suyoko suyoko
Program Studi D-3 Rekam Medis Dan Informasi Kesehatan, Fakultas Kesehatan, Universitas Dian Nuswantoro Semarang

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IMPLEMENTATION OF MEDICAL INFORMATION RELEASE FOR COMMERCIAL INSURANCE PURPOSES AT RSI SULTAN AGUNG SEMARANG IN 2021 suyoko suyoko; Novika Gema Palupi; Maulana Tomy Abiyasa; Retno Astuti Setijaningsih
VISIKES: Jurnal Kesehatan Masyarakat Vol 20, No 2 (2022): VISIKES (SUPLEMEN)
Publisher : Dian Nuswantoro Semarang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33633/visikes.v20i2Supp.5785

Abstract

ABSTRACTLaw No. 44 of 2009 concerning Hospitals, states that hospitals are obliged to respect and protect the rights of patients. The early survey found that completion time in the implementation of the release of medical information for claims was constrained, depend on the presence and willingness of doctors to fill out medical information. These obstacles can possibly cause the loss for patients. The purpose of this study was to analyze the implementation of the release of medical information for commercial insurance claims at RSI Sultan Agung Semarang.The type of this research is descriptive qualitative with a cross sectional approach. The research was conducted on May-June 2021 with 2 subjects, namely the insurance officer and the head of the medical record unit. The data were collected by online interviews and analyzed descriptively based on regulations of the Sultan Agung Hospital and the legal aspects of health and then conclusions were drawn.The results showed that the implementation of information release has maintained patient privacy, every release of medical information is followed by permission from the patient/family, release to third parties accompanied by a power of attorney, release of medical information is given by the DPJP doctor. However, the release of medical information has not been involved the director and the regulation on completion time standards has not been implemented optimally. Suggestions from this study is to evaluate the applicable regulations.Keywords: Release of Medical Information, Medical Records, Commercial Insurance     
PERAN PENANGGUNG JAWAB REKAM MEDIS (PJRM) UNTUK PENINGKATAN KETEPATAN KLAIM BPJS PASIEN RAWAT INAP DI RSUD KRMT WONGSONEGORO (RSWN) KOTA SEMARANG Retno Astuti Setijaningsih; Suyoko - -; Nova Dhea Ammar N; Supriyatiningsih - -
VISIKES: Jurnal Kesehatan Masyarakat Vol 19, No 01 (2020)
Publisher : Dian Nuswantoro Semarang

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (277.353 KB) | DOI: 10.33633/visikes.v19i01.3783

Abstract

Medical Record Document (MRD) guarantees patient safety. Besides, it related to claim accuracy to BPJS (Badan Penyelenggara Jaminan Sosial) as patient health insurance operator. In fact, from the survey conducted with 15 inpatients as the subjects, 10 MRD approved (approximately 66.67%) and the other 5 MRD or about 33.34% rejected. This happened as the consequences of whether supporting examination result which is not being submitted on 2 MRD (40%), 1 MRD or 20% hold incomplete BPJS document and other 40% caused by the inaccurate operation code in MRD. Hence, the aim of this study is to analyze the role of Person In Charge in Medical Record Department to improve MRD comprehensiveness to reach BPJS claim accuracy.The type of this study is qualitative with cross-sectional approach. Primary and secondary source observation and interview are used in collecting data. Purposive sampling with four interviewees from Person In Charge in Medical Record Department, and as the main interviewee is the head of Medical Record Department also one employee of BPJS Rumah Sakit Wongsonegoro as the triangulator.So, the main function of assembling employee is to ensure the quality of Medical Record Document (MRD), quantitatively and qualitatively. Whereas, RSWN already applied Person In Charge of Medical Record Department with concurrent analysis in controlling MRD comprehensiveness concept. According to observational result of 15 inpatients, found incomplete MRD, 13% occurs in identity section, also 13% each found both in recording and reporting. While, the authentication completes 100%. From consistency analyzing result discovered inconsistency recording about 13%. Main diagnose and inform consent recording reached 100% in consistency and 0% things that can cause loss.That is, the role of Person In Charge in Medical Record of inpatient unit needs yo be improved. The main and assembling function performs by PIC in Medical Record is both coding and indexing. Input standard, Standard Operational Procedures (SOP) and minimum services standard are already available and applied to control PIC in Medical Record performance quality. However, input, process and the output are not focus in controlling MRD comprehensiveness yet, especially in BPJS participant patient. So that, to control BPJS inpatient MRD quality, needs operational standard in methods and comprehensiveness control procedures, considered with PIC in Medical Record also performing ICD code and Medical Record Document quality requires coordination of all parties.The researchers suggest to add more points in controlling incomprehensiveness BPJS Medical Record Document procedures. Furthermore, enhance input in standard structure, operational job description in Standard Operational Procedure, also minimum services standard comprehensiveness which applied has to be reached 100% qualitatively and quantitatively.Keywords: PIC in Medical Record, BPJS claim, quantitative comprehensiveness, qualitative comprehensiveness
ANALISIS DESAIN FORMULIR KARTU PENGOBATAN PENCEGAHAN TB (TB 01 P) UNTUK KELENGKAPAN DATA DI PUSKESMAS TAHUN 2019 Suyoko suyoko; Retno Astuti Setijaningsih; Wahyu Setiyowati
VISIKES: Jurnal Kesehatan Masyarakat Vol 18, No 2 (2020): VISIKES (SUPLEMENT)
Publisher : Dian Nuswantoro Semarang

