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Fannya, Puteri
Univeritas Esa Unggul
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Ketersediaan Rekam Medis di Rumah Sakit Islam Jakarta Sukapura Gina Sonia; Lily Widjaja; Deasy Rosmala Dewi; Puteri Fannya
SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat Vol. 1 No. 2 (2022): April 2022
Publisher : Yayasan Literasi Sains Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (209.548 KB) | DOI: 10.55123/sehatmas.v1i2.110

Abstract

The medical record is an administration system that records all diagnoses and actions followed by the storage of medical records. Medical record retrieval is an important part to support the effectiveness of services in providing medical records for patients who return to the hospital. This research method uses quantitative descriptive and data collection techniques by observation, interviews and literature study. Based on the results of the research, the filing officer of the Islamic Hospital of Jakarta Sukapura often faced problems during retrieval, the results of the study found that 17 (3.4%) medical records were not found and 26 (5.2%) medical records were misplaced. Factors inhibiting the implementation of medical record retrieval include man factors such as the educational background of officers and the habitual factor of officers who do not use tracers when carrying out medical record retrieval that is not in accordance with SPO at the Islamic Hospital of Jakarta Sukapura. The money factor does not affect the implementation of medical record retrieval. The machine factor is the SMART system for medical record data entry that comes off the shelf. The method factor is that the standard operating procedure for retrieval of medical records is not fully appropriate. The material factor is the absence of loan receipts.
Tinjauan Waktu Pengembalian Berkas Rekam Medis Pasien Covid Di Rumah Sakit Sumber Waras Dede Lisda Nurjanah Dede Lisda Nurjanah; Daniel Happy Putra; Puteri Fannya; Deasy Rosmala Dewi
SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat Vol. 1 No. 2 (2022): April 2022
Publisher : Yayasan Literasi Sains Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (235.197 KB) | DOI: 10.55123/sehatmas.v1i2.247

Abstract

The return of patient documents is a component part that has a role for medical records. Standard Operating Procedures (SOP) for Sumber Waras Hospital for the standard time for returning patient documents is 1 x 24 hours after the patient is declared home. The return of patient documents at the Sumber Waras Hospital in March - April 2021 for Covid patients is known from 80 medical record documents the rate of inaccuracy of returns is 25 (31.25%). So the reason for this research is to find out the timeliness of returning the medical record documents of Covid patients at Sumber Waras Hospital. This research uses quantitative descriptive method. The sample in this observation was obtained from the length of time the medical record was returned to the medical record unit. Sampling using Simple Random Sampling. Information was collected using checklists, expedition books and interview guides. The factor causing the inaccuracy of the medical record documents for Covid patients at the Sumber Waras Hospital is the 5M component with the delay in returning medical records. This problem will cause delays in services for Covid patients who will carry out re-control. Therefore, it is necessary to disseminate the Standard Operating Procedure (SOP), with the aim that the reporting of patient medical data can run well.
Tinjauan Peranan Koder Dalam Pengajuan Berkas Klaim BPJS Kesehatan Pasien Rawat Inap Di RSUD DR. R.M. Djoelham Kota Binjai Mordekhai Immanuel Sitorus; Noor Yulia; Puteri Fannya; Nanda Aula Rumana
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Vol. 7 No. 1 (2022): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Februari
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v7i1.722

