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Optimalisasi Pengelolaan Visum et Repertum melalui Penerapan Sistem Informasi Berbasis Web dengan Fitur Tracking Status bagi Petugas Rekam Medis di RSUD Cicalengka Syifa Qolbiyah; Adhita Arif Setyawan; Sali Setiatin
Jurnal Pengabdian Masyarakat dan Penelitian Terapan Vol. 4 No. 3 (2026): Jurnal Pengabdian Masyarakat dan Penelitian Terapan (Juli - September 2026)
Publisher : Greenation Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.38035/jpmpt.v4i3.2293

Abstract

Visum et Repertum merupakan dokumen medis-yuridis yang berfungsi sebagai alat bukti dalam proses peradilan. Di RSUD Cicalengka, pengelolaannya masih dilakukan secara manual menggunakan berkas fisik sehingga sering terjadi keterlambatan dan petugas rekam medis kesulitan memantau perkembangan dokumen secara real-time. Penelitian ini merancang Sistem Informasi Visum et Repertum berbasis web yang dilengkapi fitur tracking status internal dengan tahapan Diterima, Proses, dan Selesai. Penelitian menggunakan pendekatan deskriptif kualitatif melalui observasi, wawancara, dan studi dokumentasi, sedangkan pengembangan sistem menerapkan metode Waterfall. Pengujian dilakukan menggunakan Black Box Testing dan menunjukkan bahwa seluruh fungsi sistem berjalan sesuai kebutuhan operasional. Sistem yang dikembangkan diharapkan mampu meningkatkan efisiensi pengelolaan data Visum et Repertum serta mendukung integrasi dengan sistem informasi rumah sakit pada masa mendatang.
Implementasi Sistem Pengarsipan Dokumen Klaim Jasa Raharja Berbasis Web di Rumah Sakit Dustira Nissa Nurfadilah; Sali Setiatin; Adhita Arif Setyawan
Dinasti Information and Technology Vol. 4 No. 1 (2026): Dinasti Information and Technology (July - September 2026)
Publisher : Dinasti Research & Yayasan Dharma Indonesia Tercinta (DINASTI)

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.38035/dit.v4i1.3749

Abstract

Pengelolaan serta pengarsipan dokumen klaim Jasa Raharja berperan krusial dalam administrasi rumah sakit, terutama pada proses verifikasi dan penyimpanan arsip. Hasil observasi di Rumah Sakit Dustira menunjukkan adanya kendala berupa belum tersedianya sistem pengarsipan internal, kesulitan dalam pencarian dokumen, serta kurangnya integrasi antara data pasien dengan dokumen klaim. Rumusan masalah penelitian ini yaitu bagaimana merancang sistem pengarsipan berbasis web yang mampu mengatasi kendala pencarian, integrasi, dan risiko kehilangan arsip. Tujuan penelitian ini mengimplementasikan sistem pengarsipan dokumen klaim Jasa Raharja berbasis web, yang efektif, terstruktur, dan mudah diakses. Metode pengembangan yang digunakan adalah Rapid Application Development (RAD) dengan tahapan perencanaan kebutuhan, desain sistem, pengembangan, dan implementasi. Data penelitian dikumpulkan melalui observasi, wawancara, dan studi pustaka. Hasil penelitian berupa sistem yang mampu mengelola data pasien, data klaim, penyimpanan arsip digital, pencarian dokumen, serta laporan klaim otomatis. Implementasi sistem ini meningkatkan efisiensi, mempercepat pencarian dokumen, dan mengurangi risiko kehilangan data. Saran untuk penelitian adalah perlunya sosialisasi, pelatihan staf, serta pengembangan integrasi dengan sistem informasi rumah sakit secara menyeluruh.
Systematic Literature Review Tentang Keakuratan Pengkodean Diagnosis Berdasarkan ICD-10 Pada Rekam Medis Ghazi Septiandi; Sali Setiatin
Barongko: Jurnal Ilmu Kesehatan Vol 5 No 1 (2026): Barongko : Jurnal Ilmu Kesehatan (November)
Publisher : Asosiasi Guru dan Dosen Seluruh Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.59585/bajik.v5i1.1534

