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All Journal Jambura Health and Sport Journal JISIP: Jurnal Ilmu Sosial dan Pendidikan JUKEJ: Jurnal Kesehatan Jompa
Yulianti, Mega Sara
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Arts Humanities Education Health Professions Law, Crime, Criminology & Criminal Justice Medicine & Pharmacology Nursing Public Health Social Sciences Veterinary

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KELENGKAPAN INFORMED CONSENT POLIKLINIK BEDAH UMUM RUMAH SAKIT UMUM DAERAH PROVINSI NUSA TENGGARA BARAT Yanti, Ni Komang Wijiani; Yulianti, Mega Sara
Jambura Health and Sport Journal Vol 6, No 1 (2024): Februari
Publisher : Universitas Negeri Gorontalo

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37311/jhsj.v6i1.23722

Abstract

Rekam medis sangat penting untuk proses informed consent sebagai persetujuan tindakan medis. Ketidaklengkapan dalam pengisian informed concent dapat menghambat proses pengajuan klaim kepada Badan Penyelenggara Jaminan Sosial (BPJS). Tujuan penelitian ini adalah mengetahui kelengkapan informed consent pada poliklinik bedah umum di Rumah Sakit Umum Daerah (RSUD) Provinsi Nusa Tenggara Barat (NTB). Jenis penelitian observasional deskripftif. Data dikumpulkan melalui observasi menggunakan check list lalu dilakukan analisis secara deskriptif. Populasi penelitian yaitu 808 dokumen rekam medis. Sampel yang digunakan sebanyak 89 sampel diambil dengan metode simple random sampling. Penelitian menunjukkan bahwa kelengkapan pengisian formulir informed consent pada item diagnosis 100% lengkap, terdapat kategori tidak lengkap pada tindakan kedokteran, tata cara, indikasi tindakan dan alternatif dan risiko, pemberi produk. Berdasarkan hasil tersebut maka disarankan rumah sakit melakukan sosialisasi kepada tenaga kesehatan khususnya dokter terkait pentingnya kelengkapan pengisian formulir informed consent untuk mencapai standar pelayanan minimal 100% dan mengurangi angka ketidaklengkapan dalam pengisian berkas rekam medis demi meningkatan mutu pelayanan kesehatan di rumah sakit.
ANALISIS WAKTU TUNGGU PE/LAYANAN REKAM MEDIS DI POLI DALAM PENDAFTARAN RAWAT JALAN PADA MASA PANDEMI COVID DI RSUD PATUT PATUH PATJU KABUPATEN LOBAR TAHUN 2022 Yulianti, Mega Sara; Yanti, Ni Komang Wijiani
JISIP: Jurnal Ilmu Sosial dan Pendidikan Vol 6, No 4 (2022): JISIP (Jurnal Ilmu Sosial dan Pendidikan)
Publisher : Lembaga Penelitian dan Pendidikan (LPP) Mandala

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.58258/jisip.v6i4.3754

Abstract

Patient waiting time is one indicator in assessing the quality of service in hospitals, if patient waiting time decreases it will affect the quality of service. The length of patient waiting time reflects how the hospital manages the service components that are tailored to the patient's situation and expectations. Based on a preliminary survey at the Patut Patuh Patju Hospital in 2021, the results obtained from the quality aspect of services, especially outpatient waiting times, only reached 50% of the assessment indicator achievements, which means there is a decrease in outpatient waiting times, in addition to patients who want to get outpatient services on average. The average person often complains that it is difficult to get a queue number, this is due to restrictions on the number of patients served during the Covid-19 pandemic. This study aims to determine the waiting time of outpatients during the Covid-19 pandemic. This research is a descriptive analytic study with a sampling technique using simple random sampling. Data were collected using observation sheets and interviews. Data processing uses editing, coding, data entry, cleaning and data analysis using quantitative analysis with descriptive statistics, frequency distribution of respondent characteristics variables (age, gender, education level, occupation, payment method), patient waiting time in medical record services, status patients, how to register patients, and human resources.
CHARACTERISTICS AND PERFORMANCE OF MEDICAL RECORDING OFFICERS IN THE FILING SECTION OF A REGIONAL GENERAL HOSPITAL OF NUSA TENGGARA BARAT PROVINCE Yanti, Ni Komang Wijiani; Yulianti, Mega Sara
JISIP: Jurnal Ilmu Sosial dan Pendidikan Vol 6, No 2 (2022): JISIP (Jurnal Ilmu Sosial dan Pendidikan)
Publisher : Lembaga Penelitian dan Pendidikan (LPP) Mandala