Abstract

Submission of claim files to BPJS Health is carried out every 10th of the month, BPJS Health will provide information whether the claim file is feasible or not. If the claim file is not feasible, it needs to be corrected. The purpose of the research is to describe the role of the coder in filing claims for BPJS Health inpatients at RSUD Dr. R.M. Djoelham Binjai City. The research method used is descriptive method with a quantitative approach. The sample uses 43 claim files returned by BPJS Health in April and May 2021 and also interviews with two coders. Data is collected by using observation with a checklist instrument and interviews with interview guidelines. The result shows that the hospital does not have standard operating procedures related to the submission of BPJS Health claim files, from 276 files (100%) submitted in April and May 2021, there were 233 files (84,42%) that deserve to be claimed and 43 files (15,58%) that were returned (not eligible). The reasons for the return were due to confirmation of diagnosis (18,60%), medical support (25,58%), indications for hospitalization (16,28%), coding (11,63%), purification failure (6,98%) and other causes (20,93%). The roles of the coder in handling claim files are assembling, determining the primary diagnosis code and secondary diagnosis based on ICD-10, determining the code of action (procedure) based on the ICD-9-CM, and coordinating with various internal parties for the completeness of the BPJS Health claim file. Suggestions for hospital to make standard operating procedures related to claim files submission and coders to be more thorough in preparing the complete claim files.
Analisis Kuantitatif Kelengkapan Formulir Pengkajian Medis Awal Dokter Pada RM Pasien Rawat Inap Di RS Vertikal Jakarta Timur Sarah Khonsa; Lily Widjaja; Muniroh Muniroh; Puteri Fannya; Yenni Syafitri
Indonesian Journal of Health Information Management Vol. 2 No. 2 (2022)
Publisher : Sekolah Tinggi Ilmu Kesehatan Mitra Husada Karanganyar

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.54877/ijhim.v2i2.64

Abstract

Rekam medis wajib dibuat oleh rumah sakit dan diisi lengkap dan jelas baik secara tertulis maupun elektronik. Formulir pengkajian medis awal dokter pasien rawat inap merupakan isi dari bagian rekam medis. Di RS Vertikal Jakarta Timur, pengisian formulir pengkajian medis awal dokter pasien rawat inap masih belum lengkap sehingga nilai gunanya menjadi kurang maksimal. Data yang dianalisis adalah formulir pengkajian medis awal dokter rm pasien rawat inap bulan desember 2020. Tujuan dilakukan penelitian ini adalah untuk mengidentifikasi SPO pengisian pengkajian medis awal dokter pasien rawat inap, menghitung kelengkapan pendokumentasian lembar pengkajian medis awal dokter pasien rawat inap berdasarkan analisis kuantitatif, mengidentifikasi faktor-faktor yang menghambat kelengkapan pengkajian medis awal dokter pasien rawat inap. Analisis kuantitatif merupakan melihat keseluruhan isi dari rekam medis untuk mengidentifikasi terjadinya kekurangan. Penelitian menggunakan metode secara deskriptif kuantitatif dan pengambilan sampel menggunakan simple random sampling. Berdasarkan hasil penelitian SPO pengisian pengkajian medis awal dokter pasien rawat inap sudah ada. Hasil analisis kuantitatif terhadap 90 formulir pengkajian medis awal dokter pasien rawat inap didapat rata-rata kelengkapan sebesar 81%. Faktor penyebab ketidaklengkapan pengisian formulir pengkajian medis awal dokter pasien rawat inap adalah kurangnya tingkat kepatuhan dokter dalam mengisi formulir pengkajian medis awal rawat inap, sehingga banyak formulir tidak terisi secara lengkap. Oleh karena itu, disarankan agar meningkatkan sosialisasi SPO pengisian formulir pengkajian medis awal dokter rawat secara lengkap terutama kepada dokter dan tenaga kesehatan terkait.
GAMBARAN PELAKSANAAN PATIENT SAFETY SEBAGAI SALAH SATU INDIKATOR MANAJEMEN MUTU DAN RISIKO RUMAH SAKIT (LITERATURE REVIEW) Hardi Arissaputra; Puteri Fannya; Deasy Rosmala Dewi; Daniel Happy Putra
Journal of Innovation Research and Knowledge Vol. 1 No. 10: Maret 2022
Publisher : Bajang Institute

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (293.816 KB)