Abstract

This study aims to analyze the accuracy of diagnosis coding based on the International Classification of Diseases Tenth Revision (ICD-10) in medical records using a Systematic Literature Review approach. Accurate diagnosis coding is essential for producing reliable health information and supporting healthcare services. Literature was collected from Google Scholar, GARUDA, and Open Journal System (OJS) databases for articles published between 2022 and 2025. The selection process followed the PRISMA 2020 guidelines, resulting in 20 eligible articles. Data were analyzed descriptively through identification, comparison, and synthesis of the selected studies. The findings showed that diagnosis coding accuracy remains suboptimal. The main factors affecting coding accuracy were the completeness of medical documentation, the accuracy of physicians' diagnosis documentation, and the competence of medical record coders. These findings suggest that improving medical documentation, providing regular ICD-10 coding training, implementing standard operating procedures, conducting coding audits, and applying the WHO ICD-10 guidelines consistently are essential for improving diagnosis coding accuracy. Overall, diagnosis coding accuracy is influenced by several interrelated factors that require continuous improvement to support the quality of health information.
Tinjauan Faktor yang Mempengaruhi Transisi Rekam Medis Manual ke Rekam Medis Elektronik Menuju Integrasi SATUSEHAT Erlan Apriyanto; Sali Setiatin
Jurnal Riset Sains dan Kesehatan Indonesia Vol. 3 No. 4 (2026): Juli-Agustus
Publisher : CV. Science Tech Group

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.69930/jrski.v3i4.901

Abstract

Transisi rekam medis manual ke Rekam Medis Elektronik (RME) merupakan upaya penting dalam meningkatkan mutu pelayanan kesehatan serta mendukung integrasi data kesehatan nasional melalui platform SATUSEHAT. RSU Avisena menghadapi berbagai tantangan dalam pelaksanaan transisi tersebut. Penelitian ini bertujuan untuk meninjau faktor yang memengaruhi transisi dari rekam medis manual ke RME dalam rangka kesiapan integrasi SATUSEHAT di RSU Avisena. Penelitian ini memakai pendekatan deskriptif kualitatif melalui wawancara dan observasi terhadap sepuluh orang informan penting. Hasil penelitian menunjukkan bahwa kesiapan sumber daya manusia, infrastruktur teknologi informasi, dukungan dan kebijakan manajemen, kesiapan organisasi, serta keamanan dan kerahasiaan data merupakan faktor utama yang memengaruhi keberhasilan implementasi RME. Selain itu, pemahaman dan penerimaan tenaga kesehatan terhadap RME turut menentukan efektivitas penerapan dan integrasi dengan SATUSEHAT. Penelitian ini menyimpulkan bahwa transisi RME dan integrasi SATUSEHAT memerlukan perencanaan matang, pelatihan berkelanjutan, serta komitmen manajemen yang kuat.
Analysis of the Conformity of Patient Visit Data for Cardiac Cases Based on PTMKJ Reports at Santosa Hospital Bandung Central Muhammad Fauzi Rachmatullah; Sali Setiatin
International Journal of Health Sciences Vol. 4 No. 3 (2026): IJHS : International Journal of Health Sciences
Publisher : Asosiasi Guru dan Dosen Seluruh Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.59585/ijhs.v4i3.1668

Abstract

Accurate hospital reporting depends on consistency between source medical-record data and compiled statistical reports. During implementation of the Non-Communicable Diseases and Mental Health report (Penyakit Tidak Menular dan Kesehatan Jiwa; PTMKJ), discrepancies were identified between reported cardiac-case visits and the corresponding medical-record data at Santosa Hospital Bandung Central. This study aimed to analyze the conformity of cardiac patient visit data in PTMKJ reports with medical-record data during the first quarter of 2026 and to identify factors associated with discrepancies based on observations in the Medical Records Unit. A descriptive quantitative design was used. The study applied total sampling to all recorded visits for coronary heart disease and heart failure during the study period. Data were collected through document review by comparing PTMKJ reports with medical-record visit data and were processed using Microsoft Excel to calculate differences and conformity percentages. A total of 5,510 medical-record visits were analyzed. Overall data conformity reached 95.11%, while non-conformity was 4.89%. Monthly conformity was 94.49% in January, 98.92% in February, and 91.60% in March. Observations indicated that discrepancies were associated with delays in diagnosis coding, a high volume of patient visits relative to available coding staff, data-extraction timing, recapitulation processes, and subsequent data updates. Strengthening verification, coordination, and timely completion of diagnosis coding is therefore necessary to improve PTMKJ reporting quality.
IMPLEMENTASI PENGGUNAAN MEDIA PEMBELAJARAN BERBASIS AUDIO VISUAL DALAM PRESENTASI FINANCIAL SOFT SKILL DI SMP NASIONAL BANDUNG Wahyu Trimasuti; Sali Setiatin; Santy Christinawati; Rita Zulbetti
Jurnal Ilmiah Hospitality Vol 11 No 2: Desember 2022
Publisher : Sekolah Tinggi Pariwisata Mataram

