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Faktor Penyebab Ketidakakuratan Kode Diagnosis Penyakit Pasien Rawat Inap Di Rumah Sakit X SURYANDARI, ENDANG SRI DEWI HASTUTI; Setyawati, Fitri Eka; Gunawan; Sangkot, Hartaty Sarma; Wijaya, Avid
Jurnal Kesehatan Qamarul Huda Vol. 12 No. 2 (2024): Desember 2024
Publisher : Universitas Qamarul Huda Badaruddin

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37824/jkqh.v12i2.2024.645

Abstract

The activity of coding disease diagnosis was an important activity for preparing internal and external hospital reports, planning and managing hospitals and determining hospital service rates. Based on observations of 10 files samples from inpatients at Hospital X, 2 files were found with inaccurate disease codes (20%). The aim of the research was to identify factors that cause inaccurate disease codes for patients treated at RS X. The research method used a mixed method with retrospective approach by combined quantitative and qualitative research. The sample analyzed were 100 files inpatients for the period December 2022 using a simple random sampling by lottery and 2 coders as respondents. The results showed that 82% of the diagnosis codes were accurate and 18% of the diagnosis codes were inaccurate. The factors causing inaccurate diagnosis codes at Hospital X were lack of knowledge in coding and 1 officer had never attended coding training (man factor); lack of socialization of coding SOPs which contain explanations of the use of ICD 10 as a reference in codification (method factor); there was no ICD 10 Volume 2 version for 2010 (material factor); and lack of financial support for coding training activities for officers and procurement of ICD 10 volume 2 version for 2010 (money factor). There was a need to increase knowledge and skills in codification through coding training activities for officers, carrying out revisions and socialization regarding coding SOPs and procurement of ICD 10 volume 2 to increase the accuracy of diagnosis codes.
Analisis Keakuratan Kode Diagnosis Penyakit Bronchitis berdasarkan ICD-10 di Rumah Sakit Wava Husada Kamilah, Safrina Rosa; Suryandari, Endang Sri Dewi Hastuti
Jurnal Kesehatan Qamarul Huda Vol. 13 No. 1 (2025): Juni 2025
Publisher : Universitas Qamarul Huda Badaruddin

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37824/jkqh.v13i1.2025.737

Abstract

Pelaksanaan pengkodean diagnosis harus dilakukan dengan akurat. Berdasarkan hasil studi pendahuluan di Rumah Sakit Wava Husada terhadap 14 DRM rawat inap penyakit bronchitis periode Januari – Juli Tahun 2024, diperoleh 11 DRM dengan kode akurat (78,6%) dan 3 DRM dengan kode tidak akurat (21,4%). Penelitian ini bertujuan untuk mengetahui keakuratan kode diagnosis penyakit bronchitis berdasarkan ICD-10 di Rumah Sakit Wava Husada. Metode yang digunakan dalam penelitian ini adalah metode deskriptif kuantitatif dengan pendekatan retrospektif. Populasi pada penelitian ini adalah dokumen rekam medis rawat inap penyakit bronchitis periode Januari – Juli 2024 sebanyak 249 DRM. Sampel yang digunakan sebanyak 71 DRM dengan teknik pengambilan sampel simple random sampling. Instrumen yang digunakan adalah lembar checklist SOAP. Analisis data yang dilakukan dengan analisis univariat. Hasil observasi terhadap 71 DRM menunjukkan kode diagnosis yang akurat yaitu sebanyak 55 DRM (77%) dan kode diagnosis yang tidak akurat sebanyak 16 DRM (23%). Klasifikasi ketidakakuratan kode diagnosis penyakit Bronchitis disebabkan karena kesalahan pemberian kode sebanyak 15 DRM (94%) dan kesalahan pada karakter ke-4 sebanyak 1 DRM (6%). Perlunya pelatihan kodifikasi bagi petugas coding serta diharapkan lebih teliti dalam menganalisis seluruh informasi medis pasien, untuk meningkatkan keakuratan kodifikasinya.
Hubungan Antara Kadar Hormon Dengan Perdarahan Di Luar Siklus Menstruasi Pada Wanita Usia Subur ningsih, sri mudayati; Suryandari, endang sri dewi hastuti
Care : Jurnal Ilmiah Ilmu Kesehatan Vol 12, No 1 (2024): EDITION MARCH 2024
Publisher : Universitas Tribhuwana Tunggadewi

