA-CBG’s yang akan menghambat pembayaran, ketidakakuratan angka kesakitan, kematian, dan laporan statistik rumah sakit. Penelitian dilakukan di RSIJ Cempaka Putih. Tujuan dari penelitian ini adalah untuk mengidentifikasi SPO penyakit dan kode tindakan, menganalisis keakuratan kode diagnosis penyakit tuberkulosis paru pada pasien rawat inap, dan mengidentifikasi penyebab ketidakakuratan kode diagnosis penyakit tuberkulosis paru pada pasien rawat inap. Metode penelitian yang digunakan adalah metode deskriptif dengan pendekatan kuantitatif. Populasi berjumlah 658 rekam medis dengan sampel sebanyak 96 rekam medis. Sampel ditentukan dengan menggunakan rumus slovin. SPO untuk diagnosis dan pengkodean tindakan secara umum telah berjalan. Hasil penelitian menunjukkan terdapat 46 rekam medis (48%) dengan kode diagnosa benar, 25 rekam medis (26%) salah digit ke 3, 20 rekam medis (21%) salah digit ke 4, 5 rekam medis (5%) dengan digit ke-3 dan ke-4 yang salah. Faktor penyebab tidak akuratnya kode diagnosis terdapat pada faktor manusia, dalam hal ini pembuat kode tidak memperhatikan keakuratan catatan yang merinci keakuratan pengkodean pada ICD-10. Faktor materi, belum tersedianya alat coding seperti kamus kedokteran dan buku ICD-10. Faktor metode, SPO belum menjelaskan secara spesifik langkah-langkah cara coding.
Factors for Selection of Medical Records and Health Information Study Programs for New Students at Universitas Esa Unggul, Jakarta, Indonesia Dewi, Sisilia Kartika; Nanda Aula Rumana; Dina Sonia; Lily Widjaja
Arkus Vol. 10 No. 1 (2024): Arkus
Publisher : HM Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37275/arkus.v10i1.406

Abstract

University is one of the educational facilities in order to equip oneself with the knowledge and skills needed to face the future. There are several factors that underlie prospective students in determining the major they want to enter at university. This study aimed to describe the factors for selecting a medical records and health information study program for new students at Universitas Esa Unggul, Jakarta, Indonesia. This research is a descriptive observational study. The inclusion criteria for this research were new students from the Universitas Esa Unggul medical records program class of 2023 who were willing to take part in this research process. The research subjects were carried out using proportional random sampling techniques. A total of 129 students participated in this research. Data collection was carried out using a questionnaire. The study results showed that most of the students were teenagers (58.1%) and women (67.4%) and chose the regular program (76.7%). The highest factors influencing new students' decisions are accreditation (university image) (90.31%) and employment availability (89.73%), while the lowest is the interest factor, namely the dream of becoming a medical recorder (76.16%). In conclusion, the study program image factor (accreditation) is the underlying factor in selecting a medical records and health information study program for new students at Universitas Esa Unggul, Jakarta, Indonesia.