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All Journal Faktor Exacta Jurnal Manajemen Informasi dan Administrasi Kesehatan Jurnal Kesehatan Indonesia Jurnal Manajemen Informasi Kesehatan Indonesia (JMIKI) Indonesian of Health Information Management Journal (INOHIM) Surya Medika: Jurnal Ilmiah Ilmu Keperawatan dan Ilmu Kesehatan Masyarakat Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Community Development Journal: Jurnal Pengabdian Masyarakat Jurnal Kesehatan Tambusai J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Open Access Indonesian Journal of Medical Reviews Educivilia: Jurnal Pengabdian Pada Masyarakat KESANS : International Journal of Health and Science Indonesian Journal of Health Information Management (IJHIM) Jurnal Ilmiah Kesehatan Masyarakat Sehat Rakyat: Jurnal Kesehatan Masyarakat Journal of Innovation Research and Knowledge Jurnal Sosial dan Sains Journal of Artificial Intelligence and Digital Business Student Scientific Creativity Journal Cerdika: Jurnal Ilmiah Indonesia Innovative: Journal Of Social Science Research Jurnal Medika Nusantara Vitamin: Jurnal Ilmu Kesehatan Umum Jurnal Siti Rufaidah Jurnal Rekam Medic Jurnal Ilmu Kedokteran dan Kesehatan Indonesia
Dewi, Deasy Rosmala
Prodi Rekam Medis Dan Informasi Kesehatan, Fakultas Ilmu-Ilmu Kesehatan, Universitas Esa Unggul, Jakarta, Indonesia
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Gambaran Ketersediaan Rekam Medis Rawat Jalan Berdasarkan Standar Pelayanan Minimal di Rumah Sakit Islam Jakarta Pondok Kopi Paryati Paryati; Deasy Rosmala Dewi; Daniel Happy Putra; Nanda Aula Rumana
SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat Vol. 2 No. 2 (2023): April 2023
Publisher : Yayasan Literasi Sains Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.55123/sehatmas.v2i2.1860

Abstract

The availability of medical records is greatly influenced by fast and precise distribution. If the delivery of medical records to the intended polyclinic is not on time, it will affect the waiting time for patient services. The general objective of this study was to determine the length of time it took to provide outpatient medical records at RSIJ Pondok Kopi. This type of research uses descriptive, quantitative in nature, namely a survey conducted on a set of objects which usually aims to see a picture of what is happening in a certain population. From the results of research conducted in the medical record storage room, all procedures have been carried out properly. It's just that there is still a procedure that does not exist in this case, namely standardization of the time for providing medical records for outpatient services. Based on the conclusions that can be drawn from the results of the study, namely: in the implementation of taking and compiling medical records the officers carry out according to the SPO, it's just that there is no standardization of the length of time for providing medical records for outpatient services from the patient registering until the medical record is available / found. Some suggestions that can be useful for service providers are: it is hoped that there will be a standard time regarding the provision of medical records for outpatient services, so that officers can speed up the process of providing medical records.
Tinjauan Ketepatan Kode Penyakit Tuberkulosis Paru Berdasarkan ICD-10 pada Pasien Rawat Inap di RSKD Duren Sawit Tahun 2021 Vania Rachma Putri; Puteri Fannya; Deasy Rosmala Dewi; Lily Widjaja
Sehat Rakyat: Jurnal Kesehatan Masyarakat Vol. 2 No. 2 (2023): Mei 2023
Publisher : Yayasan Pendidikan Penelitian Pengabdian Algero

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.54259/sehatrakyat.v2i2.1675