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33366/jc.v12i1.5700

Abstract

Bleeding disorders outside the menstrual cycle are reproductive system disorders commonly experienced by women during their reproductive years. These disorders are characterized by changes in menstrual periods, including alterations in cycle length, duration of menstruation, or volume of bleeding, with a worldwide prevalence ranging from 3% to 30%. Hormonal factors are often implicated as causes of bleeding disorders outside the menstrual cycle. Preliminary findings from a study conducted at RSIA Puri revealed that three female patients seeking treatment experienced bleeding disorders outside the menstrual cycle, with two of them exhibiting low estrogen levels (below 20 pg/ml) upon examination. The purpose of this study was to analyze the relationship between hormone levels, particularly estrogen, and bleeding outside the menstrual cycle in women of childbearing age at RSIA Puri Malang. The research employed a quantitative analysis through a cross-sectional approach. Primary and secondary data were obtained from laboratory examinations of estrogen levels in blood serum on the third day of menstruation. The sample consisted of 34 mothers who met the criteria of experiencing menstrual disorders and visited RSIA Puri Malang, and who willingly participated as respondents, selected through quota sampling. Data analysis was conducted using the Chi-square test, and the results revealed a significant relationship between estrogen levels and bleeding outside the menstrual cycle, or metrorrhagia (p-value = 0.018; OR = 0.107). This suggests that estrogen hormone regulation plays a crucial role in preventing menstrual irregularities. In conclusion, maintaining optimal estrogen hormone levels is essential for preventing and managing menstrual irregularities and bleeding disorders outside the menstrual cycle.    
Hubungan Kelengkapan Informasi Medis Dengan Keakuratan Kode Diagnosis Penyakit Pada Dokumen Rekam Medis Rawat Inap di RSU Universitas Muhammadiyah Malang Tahun 2024 Suryandari, Endang Sri Dewi Hastuti; Syajidah, Almira Maryam; Zein, Eiska Rohmania
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Vol. 10 No. 2 (2025): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Agustus
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v10i2.1956

Abstract

The completeness of medical information such as the medical assessment sheet, examination results sheet, and medical resume sheet greatly influences the accuracy of the diagnosis code. This study aims was to determine the relationship between the completeness of medical information and the accuracy of disease diagnosis codes at the Muhammadiyah University of Malang Hospital. The research’s design was a quantitative analytical research with a Cross Sectional Study approach. The research population were 1134 inpatient medical records (MR). The sample used were 92 MRs using the systematic sampling technique. The independent variable was the completeness of medical information and the dependent variable was the accuracy of the disease diagnosis code. Data were collected through observation in the coding section and used checklist sheets. The outcome showed the completeness of medical information was 67% and the accuracy of disease diagnosis codes was 72%. The Chi Square test showed a relationship between the completeness of medical information and the accuracy of disease diagnosis codes in the inpatient MR at the University of Muhammadiyah Malang Hospital (p-value < 0.05). It is necessary to evaluate the completeness of filling in medical information in MR continuously to improve the accuracy of disease diagnosis codes.
KEAKURATAN KODEFIKASI DIAGNOSIS PENYAKIT SISTEM URINARIA DI RSUD KANJURUHAN Sukmawati, Febrianne Arum; Suryandari, Endang Sri Dewi Hastuti
Jurnal Informasi Kesehatan Indonesia (JIKI) Vol. 11 No. 2 (2025): Jurnal Informasi Kesehatan Indonesia
Publisher : Politeknik Kesehatan Kemenkes Malang