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.47492/jih.v11i2.2341

Abstract

This study aims to determine the implementation of the use of audio-visual-based learning media in the presentation of financial soft skills at the Bandung National Junior High School. The number of participants who took part in the financial soft skills activities at the Bandung National Junior High School were 31 students. This type of research is descriptive qualitative research. The research data were collected by several techniques, namely observation, interviews and documentation. The triangulation technique is carried out by the triangulation method, namely by re-checking the information from interviews with documentation and observation. This study found that the use of audio-visual-based learning media in the presentation of financial soft skills at the Bandung National Junior High School has many advantages; 1) Students do not get bored quickly and enthusiastically in learning; 2) To improve students' understanding; 3) To increase students' learning motivation, and 4) Learning can be achieved well. Suggestions that can be used as input, one of which is for teachers. Researchers suggest teachers to always improve their creativity in finding ways that can be used to adjust students in the classroom.
Evaluation of the Implementation of Electronic Medical Records (EMR) in SIMRS Morbis at Hospital X Using HOT-Fit Method Sali Setiatin; Hanadia Maheswari
International Journal of Psychology and Health Science Vol. 3 No. 3 (2025): International Journal of Psychology and Health Science (July - September 2025)
Publisher : Greenation Publisher & Yayasan Global Research National

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.38035/ijphs.v3i3.1035

Abstract

Evaluation of the implementation of Electronic Medical Records (EMDR) in the Hospital Management Information System (SIMRS) is crucial to ensure the effectiveness of health services. This study examines the implementation of EMR in SIMRS MORBIS at Hospital X. The purpose of the study was to evaluate the success of the implementation using the HOT-Fit model by analyzing the Human, Organizational, Technology, and Net Benefit aspects. The research method used a quantitative approach by distributing HOT-Fit -based questionnaires to SIMRS MORBIS users, and the data was analyzed descriptively. The results showed a successful implementation of the human component (average score of 3.95) showing high adoption and satisfaction, the organizational component (3.85) was supportive but internal communication needed to be improved, the technology component (3.58) had good information quality, but system quality needed attention and significant Net Benefit (3.83-3.91) was achieved in efficiency and service quality. It was concluded that the implementation of EMR in SIMRS MORBIS at Hospital X was generally successful and had a positive impact, but optimization of the system quality and internal communication of the organization was needed to improve overall performance.
Evaluatio of Outpatient Icd-10 Code Variations in the Mtbs Room of the Cinagara Health Center Bhakti Ramadhan Mileniawan; Sali Setiatin; Heri Rukmana
International Journal of Psychology and Health Science Vol. 3 No. 3 (2025): International Journal of Psychology and Health Science (July - September 2025)
Publisher : Greenation Publisher & Yayasan Global Research National

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.38035/ijphs.v3i3.1060

Abstract

This study aims to evaluate the variation in the use of International Classification of Diseases 10 (ICD-10) codes in the diagnosis recording of outpatient patients in the Integrated Management of Childhood Illness (IMCI) room of the Cinagara Public Health Center. This research employed a descriptive quantitative method with a cross-sectional approach. Data collection was carried out through observation of outpatient medical records from January to December 2024. The study sample included all medical records that met the inclusion criteria. The results showed variations in the use of ICD-10 codes, with a coding accuracy rate of 78.5%. The highest variations were found in the diagnosis of acute respiratory infections (ARI) and diarrhea. Further analysis indicated that these discrepancies could affect the accuracy of morbidity and mortality data, as well as the planning and evaluation of health programs. Factors influencing coding variations include the lack of health workers' understanding of ICD-10, workload, and the availability of appropriate coding guidelines. This study recommends periodic training on ICD-10 coding, the provision of comprehensive coding guidelines, and a routine audit system to improve the quality of diagnosis coding in the MTBS room of the Cinagara Public Health Center. These efforts are expected to improve the quality of health data and facilitate more appropriate decision-making. This research provides an important contribution to efforts to improve the quality of medical record data and health information systems at the Public Health Center level. By understanding the root of the problem and implementing the recommendations provided, it is hoped that the Cinagara Public Health Center can improve efficiency and effectiveness in health services.
Analysis of the Accuracy of INA-CBG’s Coding for Medical Rehabilitation Outpatients to Facilitate BPJS Claims at Hospital X Sali Setiatin; Hesti Puspita Sari; Shinta Elvira
International Journal of Psychology and Health Science Vol. 3 No. 3 (2025): International Journal of Psychology and Health Science (July - September 2025)
Publisher : Greenation Publisher & Yayasan Global Research National