Abstract

Rumah sakit merupakan tempat untuk mendapatkan kesehatan dan keselamatan pasien. Keselamatan pasien merupakan prioritas utama bagi semua petugas rumah sakit, karena dengan mengutamakan keselamatan pada pasien itu dapat berpengaruh dalam meningkatkan kualitas rumah sakit. Tujuan dalam penelitian ini adalah untuk mengetahui gambaran pelaksanaan patient safety di RS berdasarkan 6 sasaran keselamatan pasien. Penelitian ini menggunakan metode literature review. Hasil penelitian ini berdasarkan tinjauan literature review terhadap 6 jurnal yang membahas tentang pelaksanaan patient safety berdasarkan 6 sasaran keselamatan pasien didapati persentase tertinggi sebesar 100% dan terendah 50% pada sasaran 1. Untuk sasaran ke-2 didapati persentase tertinggi 100% dan terendah 56.1%. Untuk sasaran ke-3 didapati persentase tertinggi 100% dan terendah 36.8%. Untuk sasaran ke-4 didapati persentase tertinggi 100% dan yang terendah 59.8%. Untuk sasaran ke-5 didapati persentase tertinggi 89.7% dan terendah 50.5%. Untuk sasaran ke-6 didapati persentase tertinggi 100% dan terendah 61.7%. Disarankan agar stok gelang selalu tersedia, selanjutnya selalu konfirmasi kembali saat menerima perintah dari dokter, disarankan juga agar selalu memberikan tanda pada jenis obat tertentu dan untuk tenaga kesehatan agar tidak melakukan hal yang dapat berisiko bagi kesehatan pasien.
Tinjauan Pelaksanaan Controlling (Pengawasan) Sistem Penjajaran Rekam Medis di Rumah Sakit Annisa Cikarang Nurhaliza Putrikama; Deasy Rosmala Dewi; Puteri Fannya; Nanda Aula Rumana
Sehat Rakyat: Jurnal Kesehatan Masyarakat Vol. 1 No. 3 (2022): Agustus 2022
Publisher : Yayasan Pendidikan Penelitian Pengabdian Algero

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.54259/sehatrakyat.v1i3.1089

Abstract

Medical records are one of the important files in health care facilities, both in clinics, health centers and hospitals because they contain a patient's medical history. In order to keep these medical records available when needed, supervision is needed. Thus, from the supervision of the implementation of medical records in the filing room of hospital institutions, the process can be known, whether there are deviations or errors and the extent of errors that occur in the process. Research on the implementation of the Controlling (Supervision) medical record alignment system was carried out at the Annisa Cikarang Hospital. This study aims to determine how the supervision of the medical record alignment system at the Annisa Cikarang Hospital. This study uses a qualitative method with informants 1 medical record coordinator, 1 person in charge of filing and 6 officers in the filing room. The results of the research obtained are that there is no SOP for alignment and supervision that has not been carried out using an expedition book. Suggestions for the Annisa Cikarang Hospital are to add procedures in the alignment to be more detailed, and to have an expedition book to make it easier to track medical records.
Tinjauan Analisis Desain Formulir Ringkasan Pulang Rawat Inap di RSUD Kabupaten Bekasi Tahun 2022 Anggita Nurul Fadlilah; Wiwik Viatiningsih; Puteri Fannya; Nanda Aula Rumana
Sehat Rakyat: Jurnal Kesehatan Masyarakat Vol. 1 No. 3 (2022): Agustus 2022
Publisher : Yayasan Pendidikan Penelitian Pengabdian Algero

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.54259/sehatrakyat.v1i3.1103

