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Physical Examination Results and Medical Supporting Evidence Affect the Accuracy of Pneumonia Diagnosis Codes in Hospitals Heltiani, Nofri; Arifin, Ismail; Khairunnisyah
Jurnal Manajemen Informasi Kesehatan (Health Information Management) Vol. 10 No. 1 (2025): 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.v10i1.743

Abstract

The Ministry of Health of the Republic of Indonesia, Decree No. HK.02.02/Menkes/514/2015, states that pneumonia is one of the diseases frequently leading to medical disputes, resulting in losses for hospitals. Based on an initial survey of 10 pneumonia medical records, five files contained missing supporting examination results (chest x-ray), two files contained incomplete physical examinations, and three files contained complete records (chest x-ray, physical examination), leading to doubts about the pneumonia diagnosis codes written in the medical records. This study aimed to determine the accuracy of pneumonia diagnosis codes by examining the results of physical examinations and medical support at Hospital X in 2024. This study was a quantitative descriptive study with a population and sample of 96 medical records of pneumonia cases. The data used in this study were primary and secondary data, using interview guidelines and observation sheets. The data were then processed and analyzed univariately using frequency distribution. The results of the study revealed that the completeness of the physical examination results and medical support was 38 (39%), the accuracy of the physical examination results and medical support was 35 (36%), and the accuracy of the pneumonia diagnosis code was 47 (49%). It is hoped that the Head of Medical Records will conduct a medical record audit through qualitative analysis to minimize the occurrence of medical disputes.
Perancangan Prosedur Kerja Rekam Medis Tebal (Volumenious Bulky) di RSKJ Soeprapto Provinsi Bengkulu Heltiani, Nofri; Arifin, Ismail
Jurnal Manajemen Informasi Kesehatan (Health Information Management) Vol. 7 No. 1 (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.v7i1.319

Abstract

Rekam medis volumenious bulkymerupakan salah satu permasalahan yang sering terjadi dipenyimpanan, dan keadaan dimana rekam medis pasien dengan penyakit tertentu yang rutinberobat jalan atau dirawat cukup lama dan rutin menjadi sangat tebal karena seluruh riwayatkesehatan pasien tersimpan dalam satu map rekam medis. Berdasarkan observasi di RSKJSoeprapto Provinsi Bengkulu ditemukan rekam medis volumenious bulky yang mengalamikenaikan setiap tahunnya ± 10% dengan tingkat ketebalan yang berbeda antara 3,7 s.d 4,5 cmpada masing-masing rekam medis dengan kodisi map rekam medis yang sudah mulai robekkarena tidak mampu menopang isi rekam medis. Hal ini dikarenakanpasien gangguan jiwarawat jalan yang sering kontrol rutin atau lama dirawat yang panjang dengan didukung masasimpan (retensi) aktif berkas rekam medis jiwa rawat jalan 10 tahun dan rawat inap 5 tahunmenyebabkan rekam medis mejadi tebal.RSKJ Soeprapto Provinsi Bengkulubelum memilikiprosedur kerja sebagai pedoman pengelolaan dan penyimpanan dalam rekam medisvolumenious bulky, sehingga berdampak pada kerusakan map rekam medis yang dapatmengakibatkan riwayat penyakit pasien yang bersangkutan bercecer/tidak utuh.Penelitian inibertujuan merancang prosedur kerja rekam medis volumenious bulky di RSKJ SoepraptoProvinsi Bengkulu. Jenis penelitian adalah deskriptif kualitatif dengan teknik pengumpulandata dilakukan secara observasi dan wawancara tentang proses pengelolaan rekam medisvolumenious bulky. Tahapan dalam penelitian ini meliputi tahap analisis, tahap perancangan,tahap testing dan tahap pemeliharaan prosedur kerja.Hasil penelitian adalah rancanganprosedur kerja rekam medis volumenious bulky sesuai dengan kebutuhan rumah sakit yaituprosedur kerja rekam medis volumenious bulky dengan penempatan bagian rekam medisterpisah.
Gambaran Pelaksanaan Analisis Kuantitatif Dan Kualitatif Berkas Rekam Medis Rawat Inap di RSUD Harapan dan Doa Kota Bengkulu Eki; lasmadasari, novi; arifin, ismail
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.v7i2.368

Abstract

Rsud Harapan dan Doa Kota Bengkulu is one of the hospitals that carries out patient services individually and plenary. One of them is patient services, especially in the medical records section. In their implementation in the assembling department, officers who conduct quantitative and qualitative analysis have not been carried out properly. Objective this study aims to find out an overview of the implementation of quantitative and qualitative analysis of inpatient medical record files at Rsud Harapan and Doa Kota Bengkulu. Method this type of research is descriptive quantitative with a cross sectional approach. The subjects of this study were 83 samples of medical record files for the period of June 2022 and the objects of the assembling department medical record officers as many as 4 people. The data used in this study are primary data that are processed univariately. Results: The implementation of quantitative and qualitative analysis of medical record files was only carried out by 3 (50%) procedure items from the 6 procedure items contained in the SOP; The completeness of the medical record file analyzed quantitatively as much as 32 (38.5%) complete and qualitatively analyzed as much as 54 (65%) complete; Medical record officers 100% have an educational background of D3 Medical Records; Medical record officers have good knowledge of 3 (75%) people in the implementation of quantitative and qualitative analysis of medical record
Literature Review: Utilization of Technology and Computerization in Smart Homes Arifin, Ismail; Dwi Cahya, Deni
SMART : Jurnal Teknologi Informasi dan Komputer Vol. 1 No. 1 (2022): January-June
Publisher : Gayaku Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.58222/sj.v1i1.1687

Abstract

The development of information technology and the Internet of Things (IoT) has brought significant changes to smart home systems. This article presents a literature review of five studies from accredited national and international journals that discuss the application of technology to smart homes between 2017 and 2022. The main focus includes system architecture, inter-device communication, automation, security, and energy efficiency. Based on the review results, the application of IoT technology and artificial intelligence (AI) plays a significant role in realizing smart homes that are efficient and adaptable to occupant needs. The main challenges lie in data security, system interoperability, and implementation costs. This study is expected to serve as a reference for researchers and practitioners in developing smart home innovations that are safer, energy-efficient, and user-friendly.