Abstract

Coding accuracy is the process of conforming to the diagnosis code that has been determined by the coding officer based on ICD-10 which greatly affects data reporting and administration. Pulmonary tuberculosis is an infectious disease caused by Mycobacterium tuberculosis which causes disturbances in the respiratory tract. In RSKD Duren Sawit pulmonary tuberculosis is included in the 10 biggest diseases. The purpose of this study was to determine the accuracy of the pulmonary tuberculosis disease code based on ICD-10 in inpatients at RSKD Duren Sawit in 2021. This study used a descriptive method with a quantitative approach that took 80 samples using a saturated sample technique by means of observation and interviews. The results obtained from 80 samples of the accuracy of the pulmonary tuberculosis code of inpatients at RSKD Duren Sawit found that 56 (70%) and 24 (30%) were inaccurate. There are factors that affect the inaccuracy of using the 5M (Man, Money, Material, methode, Machine) element, namely the man element due to the inappropriateness of the coding officer's profession and lack of thoroughness and the element of the coding SOP method which is still being revised. Suggestions should be officers who do coding in accordance with their profession or medical recorders.
Analisis Ketepatan Kode Diagnosis pada Kasus Persalinan Pasien Rawat Inap di Rumah Sakit Patria Ikkt Tahun 2022 Angela Marsiana Siki; Deasy Rosmala Dewi; Daniel Happy Putra; Puteri Fannya
SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat Vol. 2 No. 2 (2023): April 2023
Publisher : Yayasan Literasi Sains Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.55123/sehatmas.v2i2.1201

Abstract

Diagnostic coding must comply with ICD-10 rules. According to WHO, the coding of delivery cases consists of the code for the mother's condition (O00-O75), the method of delivery (O80-084), and the Outcome of delivery Z37.-., while the code is Z37.-. used as an additional code to determine the outcome of labor. So that the coder officer must have knowledge in setting the diagnosis code. Coding accuracy is very necessary because it is used as a reporting material. To determine the Standard Operating Procedure (SOP), the percentage of accuracy of the diagnosis code for inpatient labor cases based on 3M (complications, delivery method, and outcome of delivery) and the cause of the inaccuracy of the diagnosis code for labor cases. Descriptive research type with a quantitative approach. The population is medical records of inpatients in labor cases with a sample of 100 medical records. The sampling technique is by systematic random sampling. Collecting data by means of observation, interviews, and documentation. Research results: SOPs already exist, but not yet complete. The percentage of accuracy of the correct diagnosis code for labor cases is 22.33% while the incorrect diagnosis code is 77.67%. The cause of the inaccuracy of the ICD-10 code for delivery cases is that the diagnosis does not include the method of delivery and the outcome of delivery, and has never been done. evaluation or audit coding. The accuracy of the diagnosis of labor cases is still incomplete. Improve the SOP entry and complete the delivery method and outcome of delivery in medical records and registers.
Tinjauan Keakuratan Data pada Sensus Harian Rawat Inap Di Rumah Sakit Khusus Bedah Banjarmasin Siaga Deasy Rosmala Dewi; Gussa Azizah; Retno Juwita; STIKES Husada Borneo
Jurnal Kesehatan Indonesia Vol 4 No 3 (2014): Juli
Publisher : HB PRESS

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Abstract

Inpatient daily census is the number of inpatient at a health care facility at any given time starting at 00:01 until 24.00 each day. In practice involving nurses and medical record officer. However, there were limited data accuracy daily inpatient census at the Hospital for Special Surgery Siaga Banjarmasin such differences initial data on patients with the remaining patients the day before. Inaccuracies in charging daily census affects the quality of information produced hospital. The purpose of this study was to determine the accuracy of the data on the daily inpatient census at the Hospital for Special Surgery Siaga Banjarmasin. This research is descriptive. As a research population is daily inpatient census VIP classes, I, II, and III in January 2013 as many as 124 sheets. The samples used in this study is saturated sampling as many as 124 sheets. Data was collected through interviews and observation. The results of 124 samples of known Standard Operating Procedures (SPO) daily inpatient census at the Hospital for Special Surgery Standby Banjarmasin still using the old procedures and there has been no revision in 2013, the implementation of the inpatient daily census there are many inaccuracies in filling the remaining number of patients a day prior to the initial patients by nurses, and the rest of the room there are many inaccuracies in the rest of the patients and 53,5% of patients beginning with the criteria quite well. Recapitulation of the inpatient daily census is 46.46% with the criteria quite well.
Tinjauan Keakuratan Kode Diagnosis Gastroenteritis Pada Pasien Rawat Inap Berdasarkan ICD-10 Dan Hasil Pemeriksaan Laboratorium Di RSUD Banjarbaru Pada Triwulan III Tahun 2013 Dion Angger Priyatama; Deasy Rosmala Dewi; Ratna Auliyana; STIKES Husada Borneo; Alumni STIKES Husada Borneo
Jurnal Kesehatan Indonesia Vol 5 No 3 (2015): Juli
Publisher : HB PRESS