Abstract

Medical record form is a design tool with a predetermined filling limit to be used as one of the media. Inpatient discharge summary form is a brief record of the patient's condition during inpatient treatment. The purpose of this study was to determine the analysis of the inpatient discharge summary form design at the Bekasi District Hospital 2022. This study used a qualitative descriptive research method by re-examining the data that had been obtained in order to obtain valid data and classifying the data that had been obtained by entering it into a data table. then redesigned the form as a suggestion for the Bekasi District Hospital. Based on the data analysis that has been carried out, it is concluded that the Bekasi District Hospital has an SOP for Changes in Form Design which is used as a guide for any form design changes in the Bekasi District Hospital which has been determined by the Director of the Bekasi District Hospital on December 27, 2017. The results of the analysis carried out on Inpatient discharge summary form on physical, anatomical and content aspects shows that the paper used is still using NCR 55 gsm, the title of the form is still using an Inpatient Medical Resume not using the title of the Inpatient Discharge Summary form, on the form there is no edition number and page number, no there are instructions in filling out the form, there are unusual abbreviations such as ICD-9 CM and ICD-10 CM and there is a "/" symbol which means or.
PERANCANGAN SISTEM INFORMASI DAN PENDAFTARAN ONLINE DI LINGKUNGAN HOME CARE KESEHATAN: STUDI KASUS DI PRAKTIK DR NOVITA MARTA TUMANGGOR Bagas Saputra; Daniel Happy Putra; Puteri Fannya; Laela Indawati
Jurnal Kesehatan Tambusai Vol. 3 No. 3 (2022): September 2022
Publisher : Universitas Pahlawan Tuanku Tambusai

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31004/jkt.v3i3.6913

Abstract

Pemanfaatan teknologi dan perkembangan teknologi saat ini telah berkembang pesat dimana hampir setiap kegiatan di lakukan sehari-hari tidak dapat di pisahkan dari pengaruh teknologi informasi, baik sebagai penunjang kebutuhan sehari-hari maupun untuk kebutuhan bisnis yang baik. dr Novita Marta Tumanggor  adalah layanan kesehatan mandiri yang berlokasi di Kalimantan utara. Demi memenuhi kebutuhan dalam layanan pasien maka perancangan sistem pendaftaran pelayanan pasien berbasis komputer benar-benar sangat diperlukan untuk mencapai pelayanan kesehatan yang sangat optimal. Pendaftaran pasien pada layanan home care dilakukan diruang home care yang penjadwalanya masih menggunakan nomor antrian sehingga pasien harus antri diruang klinik untuk menunggu nomor antrian pelayanan yang mengakibatkan penuhnya ruangan pada satu waktu. Pengembangan sistem yang akan digunakan yaitu dengan menggunakan metode waterfall, dengan melakukan pendekatan secara sistematis dan urut mulai dari level kebutuhan sistem lalu menuju ke tahap analiys, design, coding dan testing, sehingga pengerjaan dari suatu sistem dilakukan secara berurutan atau secara linierPenelitian ini dilakukan dengan metode kualitatif. Metode pengumpulan data dilakukan dengan wawancara mendalam terhadap pengguna. Dalam perancangan sistem menggunakan metode waterfall dengan perancangan sistem menggunakan aplikasi wordpres. untuk menjalankan local host di gunakan software xamp dan Mysql sebagai basis data. Hasil dari penelitian ini berupa website yang dapat mempermudah dalam memberikan informasi.
TINJAUAN KELENGKAPAN REKAM MEDIS RAWAT INAP PADA KASUS DEMAM BERDARAH DENGUE DI RUMAH SAKIT ANGKATAN LAUT MARINIR CILANDAK Nur Fadilah; Deasy Rosmala Dewi; Puteri Fannya; Muniroh Muniroh
Jurnal Kesehatan Tambusai Vol. 3 No. 3 (2022): September 2022
Publisher : Universitas Pahlawan Tuanku Tambusai

