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Overview of the Implementation of Medical Record Maintenance at Tarakan Hospital Jakarta in 2021: A Qualitative Study Noviliana, Tiara; Siswati; Puteri Fannya; Wiwik Viatiningsih
Open Access Indonesian Journal of Medical Reviews Vol. 2 No. 2 (2022): Open Access Indonesian Journal of Medical Reviews
Publisher : HM Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37275/oaijmr.v2i2.181

Abstract

A medical record is a file that contains notes and documents about patient identity, examination, treatment, actions, and other services that have been provided to patients. Medical records in carrying out maintenance and protection so that medical records are protected from damage and can facilitate the service process. This study discusses the process or activities of maintaining medical records at the Tarakan Hospital, Jakarta. The purpose of this study was to find out what factors could trigger the occurrence of damage or dangers to the medical record unit and to find out the preventive actions taken by the hospital in protecting medical records. This type of research uses a qualitative descriptive method, which describes the implementation of the maintenance of medical record files in the filing room in 2021. The implementation of medical record maintenance by medical record unit officers, it does not follow the SOP that has been set by Tarakan Hospital Jakarta. Constraints in maintaining medical records are seen from biological, chemical, environmental, and security factors. These obstacles are often the factors that cause damage to medical records such as dust, fire/coal on cigarettes, pests/insects, and chemical liquids and maintenance of medical records at the Tarakan Hospital.
Overview of the Accuracy of Fracture Main Diagnostic Codes in Inpatients at Gatot Soebroto Army Hospital Carono; Siswati; Deasy Rosmala Dewi; Laela Indawati
Open Access Indonesian Journal of Medical Reviews Vol. 2 No. 3 (2022): Open Access Indonesian Journal of Medical Reviews
Publisher : HM Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37275/oaijmr.v2i3.194

Abstract

Coding activities include the coding of diagnosis and the coding of medical treatment. The important thing that must be considered by medical recorders is the accuracy in giving the diagnosis code. This study aims to determine the accuracy of the main diagnostic code for fractures in inpatients at Gatot Soebroto Army Hospital using ICD-10. This research is an observational study with a descriptive method. The study was conducted at the medical record unit of the Gatot Soebroto Army Central Hospital from October to December 2020. Sampling in this study was carried out using a systematic random sampling technique. The sample in this study was the medical record of patients with a fracture diagnosis at Gatot Soebroto Army Hospital. This study found that standard operating procedures (SOPs) for giving diagnosis codes in general according to ICD-10 at Gatot Soebroto Army Hospital already exist. However, the SOP code for fracture diagnosis is not yet available. Most of the documents (72.88%) had a diagnosis code that did not match the ICD-10. In conclusion, Gatot Soebroto Army Hospital does not yet have a special SOP regarding the diagnosis code for fracture cases. Most fracture diagnosis codes in medical record documents are incorrect. This is probably due to the lack of accuracy of the coder in coding the diagnosis, the absence of an evaluation or audit of the diagnosis coding for fracture cases, and the writing of the diagnosis by doctors being unclear and illegible.
Analysis of Medical Records Unit Employee Workload During the COVID-19 Pandemic at Mitra Masyarakat Hospital, Mimika, Indonesia Raru, Amida Morina; Siswati; Deasy Rosmala Dewi; Nanda Aula Rumana
Open Access Indonesian Journal of Medical Reviews Vol. 3 No. 4 (2023): Open Access Indonesian Journal of Medical Reviews
Publisher : HM Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37275/oaijmr.v3i4.325

Abstract

The workload of medical record unit staff at a hospital can vary depending on the size and type of hospital, the number of patients, and the internal policies implemented. Medical record unit employees are responsible for collecting, managing, and storing patient medical records. During the COVID-19 pandemic, the workload of employees in the medical records unit greatly increased because there was a surge in patients due to the pandemic. An increase in the number of patients occurred in all hospitals in Indonesia, including Mitra Masyarakat Hospital, Mimika. This study aimed to describe the workload profile of employees in the medical records unit at Mitra Masyarakat Hospital during the COVID-19 pandemic. This research is descriptive observational research. The location of this research is Mitra Masyarakat Hospital, Mimika, Indonesia. The research was conducted from March to August 2021. Data sources were obtained from interviewing informants, observing and measuring workload in the medical record unit before and during the pandemic. The variables measured in this study were available working time, workload standards, supporting task standards, and supporting task factors, as well as the need for human resources in the Mitra Masyarakat Hospital work unit. The results of the study show that the available working time for medical record unit personnel for each section is 1300 hours/year or 78,000 minutes/year. The need for health human resources for the medical record unit is as many as 20 people. There are 9 medical record officers currently owned by RSMM. Thus it can be concluded the number of employees is less when compared to the workload in the medical record unit at Mitra Masyarakat Hospital.
Hubungan Self Care Management Dengan Tekanan Darah Pada Lansia Dengan Hipertensi Siswati; Maryati, Heni; Praningsih, Supriliyah; Desy Siswi Anjar Sari; Fitri Firranda Nurmalisyah
Jurnal Ilmu Kesehatan Insan Sehat Vol. 13 No. 2 (2025): Jurnal Ilmu Kesehatan Insan Sehat
Publisher : STIKES Intan Martapura