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (477.797 KB) | DOI: 10.33633/visikes.v18i2.3676

Abstract

Tuberculosis is an infectious disease which becomes a global problem. The increase in TB case is caused by inadequate monitoring of treatment, unavailability of standardized recording and reporting system. This research was conducted to evaluate the completeness TB form design in providing more complete information. This research was administered in the form of a case study. Interviews were done to 3 nurses and 1 doctor and TB Form (TB.01P) was observed at Miroto Health Center. The completeness of 33 TB form filling (TB.01P) at the Malmahera Health Center was also evaluated. The obtained data were descriptively analyzed. The results showed the completeness of identification review reached 96%, recording review of 90%, reporting review of 64%,and 0% for authentication review. Incomplete information led to inaccurate TB control information. This incompleteness was associated toimproper design of the form, especially the unavailability of form filling instructions, names and signatures of officersin the anatomic aspect. In the aspect of content, lack of clinical data was also found. Regarding to the results of this research, revision in the design of TB Treatment and Prevention Card is needed in order to accommodate the data completeness of TB patients. This research also proposed a better design of TB Treatment and Prevention Card Keywords : Quantitative Completeness, Tuberculosis, Form Design, TB Treatment Card (TB.01P) 
THE MANAGEMENT OF MEDICAL REPORT COMPLETENESS FOR THE LEGALITY OF MEDICAL RECORD DOCUMENTS AT RSUD KRMT WONGSONEGORO (RSWN) SEMARANG CITY Suyoko suyoko; Aylin Ivana; Arinda Juwita; Retno Astuti Setijaningsih
VISIKES: Jurnal Kesehatan Masyarakat Vol 20, No 2 (2021)
Publisher : Dian Nuswantoro Semarang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33633/visikes.v20i2.5069

Abstract

ABSTRACTBackground: Quality hospital services is reflected in the achieving of medical records. Improper medical record documentation would negatively affect the quality of service delivered to patients and it would disadvantage the hospital when medical disputes occur.Objective:Analyzing the management of medical record completeness at RSWN to guarantee the legality of medical record documents and its effect in supporting the completeness of medical record documents.Method:In this qualitative research,  observation and interviews were conducted to 60 PJRM officers in the Arimbi ward, Banowati, Nakula I and Prabukresna. The obtained data were qualitatively and quantitatively analyzed based on several underlying theories.Results:The results showed that the completeness of some aspects includinghuman, money, method, material and machine elements was proper. The quantitative analysis showed 100%, while the qualitative analysis showed a percentage of 100% with the exception on the informed consent component with the potential for loss of 99%.Conclusions:The human element required periodic outreach to PPA. In the machine element, special computerswere needed for PJRM officers, and the importance of informed consent for patients undergoing hemodialysis to obtain medical records with strong legal force. Key Words           :Management, Medical Record Completeness, Legality of Medical Records.
TELOGOREJO HOSPITAL BED PREDICTION 2021-2022 Nias Amelia Rahmawati; Evina Widianawati; Suyoko Suyoko; Widya Ratna Wulan
VISIKES: Jurnal Kesehatan Masyarakat Vol 20, No 2 (2022): VISIKES (SUPLEMEN)
Publisher : Dian Nuswantoro Semarang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33633/visikes.v20i2Supp.5934