Show Abstract | Download Original | Original Source | Check in Google Scholar

Abstract

Keakuratan kode diagnosis penyakit sistem urinaria di RSUD Kanjuruhan belum mencapai 100%. Penelitian ini bertujuan untuk mengetahui keakuratan kode diagnosis penyakit sistem urinaria di RSUD Kanjuruhan. Jenis penelitian ini merupakan penelitian deskriptif kuantitatif dengan pendekatan retrospektif. Populasi yang digunakan sebanyak 303 DRM (Dokumen Rekam Medis) penyakit sistem urinaria periode Triwulan II 2024. Penentuan sampel menggunakan Simple Random Sampling, didapat sebanyak 75 DRM penyakit sistem urinaria. Instrumen penelitian menggunakan lembar checklist untuk mencatat hasil analisis keakuratan kode diagnosis yang tertera dalam DRM. Analisis data menggunakan analisis univariat. Hasil observasi terhadap 75 DRM menunjukkan kode diagnosis yang akurat yaitu sebanyak 38 DRM (51%) dan kode diagnosis yang tidak akurat sebanyak 37 DRM (49%) Hasil analisis berdasarkan 3 komponen keakuratan didapatkan, completeness dan validity masing-masing sebesar 56% dan reliability sebesar 51%. Perlu dilakukan pelatihan koding berkelanjutan dan peningkatan ketelitian petugas koding untuk meningkatkan keakuratan dalam melakukan kodefikasi diagnosis penyakit.
Relationship Between Satisfaction and Waiting Time in Polowijen Primary Health Care Malang Sangkot, Hartaty Sarma; Putri, Amalia Yunan; Pitoyo, Achmad Zani; Suryandari, Endang Sri Dewi Hastuti; Wijaya, Avid
Interest : Jurnal Ilmu Kesehatan Article in Press: INTEREST-Jurnal Ilmu Kesehatan
Publisher : Poltekkes Kemenkes Surakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37341/interest.v15i1.576

Abstract

Background: Patient satisfaction depends on the quality of service, service waiting time, and the efforts made by officers to fulfill patient desires with the services provided. Waiting time that is too long will cause dissatisfaction with the patient. This study aims to analyze the relationship between waiting time and patient satisfaction in the outpatient registration section of the Polowijen Primary Health Care (PHC).  Methods: This study used an analytic survey with a crosssectional approach. The population in this study were patients during August-October 6,214 people. The sample was calculated using the slovin formula of 100 people. The sampling technique uses quota sampling. Data analysis used the Chi-Square test. The waiting time at the Polowijen PHC registration section was > 10 minutes (not ideal) for 90 respondents (90%) and waiting time ≤ 10 minutes (ideal) for 10 respondents (10%). The level of patient satisfaction as many as 66 respondents (66%) felt very satisfied and 34 respondents (34%) felt satisfied.  Results: There is no relationship between waiting time and patient satisfaction at outpatient registration at the Polowijen PHC (p Value > 0.05).  Conclusion: As conclusion The waiting time obtained by patients > 10 minutes does not affect patient satisfaction. This happens because the Polowijen Health Center is the only health facility of choice for the patient, so waiting times that are not ideal do not affect patient satisfaction.
Co-Authors Akbar, Prima Soultoni Amalia, Salma Avid Wijaya Fristara Alintia Gunawan Gunawan . Hartaty Sarma Sangkot Kamilah, Safrina Rosa Mudayatiningsih, Sri Muttaqien, Anis Nurul Fataya ningsih, sri mudayati Pitoyo, Achmad Zani Putri, Amalia Yunan Rahayu, Afridyahwati Sangkot, Hartaty Sarma Setyawati, Fitri Eka Sukmawati, Febrianne Arum Susanti, Natalia Nur Syajidah, Almira Maryam Tanto Hariyanto Ulimaz Latifah Zein, Eiska Rohmania