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.58258/jisip.v6i2.3007

Abstract

Patient waiting time is a tangible manifestation of the performance of human resources. Based on the results of a preliminary study conducted by researchers on November 5, 2021 at the NTB Provincial  Hospital, the problems that exist in the filing are delays in returning medical record files from inpatient care, incorrect file storage, wide medical record filing space, so the waiting time for the provision of medical record files not up to standard. The purpose of the study was to identify the characteristics and performance of medical record officers in the filing section of the NTB Provincial Hospital. This type of research is descriptive with a cross sectional design. The population of all medical record officers is 45 people with a sample of 25 people. The sampling technique used incidental sampling, data collection using a questionnaire. Data processing uses editing, coding, data entry, cleaning and data analysis using quantitative analysis with descriptive statistics, frequency distribution of characteristic variables and performance of medical record officers. The results of the research on the characteristics of medical record officers at the NTB Provincial Hospital showed that the average age was >30 years 60%, female sex 52%, diploma education 60%, training 96%, knowledge 88%, years of service >1 year 96%, and the performance level of medical record officers at the NTB Provincial Hospital in the sufficient category is 64%. The suggestion is that medical record officers need to increase knowledge through education as a medical recorder, the higher the education, the better the performance in carrying out the main tasks and functions included in the administration of medical record services at the NTB Provincial Hospital.
Factors Affecting Delays in Retrieval of Inpatient Medical Record Filesat the West NTB Provincial Hospital Yanti, Ni Komang Wijiani; Yulianti, Mega Sara
JISIP: Jurnal Ilmu Sosial dan Pendidikan Vol 7, No 4 (2023): JISIP (Jurnal Ilmu Sosial dan Pendidikan) (November)
Publisher : Lembaga Penelitian dan Pendidikan (LPP) Mandala

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.58258/jisip.v7i4.5737

Abstract

Every patient comes to visit a health care facility for health service needs so that medical record files must always be available, but medical record files often experience delays in returning them. Delays in the retrieval of inpatient medical record files were caused by duplicate medical record files, incorrectly stored, and not completed by the inpatient doctor. The aim of this study was to determine the factors that influence the delay in the retrieval of inpatient medical record files at the NTB Provincial Hospital. The type of research used is quantitative with cross sectional design. The population in this study were all medical record officers at the NTB Provincial Hospital, totaling 45 people with a total sample of 6 retrieval officers. The sampling technique uses incidental sampling. Data collection was carried out by observing or observing all medical record file retrieval officers using a check list. Data processing is done by editing, coding, data entry, and cleaning. Analysis of the data used is descriptive quantitative analysis. The results of the study based on the medical record file officers were categorized as good 0 (0%), and as many as 3 people (50%) categorized as sufficient, while the medical record file officers were categorized as lacking as many as 3 people (50%). The results of the study based on medical record files were categorized as good with a total of 0 (0%), and categorized as sufficient with a yes answer of 10 items (71.4%), while medical record files were categorized as lacking with 4 items (28.6%). It is necessary to increase medical record officers, especially officers in filing, so that their accuracy is increased in separating medical record numbers before storing them so that medical record files are not misplaced so that services at the hospital run smoothly.
Analisis Kelengkapan Resume Medis dan Akurasi Koding Terhadap Ketepatan Klaim BPJS Di RSUD Provinsi NTB Tahun 2024 Yulianti, Mega Sara; Urrahmah, Husnuzzia
JUKEJ : Jurnal Kesehatan Jompa Vol 4 No 1 (2025): JUKEJ: Jurnal Kesehatan Jompa
Publisher : Yayasan Jompa Research and Development

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.57218/jkj.Vol4.Iss1.1561

Abstract

Ketidaklengkapan resume medis menjadi salah satu penyebab tertundanya klaim BPJS yang berdampak pada keterlambatan pembayaran dan potensi kerugian finansial bagi rumah sakit. Kelengkapan dokumen serta keakuratan kode diagnosis merupakan komponen penting dalam mempercepat pengajuan dan pencairan klaim sesuai ketentuan INA-CBGs. Penelitian ini bertujuan untuk mengetahui persentase kelengkapan resume medis rawat inap dan keakuratan kode diagnosis terhadap ketepatan waktu klaim BPJS di RSUD Provinsi NTB. Penelitian menggunakan metode deskriptif kuantitatif dengan pendekatan cross-sectional. Populasi sebanyak 7.885 resume medis pasien rawat inap Oktober–Desember 2023, dengan sampel 99 dokumen. Data dikumpulkan melalui observasi dan dianalisis menggunakan SPSS. Kelengkapan tertinggi tercatat pada aspek tidak adanya tipe-x sebesar 100%, sedangkan ketidaklengkapan tertinggi pada autentikasi nama dan gelar dokter sebesar 53,5%. Keakuratan kode diagnosis menunjukkan 84 dokumen (84,7%) dikode benar, 3 dokumen (3,1%) tidak sesuai, dan 12 dokumen (12,1%) tidak dikode. Ketepatan waktu klaim BPJS menunjukkan 84 dokumen (84,7%) tepat waktu dan 15 dokumen (15,3%) terlambat. Kelengkapan autentikasi dan akurasi kode diagnosis masih belum optimal dan menjadi faktor yang memengaruhi ketepatan waktu klaim. Disarankan untuk menyusun dan menerapkan SOP pengisian resume medis yang menekankan autentikasi dan akurasi kode diagnosis. Perlu dilakukan pelatihan rutin bagi dokter dan petugas rekam medis sesuai standar verifikasi BPJS. Audit internal berkala juga perlu dilakukan untuk memastikan kesesuaian resume medis dengan standar INA-CBGs dan PMK No. 76 Tahun 2016.
Co-Authors Apriawan, Andika Aswandi, Joni Ayuningtyas, Parihayani Dian Neni Naelasari Dwi Andayani, Dwi Fatuhu, Muhamad Siladani Megawati - Nadia, Dea Ni Komang Wijiani Yanti Urrahmah, Husnuzzia Yanti, Ni Komang Wijiyani