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Abstract

Coding is a key of health treatment organization. The accurate coding is a very important thing in data organizing, reimbursement, and another problems. Inaccuracy of Gastroenteritis diagnosis code found in Banjarbaru hospital which caused by there is no recheck toward additional information such as laboratory report in coding process. This research has purpose to confirm the accuracy of Gastroenteritis diagnosis code of inpatient based on ICD-10. This research use descriptive analysis with 106 medical records of inpatient of Gastroenteritis diagnosis case as the sample. Data collection methods which used in this research are observation and interview. This research use univariate analysis and the result presented in tabulation and text explanation. The result of research shows that only 2,83% Gastroenteritis code is accurate and 97,17% is not. The output of Gastroenteritis diagnosis code use as RL 4a report, disease index, top 10 of common disease list, and hospital activity/service data. Human resouces who involved in Gastroenteritis diagnosis coding process are manager of medical record department, inpatient coder, and doctor.
Gambaran Pengetahuan Perawat Tentang Kelengkapan Pengisian Asuhan Keperawatan di Ruang Penyakit Dalam RSUD H. Damanhuri Barabai Tahun 2015 Deasy Rosmala Dewi; Armiati Armiati; Anjar Retno Astrini; STIKES Husada Borneo; Alumni STIKES Husada Borneo
Jurnal Kesehatan Indonesia Vol 6 No 1 (2015): November
Publisher : HB PRESS

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Abstract

One of the factors that affect the completeness of nursing care is knowledge. Knowledge is influenced by several factors: education, experience, and age. Namely the identity of the patients 82%, 84% evaluation, planning 80%, and 80% of nurses initials. The research aim to determine the knowledge of nurses about completeness of nursing care in internist room H. Damanhuri Barabai Hospital. The method used is descriptive with the sample were 20 nurses in internist room. Knowledge of nurses towards completeness of nursing care in internist room H. Damanhuri Barabai Hospital who have a good knowledge as many as 6 respondents (30%),9 respondents (45%) have enough knowledge and 5 respondents (25%) have less knowledge.
Faktor Yang Berpengaruh Dalam Penggunaan Sistem INA CBGs Di Rumah Sakit Islam Jakarta Pondok Kopi Putra, Daniel; Kirani, Niken; Rumana, Nanda Aula; Dewi, Deasy Rosmala
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Vol. 8 No. 2 (2023): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Agustus
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v8i2.1284

Abstract

The implementation of the financing system in hospitals using the INA-CBGs system. The INA-CBGs system is a payment made at a package rate covering all components of resources in hospitals used in services, both medical and non-medical services. This research aims to identify the application of the INA-CBGs system and factors influencing the 6M method. The method used in this research is descriptive analysis with a qualitative approach. Descriptive analysis is the process of analyzing, explaining and summarizing events and phenomena from data obtained through interviews and field observations directly regarding the use of the INA-CBGs system. The results showed that the influence factor in the use of the INA-CBGs system can be reviewed from 6M. Man, the influence of humans is the incompatibility of the required crew with officers who do three jobs at once, the incompatibility of the educational background of outpatient coding officers with professional standards and the lack of implementation of special training regarding the INA-CBGs system. Materials, the influence of this factor is the unavailability of ICD-10 and ICD-9-CM books in casemix. Machines, the influence of machine factors, namely sometimes the internet is less stable and the lack of printer machines provided. Methods, the influence of the method factor, namely the unformed SPO from the hospital regarding the use of the INA-CBGs system. Money, the supporting factor is that there is a reward in overtime to encourage officers, while the obstacle is the difference in hospital costs and INA-CBGs packages. Market, supporting influence in the target market, namely inpatient BPJS patients with class 3 selection.
Ketepatan Kodifikasi Penyebab Dasa Kematian pada Resume Medis di RSKD Duren Sawit Tahun 2022 Rosa Patricia; Deasy Rosmala Dewi; Puteri Fannya; Daniel Happy Putra
SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat Vol. 2 No. 4 (2023): Oktober 2023
Publisher : Yayasan Literasi Sains Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.55123/sehatmas.v2i4.2545