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31004/jkt.v3i3.7008

Abstract

Rekam medis harus dibuat secara tertulis dan terisi dengan lengkap guna dapat dipergunakan untuk keperluan khusus. Di Rumah Sakit Angkatan Laut Marinir Cilandak  masih ditemukan rekam medis yang pengisiannya masih belum lengkap padahal rekam medis sangat penting sebagai sumber informasi untuk mengindeks rekam medis serta menyiapkan laporan ke rumah sakit dan Dinas Kesehatan. Data yang dianalisis adalah rekam medis rawat inap pada kasus Demam Berdarah Dengue. Penelitian ini menggunakan metode deskriptif, analisis yang dipakai adalah analisis kuantitatif kelengkapan rekam medis. Berdasarkan hasil penelitian terhadap 81 rekam medis rawat inap pada kasus Demam Berdarah Dengue didapatkan total kelengkapan rekam medis rawat inap pada kasus Demam Berdarah Dengue sebesar 90,12% dan 4 komponen analisis kuantitatif yaitu identitas pasien diisi dengan lengkap 86,41%, laporan penting di isi lengkap 92,59%, autentifikasi penulis diisi lengkap 85,18%, catatan yang baik di isi lengkap 96,29%. Peningkatan pengisian kelengkapan rekam medis dapat dilakukan dengan cara sosialisasi hasil pengisian rekam medis kepada dokter dan perawat, komite rekam medis sehingga menyadari bahwa pengisian dengan lengkap dapat menciptakan rekam medis yang berkualitas dan dapat di pertanggung jawabkan keaslian dari rekam medis tersebut.
GAMBARAN PENGETAHUAN TENTANG COVID-19 DAN SIKAP MAHASISWA REKAM MEDIS DAN INFORMASI KESEHATAN UNIVERSITAS ESA UNGGUL TERHADAP PROTOKOL KESEHATAN DALAM MENGHADAPI MASA PANDEMIC COVID-19 Ratna Sari; Puteri Fannya; Nanda Aula Rumana; Wiwik Vitianingsih
Nusantara Hasana Journal Vol. 2 No. 5 (2022): Nusantara Hasana Journal, October 2022
Publisher : Nusantara Hasana Berdikari