Abstract

AbstractBackground. Hospital statistical indicators during the Covid-19 pandemic will be different from normal conditions before covid-19, One of the indicators for inpatient services is BOR which is the percentage of bed usage with Barber Johnson's ideal standard of 75-85%. During a pandemic, BOR information is needed to assist hospitals in terms of speed of service and policies in the use of beds and rooms. The purpose of this research is to predict the bed at Tlogorejo Hospital in 2021-2022. Method. This type of research is quantitative descriptive and uses secondary data, the data used is from March 2020 - June 2021 by way of observation. Result. The study results from the Barber Johnson chart with linear bed predictions are not efficient from July 2021 - May 2022 and efficient from July 2021 - May 2022. June 2021 - Dec 2022 while the results of the barber johnson chart predict beds with a BOR of 75% that all wards from July 2021-Dec 2022 are efficient. Conclusion. Therefore it is recommended to Tlogorejo hospital to add beds according to the predicted results of beds BOR 75 % or predicted results of bed Linier.Keywords: Predictions, beds, barber johnson charts and BOR. 
Hospital Responsibility for Release of Medical Information of to Claim The Insurance in Telogorejo Hospital Semarang Suyoko suyoko; Budi Sarwo; Tjahjono Kuntjoro
SOEPRA Vol 5, No 1: Juni 2019
Publisher : Universitas Katolik Soegijapranata Semarang

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (353.534 KB) | DOI: 10.24167/shk.v5i1.1649

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Hospitals are responsible to establish the patients’ medical information. However, in reality they should encounter conflicts with the third party who represents the patients to get the medical information, such as the insurance company. This research aims to discover about hospital’s responsibility in establishing patients’ medical information as a proof to claim the insurance and the problems that should be encountered by the hospital in carrying out the responsibility.This research was conducted in Telogorejo Hospital, Semarang. It implements juridical sociology approach with analytical description. The primary and secondary data were gathered from observation result, interview result, and questionnaires analyzed using the qualitative-descriptive method.The result shows that from legal aspect, Telogorejo Hospital has agreed to give the insurance companies which have partnership-relation the access to the patients’ medical information.Whereas for the insurance company which has no partnership-relation with the hospital, the medical information is given after getting the permission from the patients. It is also found out that the patients’ right for reimbursement claim has not yet been given at its best because the filling of the patients’ medical information has not satisfied the minimum, relevant, and adequate principals, so if it causes some disadvantages to the patients, the hospital is legally responsible following the Law of the Republic of Indonesia Article 46 Act Number 44 Year 2009 about Hospital based on the principle of Vicarius Liability. Nevertheless, there is no claim from the injured party. The criminal responsibility aspect of Telogorejo Hospital has protected the confidentiality of the medical information, so the implementation does not contradict with Article 322 of the Criminal Code of the Republic of Indonesia. From the administrative responsibility, Telogorejo Hospital can be expected to be responsible according to the Law of the Republic of Indonesia Article 29 verse 2 Act Number 44 Year 2009 about hospital because Telogorejo Hospital has not optimally implemented the fulfillment of the patients’ right for the medical information. Besides that, the government has not fully monitored and given proper guidance to the hospitals. The other findings are the internal factors which include the incomplete medical records and the external factors, such as the lack of understanding about medical information by the third party, such as the insurance company, and the regulation of medical information release also affect the hospital responsibility.
Literatur Review Kualitas Visum et Repertum dalam Mendukung Penegakan Hukum di Indonesia Suyoko Suyoko
Indonesian of Health Information Management Journal (INOHIM) Vol 10, No 2 (2022): INOHIM
Publisher : Lembaga Penerbitan Universitas Esa Unggul