Abstract

Coding accuracy, namely the process of conformity of the diagnosis code that has been set by the coding officer based on ICD-10 which greatly affects data reporting and administration. The basic cause of death is the course of any disease, sick condition, or injury that causes or causes the accident that causes death. The purpose of this study was to determine the accuracy of the underlying cause of death code based on the selection rule and the MMDS table in patients who died at the Duren Sawit Hospital in 2022. This study used a descriptive method with a quantitative approach which took 88 samples using a saturated sample technique by means of observation and interviews. The results of the study were obtained from 88 samples of the accuracy of the basic causeof death codes based on the general principle selection rule and rule 1 at the Duren Sawit RSKD found that 49 (56%) and 39 (44%) were incorrect. There are factors that affect the inaccuracy of using the 5M elements (Man, Money, Material, method, Machine), namely the man element because the coding officer's profession is not appropriate and less thorough and the elements of the general coding SPO method which are still being revised, do not use selection rules and MMDS tables. Suggestions that officers should be given socializationabout the selection rules and MMDS tables.
Perencanaan Kegiatan Retensi Rekam Medis di Rumah Sakit Islam Jakarta Pondok Kopi Diva Angelita; Puteri Fannya; Deasy Rosmala Dewi; Daniel Happy Putra
SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat Vol. 3 No. 3 (2024): Juli 2024
Publisher : Yayasan Literasi Sains Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.55123/sehatmas.v3i3.3931

Abstract

Medical record retention (shrinkage) is the reduction of archives through the process of sorting documents 5 years after the patient dies or the last date of treatment. This study aims to plan medical record retention activities at RSIJ Pondok Kopi to overcome the problem of file accumulation, improve the efficiency of medical record management, and support better health services. This study uses a qualitative descriptive method and is sourced from 4 informants consisting of the head of medical records and medical record officers, in attracting informants using purposive sampling techniques. In the initial observation, the Jakarta Islamic Hospital Pondok Kopi has not resumed retention of medical records for the last 4 years due to hospital policies regarding service priorities. The results of this study indicate that RSIJ Pondok Kopi already has adequate retention SOPs, but has not retained medical records since 2020. This has resulted in the accumulation of medical record files in the storage room. Based on the results of the study, it can be concluded that RSIJ Pondok Kopi needs to immediately implement medical record retention to overcome the problem of file accumulation. The retention activity plan was made as input for retention so that it can overcome the problems in the medical record unit due to not having medical record retention.
Tinjauan Lama Waktu Tunggu Pelayanan Pasien Rawat Jalan Poli Jantung di Rumah Sakit Angkatan Laut Marinir Cilandak Tahun 2022 Fingky Rizki Wulandari; Puteri Fannya; Deasy Rosmala Dewi; Daniel Happy Putra
Student Scientific Creativity Journal Vol. 1 No. 4 (2023): Juli : Student Scientific Creativity Journal
Publisher : Pusat Riset dan Inovasi Nasional