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.54004/jikis.v13i2.412

Abstract

Pendahuluan: Penatalaksanaan hipertensi pada lansia merupakan tantangan bagi dunia kesehatan mengingat jumlah lansia dengan hipertensi semakin meningkat. Keterlibatan secara langsung dan kemampuan pasien dalam mengelola perawatan diri diharapkan dapat membantu mengendalikan tekanan darah tetap stabil. Tujuan: mengetahui hubungan self care management dengan tekanan darah pada lansia hipertensi, Metode: penelitian menggunakan desain analitik korelasi dengan pendekatan crossectional, populasi lansia dengan hipertensi sejumlah 98 dengan sampel yang memenuhi kriteria inklusi dan eksklusi sejumlah 44, pengumpulan data variabel independent self care management menggunakan kuesioner yang telah diuji validitas dan reliabilitas, variabel dependen tekanan darah diambil dari hasil pengukuran saat posyandu. Analisa data menggunakan spearman rank. Hasil: pengolahan data didapatkan self care management 56,8% responden tergolong kategori baik dan tekanan darah 68,2% tergolong dalam kategori hipertensi ringan, uji spearman rank p=0,067 > 0,05 yang artinya tidak ada hubungan self care management dengan tekanand arah pada lansia hipertensi. Kesimpulan: self care management yang telah dilakukan lansia membutuhkan validasi terkait kondisi kesehatan lansia, yang artinya banyak faktor yang dapat mempengaruhi tekanan darah pada lansia, dalam kondisi ketaatan yang ketat dapat membuat lansia stres yang tidak disadari.  Saran: Perlu mempertimbangkan variabel moderator yang dapat mempengaruhi hubungan antara self care management dengan tekanan darah.
Analysis of the Factors Influencing the Coding Quality in East Java Hospital of Indonesia: Diabetes Mellitus as A Case Study Markam, Hosizah; Ningsih, Kori Puspita; Widjaja, Lily; Nisak, Umi Khoirun; Marzo, Roy Rillera; Siswati
Window of Health : Jurnal Kesehatan Vol 8 No 2 (April 2025)
Publisher : Fakultas Kesehatan Masyarakat Universitas Muslim Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33096/woh.v8i2.1702

Abstract

Code precision has received significant attention due to the increased utilization of encoded procedural data. Coding errors have been documented in multiple research investigations. This study aims to assess the variables that affect coding quality. The prevalence of diabetes has increased substantially in the past two decades and is a significant cause of morbidity and mortality. Method: This study was conducted in 2 hospitals in East Java, Indonesia, that were selected through simple random sampling from a population of hospitals meeting the predefined inclusion criteria. The bed capacities of these hospitals are 211, with details of 62 and 149, respectively, for the specialised ones. The sample in this study was 60 medical record files taken randomly in 2022 in the case of diabetes mellitus. The result showed coding quality testing uses six elements: reliability, accuracy, relevancy, timeliness, completeness, and legibility. Data analysis was carried out analytically using the Fisher Exact test. The results of the study from 60 samples showed that four elements were significant out of a total of 6 aspects of coding quality elements. The four essential elements consisted of Accuracy (p=0.001), Reliability (p=0.001), Completeness (p=0.046), and Legibility (p=0.046). Reliability elements also impact coding accuracy or vice versa (p=0.001); Completeness also affects Legibility and vice versa (p=0.046). The odds ratio value of each component shows that Reliability and Accuracy are 8.782, which means that Reliability can increase Accuracy 8 times and vice versa. Meanwhile, completeness and legibility are at 3.818, which means completeness also increases legibility by three times and vice versa. The Hospitals should consider four significant coding quality elements, including completeness, accuracy, reliability, and legibility, for use in coding audits. Timeliness and Relevance were insignificant.
Sayang Remaja “Pemberian Tablet Ferum Terintegrasi dengan Olahraga” masturoh, Masturoh; Siswati; Ike Putri Setyatama; Nurlaila
Jurnal Suara Pengabdian 45 Vol. 5 No. 1 (2026): Maret: Jurnal Suara Pengabdian 45
Publisher : LPPM Universitas 17 Agustus 1945 Semarang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.56444/3s5t5773