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.38035/ijphs.v3i3.1079

Abstract

The accuracy of diagnosis and procedure coding in the INA-CBG’s system is a key factor in the smooth submission of BPJS claims at hospitals. This study aims to analyze the relationship between the accuracy of coding and the validity of BPJS claims in medical rehabilitation outpatients at Hospital X. The method used is mixed methods with a sequential explanatory approach. The quantitative stage analyzed 2,216 patient claim files for January 2025 using the Chi-square test. Next, in-depth interviews were conducted with those responsible for managing outpatient claims to explore the causes of coding inaccuracies. The results show that 96.2% of files were coded correctly, 3.8% were coded incorrectly, and all are pending claims. The Chi-square test shows a significant relationship between coding accuracy and claim eligibility (p = 0.000). Qualitative findings revealed major obstacles in the form of differences in interpretation of coding, limited training in coding, and suboptimal hospital information systems. Regular training, improved coordination between units, and development of an electronic recording system in line with medical rehabilitation service needs are recommended. This study is expected to contribute to improving the quality of medical documentation and the effectiveness of health care financing through the INA-CBG’s claims system.
Analysis of Patient Data Security and Privacy in Electronic Medical Record Systems in Hospital X Sali Setiatin; Ervien Agus Jakaria; Nadia Rizki Pratami
International Journal of Psychology and Health Science Vol. 3 No. 3 (2025): International Journal of Psychology and Health Science (July - September 2025)
Publisher : Greenation Publisher & Yayasan Global Research National