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.55606/sscj-amik.v1i4.1548

Abstract

Patient is a person who, directly or indirectly, consults a doctor or medical service about a health problem in order to receive the medical care the patient needs. After registering, patients need to wait until they get health services from the intended poly. The waiting time is understood as the time required from the arrival of the patient to the moment when the specialist performs the service. This study aims to review the length of waiting time for cardiac outpatient services at the Cilandak Marine Marine Hospital in 2022 using a quantitative approach with descriptive research methods, namely conducting direct interviews with outpatients and directly reviewing the length of waiting time for patients. 74 patient samples, there were 23 patients (31.08%) whose waiting time was appropriate or below the minimum service standard of waiting time (≤60 minutes), while for 51 patients (68.92%) the waiting time did not meet the minimum service standard of time. waiting time (>60 minutes), with an average patient waiting time of 96 minutes. The fastest waiting time for patients is 41 minutes, while the longest waiting time for patients is 173 minutes. Factors that cause long waiting times for outpatients are the inadequate number of medical record officers and medical personnel, the number of patients who come at the same time, causing queues at the registration counter and queues at the poly, doctors' practice hours are quite at odds with registration hours at the counter, negligence of the patient when registering, not carrying a medical card, not carrying the necessary documents, and not the patient concerned who registers, and the number of medical personnel and officers is not sufficient.
Co-Authors -, Muniroh Adelia Anggraini Adham, Yunan Adijaya, Nuryansyah Adil Hidayat Ahmad Hikmi Aldio Ahmad Ripki Al Faqih, M. Rolan Tiro Aldio, Ahmad Hikmi Almahshunatul Hanifah Alumni STIKES Husada Borneo Anastasyannisa Ramadhanty Angela Marsiana Siki Angelina, Noviana Dian Anggraini, Adelia Ani Kipatul Hidayah Anisa Batunnajariah Anisa Nur Safitri Anjar Retno Astrini Ardianti, Tita Arip Budiana Athirah Iwani Rahman Athiyyah, Hanifatul Bahlani Bayu Fajar Ilhami Budiana Gustiara Carono Cindi Trisa Olivia Daniel Happy Putra Dede Lisda Nurjanah Dede Lisda Nurjanah Deta Nurfena Nurfena Diah putri Ayu Islammia Dian Nur Muslimah Dianty, Gebbrien Anggia Dinda Melani Safitri Dion Angger Priyatama Diva Angelita Dwijayanti, Risma Mei Edi Kurnianto Elina Intan Apzari Endang Palupi Ningsih Fannya, Puteri Fatkhurohman, Mohammad Fajri Fatkur Ridho Fauzan Habibilah Fauziah Irfany Febri Irawan Febriyan Awi Pasa Feni Fajriani Fingky Rizki Wulandari Fitria Atmojowati Gina Sonia Gussa Azizah Hardi Arissaputra Hari Rinaldi Ilham Abdurohman Ilhami, Bayu Fajar Iman Harapan Jaya Zalukhu Indawati, Laela Indrawati, Laela Intan Novarinda Iqbal, Muhammad Fuad Kirani, Niken Leni Karunia Septiani Mekhtildis Suryati Muammar Dzachwani Muhamad Al Imran Rangga Putra Munazhifah Munazhifah Muniroh Muniroh - Muniroh Muniroh Muniroh Muniroh Muniroh Muniroh Nabila Raihani Nabila Zahara Ramadan Nanda Aula Romana Nanda Aula Rumana Nanda Rumana Navry Nanda Aprilian Noviana Dian Angelina Nur Fadilah Nurasiyah Nurfena, Deta Nurfena Nurhaliza Putrikama Nurmalasari, Dinda Nurmalasari, Mieke Paryati Paryati Purwoko, Agus Putri, Alifatul Aulia Sagita Putri, Dwi Tania Putri, Sisilia Raru, Amida Morina Ratna Auliyana Retno Juwita Rianta Sari Gultom Rosa Patricia Safitri, Dinda Melani Salsabella, Pradita Sansy Dua Lestari Selvi Damayanti Silfa Haniasti Siswati Siswati Siswati Siswati Siswati Siva Maulia Fauziah Sri Kholifatun STIKES Husada Borneo Suprobowati Suprobowati Suryati, Mekhtildis Sutarto, Mutia Syafitri, Umi Syifa Erintan Temesvari, Nauri Anggita Umi Syafitri Vania Rachma Putri Viatiningsih, Wiwik Wahyudi Prasetyo Widjaja, Liliy Widjaja, Lily Willy Haposan Winda Indri Anggraeni Windiana Mega Sukmawati Wini Wini Yeni Safitri Yulia, Noor