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All Journal Jurnal Rekam Medis dan Manajemen Informasi Kesehatan PELS (Procedia of Engineering and Life Science) Indonesian Journal of Health Information Management Services (IJHIMS) JURNAL KESEHATAN, SAINS, DAN TEKNOLOGI (JAKASAKTI) Jurnal manajemen informasi kesehatan
Budiarti, Anggia
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Agriculture, Biological Sciences & Forestry Biochemistry, Genetics & Molecular Biology Chemistry Computer Science & IT Control & Systems Engineering Decision Sciences, Operations Research & Management Electrical & Electronics Engineering Engineering Health Professions Medicine & Pharmacology Public Health Social Sciences

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Gambaran Kelengkapan Informasi Medis Dan Keakuratan Kode Diagnosis Di Rumah Sakit Bhayangkara Bengkulu Harmanto, Deno; Budiarti, Anggia; Herisandi, Ari
Jurnal Manajemen Informasi Kesehatan (Health Information Management) Vol. 7 No. 2 (2022): Health Information and Management
Publisher : Sekolah Tinggi Ilmu Kesehatan Sapta Bakti

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.51851/jmis.v7i2.369

Abstract

Medical records must contain medical data that describes in detail all aspects of patient care that occur. Hospital Minimum Service Standard Completeness of medical record filling 24 hours after completion of service is 100%. Incomplete medical record filling describes the health services provided and the quality of medical record services. Incomplete medical record documents will make it difficult for officers to recognize the patient's medical history and claims to insurance companies. The aim is to find out the description of the completeness of inpatient medical information on the accuracy of the ICD-10 based diagnosis code at Bhayangkara Hospital Bengkulu. The research method used was descriptive research, namely collecting data by direct observation of the research object. The sample in this study consisted of 83 inpatient medical record files. Results: Of the 83 inpatient medical record files, 42 sheets were filled out in the Anamnesa sheet with the percentage (51%) not filled in completely, laboratory examination results totaling 36 sheets with the percentage (44%) not filled out completely, the medication record sheet was more than partial totaling 46 sheets with a percentage (55%) not filled in completely, and writing patient diagnoses, namely more than a portion of 49 sheets with an unclear percentage (59%).
Completeness of Cataract Medical Information Supports the Accuracy of RME Based Diagnosis and Action Codes at RS.X Heltiani, Nofri; Agusianita; Budiarti, Anggia
JURNAL KESEHATAN, SAINS, DAN TEKNOLOGI (JAKASAKTI) Vol. 4 No. 3 (2025): JURNAL KESEHATAN, SAINS, DAN TEKNOLOGI (JAKASAKTI)
Publisher : LPPM Universitas Dhyana Pura

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.36002/js.v4i3.5006

Abstract

The completeness of visual acuity (visual acuity) examination results, the completeness of slit lamp examination results, and the accuracy of diagnosis are very important in supporting the accuracy of diagnostic codes and action codes. The initial survey results of 10 e-RMs obtained 6 (60%) accurate and 4 (40%) inaccurate. This is because the results of the visual acuity examination and slit lamp examination are incomplete, resulting in inaccurate diagnostic codes and action codes that impact the quality of data, information, and reports, as well as the accuracy of INA-CBG's rates, which can result in a decrease in the quality of hospital services. This study aims to determine the accuracy of cataract diagnosis and treatment codes based on the completeness of e-RM-based medical information at Hospital X. This type of study is an observational study with a quantitative descriptive design. The study population was 548 e-RMs, with a sample of 85 e-RMs taken by simple random sampling. This study uses secondary data measured by observation sheets, and then the data is processed and analyzed univariately using frequency distribution. The results of this study obtained completeness of visual acuity examination results of 74 (87%), completeness of slit lamp examination results of 77 (91%), accuracy of diagnosis codes of 79 (93%), and accuracy of action codes of 72 (85%). The need to conduct periodic control of the completeness of medical information through medical record audits, establish communication if there is an inaccurate diagnosis, and improve coder skills through coding classification training.
Co-Authors Agusianita Agusianita, Agusianita Ayu, Dinda Evendy, Nova Gufran, Azmi Harmanto, Deno Heltiani, Nofri Herisandi, Ari Nopriza, Eke Rahayu, Dinda Sri Sri Rahayu, Dinda