Abstract

Anemia merupakan suatu kondisi dimana jumlah sel darah merah atau hemoglobin (Hb) seseorang kurang dari normal. Anemia adalah suatu keadaan dimana jumlah sel darah merah atau konsentrasi pengangkut oksigen dalam darah (hemoglobin) tidak mencukupi kebutuhan fisiologis. Remaja putri dikatakan anemia apabila dari hasil pemeriksaan kadar Hb kurang dari 12 gr%. Tujuan kegiatan ini adalah untuk mencegah anemia pada remaja dengan pemberian tablet penambah darah yang terintegrasi dengan olahraga pada remaja. Metode yang dipakai pada kegiatan ini adalah edukasi langsung dan diskusi kelompok terfokus, olahraga/senam terjadwal yang dipandu kader remaja, pembagian tablet Fe dan pemantauan kadar Hb berkala. Hasil dari kegiatan ini yaitu peserta yang hadir berumur 12 tahun dengan prosentase 30,43%, peserta dengan umur16 tahun  prosentase 21,74%, selebihnya peserta berumur 13 tahun (13,04%), 14 tahun (8,70%), 15 tahun (13,04%), 17 tahun (4,35%) dan 18 tahun (8,70%). Jumlah target posyandu remaja di Desa Randusari yaitu 35 peserta, tetapi yang hadir hanya 23 peserta. Hal ini terjadi karena ada beberapa peserta yang belum bisa menghadiri posyandu remaja karena teman sebaya tidak bisa hadir di posyandu remaja. Peserta posyandu di Desa Randusari memiliki kadar hemoglobin normal sejumlah 73,91%, anemia ringan 13,04% dan anemia sedang 4,35%.
Peran Keluarga dalam Merawat Pasien Lansia Penderita Hipertensi dengan Tekanan Darah Tinggi Maryati , Heni; Supriliyah Praningsih; Fitri Firranda Nurmalisyah; Siswati
Jurnal Keperawatan Muhammadiyah Vol 10 No 4 (2025): JURNAL KEPERAWATAN MUHAMMADIYAH
Publisher : UNIVERSITAS MUHAMMADIYAH SURABAYA

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.30651/jkm.v10i4.30272

Abstract

Objective: Hypertension is a condition of persistently elevated arterial blood pressure and continues to be a major global health problem. The WHO estimates that by 2025, 1.5 billion people will suffer from hypertension, and 10.44 million people are predicted to die from hypertension and its complications each year. The role of the family is crucial in managing hypertension. Families play a crucial role as caregivers in improving the health status of their sick family members, as they play a crucial role in maintaining the health of those with hypertension. This study aimed analyzing the role of family in caring for elderly hypertension on blood pressure Methods: This research is a correlational study with a cross-sectional design using purposive sampling. The subjects were 46 elderly people with hypertension in Puton Village, Diwek District, Jombang Regency, according to the inclusion criteria for the 2025 study. The instruments used were the role of the family in caring for elderly people with hypertension using questionnaires and interviews (food selection, physical activity, stress management, referral to health facilities), and blood pressure measurements. Data were analyzed using coding, editing, tabulation, and scoring, and statistical tests were performed using the Chi Square test. Results: Based on the research results, it was shown that out of 47 respondents, 26 (55.3%) respondents had a not good family role in caring for elderly people with hypertension. Classification of hypertension based on blood pressure values, namely the majority (63.84) in the grade 2 hypertension category. Chi Square test for using SPSS yielded a p value of 0.02 less than 0.05 indicating correlation between the role of family in caring for elderly hypertension on blood pressure Conclusion: The role of the family in motivating the elderly with hypertension through exercise, regulating diet, encouraging them to control their blood pressure and taking medication, and regularly visiting health services can control blood pressure. The greater the role of the family, the better the quality of life of the elderly, which can be seen from the number of elderly whose blood pressure is controlled.
Asuhan Kebidanan Komprehensif Ny. S Usia 22 Tahun G1P0A0, di Wilayah Kerja Puskesmas Kaliwungu Kecamatan Kaliwungu Siswati; Moneca Diah Listiyaningsih
Prosiding Seminar Nasional dan CFP Kebidanan Universitas Ngudi Waluyo Vol. 4 No. 2 (2025): Prosiding Seminar Nasional dan Call for Paper Kebidanan Universitas Ngudi Waluy
Publisher : Universitas Ngudi Waluyo