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.38035/ijphs.v3i3.1275

Abstract

The development of digital technology has had a significant impact on the world of healthcare, especially in terms of patient data management, which is now turning to Electronic Medical Records (RME). RME is expected to be a mainstay solution to improve efficiency, accuracy, and ease of access to patient data between various health facilities. In Indonesia, the One Health Data initiative from the Ministry of Health plays a crucial role in this data integration process. However, the digitization of health information also raises new problems, especially related to the protection of sensitive patient personal data. This study aims to review the extent to which security and privacy aspects have been implemented in the RME system, particularly in Hospital X. This research uses a qualitative approach through observation, in- depth interviews, and document studies. The results of the study revealed that although the RME system is equipped with a simple authentication system using usernames and passwords, the security practices implemented are still less than optimal. There is still a lack of weak password use, a reluctance to change passwords periodically, and the absence of a special Standard Operating Procedure (SOP) that regulates the security and confidentiality of patient data. In addition, user awareness of the importance of protecting data is also still relatively low. These findings show that the successful implementation of RME does not only depend on the availability of technology, but also requires strengthening administrative policies and increasing understanding of cybersecurity among medical personnel. Therefore, a comprehensive strategy is needed to ensure the protection of patient data on an ongoing basis.
Co-Authors Abdul Wahab Abdussalaam, Falaah Achmad Alwan Alfarisi Adhita Arif Setyawan Adilla Salsabila Ahmad Fatoni Dwi Julian Ahmad Fatoni Dwi Julian Ai Susi Susanti Aldi Miftahul Rizal Alfarisi, Achmad Alwan Alfarizi, Fikri Ainta Ali Amirudhin Amalia, Melda Amirudhin, Ali Andini Kusdiantini Andira Putra, Sabila Andzara Aulia Aneu Rahma Tunisa Anggi Bela Larita Anisa Nuraulia Annisa Khoifah M Anusuci, Elia Arif Setyawan, Adhita Aris Susanto Aris Susanto Aris Susanto Aris Susanto Aris Susanto Susanto Asep Ma'mun Sanusi Aufa Luthfiyati Aqilah Aulia Nurfadillah Aulia Zeta Andhani Aulia, Andzara Ayu Septiyana Dewi Azizah, Vanny Hendriyan Bhakti Ramadhan Mileniawan Bhakti Ramadhan Mileniawan Bram Burmanajaya Candra Mecca Sufyana Chaedir Pratama Christinawati, Santy Cici Lara Widiya Desy Widyaningrum Dewi, Ayu Septiyana Dewi, Sofia Dian Mardiana Diansyah Dinda Nurul Lita Saptarini Dindin Solehudin Dita Alfiani Widi Saputri Edi Suharto Eka Rusmana, Wempi Elvira, Shinta Erlan Apriyanto Ervien Agus Jakaria Fadhilah, Saeful Fadila Amanda Faris Bastami, Muhamad Fauzi, Muhamad Rizal Fauzia, Rizky Miftah Fuji Sri Hartini Gema Giatsyal Akbar Sya Ghazi Septiandi Gunawan, Sandi Pebrian Hadi Priatmoko Hadiyanti, Rahma Suci Hafizan, Muhammad Ihsan Hakim, Nindia Shalsabillah Hanadia Maheswari Hanadia Maheswari Hendro Hendro Hera Siti Rohmah Herfiyanti, Leni Heri Rukmana Heri Rukmana Herlina Nur Yuniawati Hesti Puspita Sari Ihsan Marga Wiyaksa Indar Farwanti Wahyuni Isna Bidari Israwati Israwati Ivanna Rahmadita Johni S. Pasaribu Kusnadi, Fery Kusuma, Salma Aurellia Latifah, Fania Nazla Nur Latipah, Tania Lita Saptarini, Dinda Nurul Mahendra, Sandy Majdi, Faiq Muhammad Majiid, Nurul Salsasabilla Makaminan, Desviani Marwiyah, Hani Marya Asriadisa Nurobul Tabar Matoeari Soelistijaningroem Mayang Sari Ma’rifatulloh, Rizqi Melda Amalia Moh Arya Putra Ramadhan Muhamad Faris Bastami Muhamad Rizal Fauzi Muhammad Fauzi Rachmatullah Muhammad Ihsan Hafizan Muhammad Zahran Ramdhani Mutiara Cinta Sari Nadia Rizki Pratami Nadia Rizki Pratami Nadila Nur Umitri Nadya Muthiara Putri Naila Salsabila Jamilah Napitupulu, Sagita Noviana Narjati Soejoto, Nina Nina Agustina Ningrum, Intan Septiana Nissa Nurfadilah Norberta Ohoiwutun Novita Krisnawati Nugraha, R. Iqbal Taufik Nur, Ropina Hardian Nuraulia, Anisa Nurfadillah, Aulia Nurul Salsasabilla Majiid Ohoiwutun, Norberta Okky Nur Zahara Pinasti Intan Syafitri Pradesna, Syakira Ratu Prakarsa Al Qadr Saleh, Muhammad Pratama, Sergil Bhakti Purnama, Sandi Rian Putik Cinta Putri Aprilia Kartika Putri, Ismiati Malika Putri, Rizka Auliana Rachmawati, Ghaida Fauziyyah Rahma Aulia Rahma Suci Hadiyanti Rani Muharomah Ratna H, Yunyun Rd. Sekar Putri Defiyanti Rd. Sekar Putri Defiyanti Rena Novia Dewi Rena Resa Yusnia revi rosalinda Rini Suwartika Kusumadiarti Risa Juli Saputra Rita Zulbetti Rizka Auliana Putri Rizky Miftah Fauzia Ropina Hardian Nur rosalinda, revi Rosita Apriyanti Rosita Apriyanti Sabila Andira Putra Saeful Fadhilah Salma Salsabila Qurrotaaini Salwa Rizkiani Syah Sandi Pebrian Gunawan Sandra Laksamana Sandy Mahendra Santy Christinawati Santy Christinawati Sari, Hesti Puspita Sari, Mutiara Cinta Septiani Tri Utami Setiawan, Akbar Pratama Shinta Elvira Sinta Rizki Agustin Siti Insani Siti Lailatul Lutfiah Siti Solihah Soelistijaningroem, Matoeari Solihah, Siti Sri Nurcahyati SRI RAHAYU Surahman Surya Cahyadi Susanto, Aris Susanto Syakira Ratu Pradesna Syifa Qolbiyah Tania Latipah Tania Nurjanah Tasya Farida H Tausiah, Ai Lia Tiara Kusumawardani Trimasuti, Wahyu Tuti Herawati Utami, Septiani Tri Vanny Hendriyan Azizah Vina Anggilia Puspita Vira Farihah Aliansyah Wahyu Trimastuti Wahyu Trimasuti WIDDI SUKMA RAMADHANI Widia Nurrul Irsani Widya Nadiroh Winda Putri Indah Lestari Wirahadi, Umar Yayah Fauziyah Yayang Ayu Nuraeni Yola Nikmatillahi Yola Vandani Imran Yuda Syahidin Yuwanita Kartikaningrum Yuyun Yunengsih Zahran Ramdhani, Muhammad Zulpa Lutfiyyah