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.47007/inohim.v10i2.391

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AbstractDoctors are required to issue Visum et Repertum upon a written request from investigators. Unfortunately, prior studies have revealed that most of Visum et Repertum had poor quality. This literature review study describes the quality of Visum et Repertum based on relevant literatures published between 2015-2021 collected from Google Scholar and Garuda search engines based on several keywords; quality and Visum et Repertum. Articles were sorted based on the inclusion and exclusion criteria. Scoring method was employed to analyze the articles. The results showed that the overall quality of Visum et Repertum was 54.08% (moderate). The quality of the Visum et Repertum in the opening section was 75% (moderate), and 79.15% (good) in the introduction section. Both news section and conclusion section were categorized moderate with 51.46% and 51.13%, respectively. Only the closing section scored 100% (good). Poor quality of VeR could reduce the function of VeR as evidence that helps judges in a court hearing. Hospitals need to set guidelines for doctors in making proper VeR that can be used as legal evidence in a court.Keyword: literatur review, Visum et Repertum, Visum et Repertum quality AbstrakDokter wajib membuat Visum et Repertum jika ada permintaan secara tertulis dari penyidik. Beberapa penelitian  diketahui bahwa kualitas pembuatan Visum et Repertum (VeR) belum menunjukkan kualitas yang baik. Tujuan dari penelitian ini adalah ingin menggambarkan bagaimana kualitas pembuatan Visum et Repertum melalui literatur review. Jenis Penelitian ini menggunakan metode studi literatur, Pencarian data menggunakan mesin pencari google scholar dengan kata kunci kualitas, Visum et Repertum pada artikel yang diterbitkan pada tahun 2015-2021. Hasil penelitian diseleksi sesuai kriteria inklusi dan ekslusi selanjutnya dianalisa dengan metode scoring. Hasil penelitian diketahui kualitas Visum et Repertum secara keseluruhan adalah bernilai 54,08% yang berarti kategorikan sedang. Kualitas Visum et Repertum pada bagian pembukaan bernilai 75% dengan kategori sedang, bagian pendahuluan bernilai 79,15% dengan kategori kualitas baik, bagian pemberitaan bernilai 51,46% dengan kategori sedang,  bagian kesimpulan bernilai 51,13% dengan kategori sedang dan bagian penutup bernilai 100% kategori baik. Kurang sesuainya kualitas VeR dapat mengurangi fungsi VeR sebagai alat bukti dalam membantu hakim mengadili perkara. Rumah sakit perlu menetapkan pedoman bagi dokter dalam membuat VeR yang tepat yang dapat digunakan sebagai alat bukti yang sah di pengadilan.Kata Kunci: literatur review, Visum et Repertum, kualitas Visum et Repertum 
ANALISIS PROSEDUR DAN KETENTUAN UMUM DALAM PEMBUATAN VISUM ET REPERTUM TAHUN 2022 Suyoko Suyoko; Azahra Alya Nabila; Amable Firliana Putri; Utami Rahma Fadilah; Rosiyana Nurkhaliza
Cerdika: Jurnal Ilmiah Indonesia Vol. 3 No. 11 (2023): Cerdika : Jurnal Ilmiah Indonesia
Publisher : Publikasi Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.59141/cerdika.v3i11.668

Abstract

Dalam mengejar keadilan, penyelidik memiliki wewenang untuk memulai permintaan Visum et Repertum sebagai bahan bukti dengan signifikansi hukum substansial yang diperoleh melalui prosedur, desain, dan format khusus. Penelitian ini secara komprehensif menganalisis penciptaan Visum et Repertum, dengan penekanan utama pada seluk-beluk prosedural dan keselarasan dengan ketentuan yang telah ditentukan. Dalam penelitian deskriptif kualitatif ini, wawancara dan observasi dilakukan di empat fasilitas medis berbeda pada Juni 2022: RSUD Dr. Asmir Salatiga, RS Jenderal Ahmad Yani Metro Lampung, Hj. Anna Lasmanah Banjarnegara, dan RS Majenang. Informan adalah mereka yang ditugaskan untuk membuat Visum et Repertum. Analisis data selanjutnya dilakukan melalui teknik deskriptif. Temuan mengungkapkan variasi dalam prosedur Visum et Repertum di seluruh rumah sakit meskipun berakar dari kerangka teoritis yang sama. Beberapa rumah sakit menghilangkan rincian mengenai tingkat peringkat yang diizinkan dari penyelidik yang berwenang untuk meminta Visum et Repertum. Kepatuhan terhadap ketentuan umum Visum et Repertum mencapai 100%. Namun, masih ada kebutuhan untuk membuat peraturan yang tepat dalam kebijakan rumah sakit, terutama dalam hal menetapkan kualifikasi pangkat personel penegak hukum yang memenuhi syarat untuk meminta Visum et Repertum.
Penyebab Pending dan Dispute Klaim Kasus Covid-19 Di Rumah Sakit Tipe C dan D Jawa Tengah Khamna Diah Oktavia Chalimah; Sutrisno Sutrisno; Umi Hanik; Umi Maftukhah; Suyoko Suyoko; Faik Agiwahyuanto; Deddy Setiadi
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 5 No 2 (2024): March
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v5i2.4286

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Return of claims for cost of treating COVID-19 patients from BPJS Health is common occurrence due to administrative and service problems. In 2021, there were 215 pending files and 32 unapproved files in type C and D hospitals in Central Java. To determine causes of pending and disputed COVID-19 cases in type C and D hospitals in Central Java. Methods: Descriptive research was conducted by observing all pending and dispute files of COVID-19 cases, totaling 247 cases in 2021. Data collection method was documentation. Univariate data analysis. Panti Wilasa Dr. Cipto Semarang Hospital has highest pending claims for COVID-19 cases. Kelet Jepara Hospital has pending claims for most COVID-19 cases. Majority of pending claims for COVID-19 cases do not have supporting files or are not appropriate, while smallest scanned laboratory results (albumin, PCR) are not attached, and INA-CBGs entry or exit date does not match the medical resume. Most pending and dispute claims for COVID-19 cases are mismatch of diagnosis and diagnostic results with KMK Technical Guidelines, while mismatch of diagnosis with results of actions is least.