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

Abstract

Maternal Mortality Rate (MMR) and Infant Mortality Rate (IMR) remain crucial indicators for assessing the quality of healthcare services. According to the 2022 data from the Indonesian Ministry of Health, the MMR was 207 per 100,000 live births, while the IMR was 22 per 1,000 live births, both still above the national targets. The main causes of maternal death include hemorrhage, preeclampsia/eclampsia, infection, prolonged labor, and postpartum complications. Infant mortality is influenced by prematurity, asphyxia, infection, and congenital anomalies. Efforts to reduce MMR and IMR are implemented through the Safe Motherhood program and the Continuity of Care (CoC) approach, which provides integrated midwifery services from pregnancy, labor, postpartum, newborn care, to family planning. Comprehensive and continuous care contributes to early risk detection, complication prevention, and improved maternal and neonatal health. This study employed a descriptive case study method on Mrs. S, 22 years old, P1A0, who received comprehensive midwifery care at Puskesmas Kaliwungu. The care included pregnancy assessment, labor monitoring, postpartum care, newborn care, and family planning counseling. Interventions followed standard protocols, including ANC examination, normal labor management, physiological newborn care, breastfeeding education, and postpartum family planning. All stages of care—from pregnancy, labor, postpartum, newborn care, to family planning—proceeded physiologically without complications. The mother demonstrated good understanding of pregnancy warning signs, labor preparation, postpartum self-care, exclusive breastfeeding, and newborn care. She chose postpartum contraception (3-month injectable) according to her condition. The newborn adapted well and showed normal growth and development. Comprehensive Continuity of Care (CoC) midwifery services are effective in early risk detection, increasing maternal knowledge, supporting maternal and neonatal health, and optimizing breastfeeding and maternal comfort. Continuous implementation of CoC services is crucial to support efforts in reducing MMR and IMR. Abstrak Angka Kematian Ibu (AKI) dan Angka Kematian Bayi (AKB) masih menjadi indikator penting dalam menilai kualitas pelayanan kesehatan. Berdasarkan data Kemenkes Indonesia tahun 2022, AKI tercatat sebesar 207 per 100.000 kelahiran hidup, sedangkan AKB sebesar 22 per 1.000 kelahiran hidup, masih di atas target Renstra. Penyebab kematian ibu umumnya meliputi perdarahan, preeklamsia/eklamsia, infeksi, partus lama, dan komplikasi nifas, sementara kematian bayi dipengaruhi oleh prematuritas, asfiksia, infeksi, dan kelainan bawaan. Upaya penurunan AKI dan AKB dilakukan melalui program Safe Motherhood dan penerapan Continuity of Care (CoC), yaitu pelayanan kebidanan berkesinambungan mulai kehamilan, persalinan, nifas, bayi baru lahir hingga keluarga berencana. Pelayanan yang komprehensif dan terintegrasi berkontribusi dalam deteksi dini risiko, pencegahan komplikasi, serta peningkatan kesehatan ibu dan bayi. Penelitian ini menggunakan metode studi kasus deskriptif pada Ny. S, usia 22 tahun, P1A0, yang menerima asuhan kebidanan komprehensif di Puskesmas Kaliwungu. Asuhan meliputi pengkajian kehamilan, pemantauan persalinan, perawatan nifas, perawatan bayi baru lahir, dan konseling keluarga berencana. Tindakan yang diberikan sesuai standar, antara lain pemeriksaan ANC, manajemen persalinan normal, perawatan bayi baru lahir fisiologis, edukasi menyusui, serta konseling dan pemberian KB pasca persalinan. Seluruh proses asuhan berlangsung fisiologis tanpa komplikasi. Ibu menunjukkan pemahaman yang baik mengenai tanda bahaya kehamilan, persiapan persalinan, perawatan diri masa nifas, pemberian ASI eksklusif, dan perawatan bayi. Pemberian KB pasca persalinan dipilih sesuai kondisi ibu (KB suntik 3 bulan). Bayi baru lahir menunjukkan adaptasi yang baik dan tumbuh kembang normal. Asuhan kebidanan berkesinambungan (CoC) terbukti efektif dalam mendeteksi dini risiko, meningkatkan pengetahuan ibu, mendukung kesehatan maternal dan neonatal, serta membantu optimalisasi pemberian ASI dan kenyamanan ibu. Penerapan layanan CoC secara komprehensif perlu terus dilakukan untuk mendukung penurunan AKI dan AKB.