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

Abstract

The implementation of health protocols plays a crucial role in handling the Covid-19 pandemic. Breaking the chain of spread of Covid-19 is the main key to handling the Covid-19 pandemic. This can be achieved by implementing massive health protocols that are universally adhered to by all components of society. The successful implementation of this health protocol will drastically reduce the number of hospitalizations for Covid-19 patients with severe symptoms. Thus, the burden on health care facilities is reduced drastically and health workers can focus on palliative care for patients with moderate to severe symptoms. The scope of this research is the knowledge and attitudes of students towards health protocols in the Student Medical Record and Health Information study program at Esa Unggul University, Kebon Jeruk which will be held in December 2021. Which aims to find out how the description of knowledge about covid-19 and the attitude of Medical Record and Health Information students at Esa Unggul University towards health protocols in dealing with the covid-19 pandemic period. By using a quantitative descriptive method with a cross sectional approach with the sampling technique in this study using the Slovin formula. Based on the results of research conducted on 186 respondents, researchers found that the description of the level of student knowledge of health protocols in dealing with the Covid-19 pandemic was in the good category with a percentage of 98.4%. health protocols are included in the positive category with a percentage of 98.4%. The advice from the author is for students of medical records and health information at esa superior university to remain disciplined in implementing good and correct health protocols that have been set by the government in order to reduce the spread of the Covid-19 virus directly or indirectly.
Co-Authors -, Muniroh Adham, Yunan Adil Hidayat Afra, Rara Ahmad Rizky Aliyani Aliyani Alvina Amalia Amalia, Isnaini Amirah Syafiqah Zahra Anas Fajry Rhomadon Aneu Rosliana Angela Marsiana Siki Angelina Angelina Anggita Nurul Fadlilah Anisa Dyah Irawati Anisa Nur Safitri Anisa Nur Zulkarina Annida Ariyani Annisa Azzahra, Annisa Aqshal Hidayatullah Armila Astiyana Triadi Athiyyah, Hanifatul Aulia, Ni Wayan Riskita Ayu Hardianti Bagas Saputra Bangga Agung Satrya Betji Nadiana Bissilisin Brigita Natalia Br Surbakti Budi Sunaryo Budiana Gustiara Chresia Ericha Cindi Trisa Olivia Daniel Happy Putra Debbie Friscilla Carolina Manalu Dede Lisda Nurjanah Dede Lisda Nurjanah Delmi Sulastri Dessy Safutri Deta Nurfena Nurfena Dewi Kisaputri Dewi Sartika Dewi, Deasy Rosmala Dila Yuliandini Dina Munadiatu Dina Sonia Dinda Melani Safitri Diva Angelita Diva Sabina Dwi Chandrarika Putri Aulia Dwi Nurul Fadila Edi Kurnianto Endika Rachmad Fadia Eka Septiawati Faiha, Hana Fandhika, Lilin Tata Fani Nur Azizah Fathul Baari Fingky Rizki Wulandari Fiqih Nurhidayah Fretycia Laurenty Gina Sonia Hana Faiha Hardi Arissaputra Ilham Abdurohman Indawati, Laela Iqbal Tri Putra Iqbal, Muhammad Fuad Isnaini Amalia Izmi Novianita Jack Febrian Rusdi Kevin Handynata Khoirunnisa Sabiladina Lasmaria Simorangkir Lilin Tata Fandhika Lily Widjaya Lily Widjaya Lily Widjaya Listania Aisyah Putri Luthfiah Aulia Rachman M. Fuad Iqbal Maeimunah, Siti Magdalena, Selvy Manalu, Debbie Friscilla Carolina Mei Nur Khasanah Melani Aulia Mufida Mordekhai Immanuel Sitorus Muammar Dzachwani Muhamad Al Imran Rangga Putra Muhammad Arif Sutrasno Muhammad Hafiz Zuhri Munazhifah Munazhifah Muniroh Muniroh - Muniroh Muniroh Muniroh Muniroh Muniroh Muniroh Muniroh Muniroh Muniroh, Muniroh Nabila Zahara Ramadan Nabilah Khairunisa Nanda Aula Rumana Navry Nanda Aprilian Nazira Nur Amalia Nicki Nugrahaningtyas Noviliana, Tiara Nur Fadilah Nur Mawaddah, Nur Nurfena, Deta Nurfena Nurhaliza Putrikama Nurmayantih Nusamina Pulungan Piter Serhalawan, Roi Putri Rafikasani Putri Syaikhu Putri, Listania Aisyah R Gumilar Hadiningrat Rahmawati, Rena Maulina Ramadhana, Nur Fatihah Adlia Ratna Sari Rifda Ulfa Andini Rifqi Fauzan Risma Ayu Fitriyani Risma Sisni Fadilla Rizky Alfiansyah Rizky Khaerunnisa Roi Piter Serhalawan Rosa Patricia Rosfita Rasyid Rosita, Annida Ulfiar Rumana, Nanda Sabiladina, Khoirunnisa Sabina, Diva Safitri, Dinda Melani Salsabella, Pradita Salsabillah Zahrah Hayati Sarah Khonsa Seastama, Komang Cyntia Noviari Selvi Damayanti Shafa Aulia Ananda Hermanto Simorangkir, Lasmaria Siswati Siswati Siswati Sonaria Tambunan Suciyanti Suciyanti Surlialy, Dewi Sutrasno, Muhammad Arif Syahrul Dwi Ramadhani Tantri Wilananda Tedja Gurat Baktina Tri Putra, Iqbal Trideswira Tryandi Rohmadoni Usman, Nadia Salim Bin Vania Rachma Putri Viatiningsih, Wiwik Vitianingsih, Wiwik Wahyudi Prasetyo Widjaja, Lily Widjaya, Lily Winda Febriarini Windiana Mega Sukmawati Wiwik Vitianingsih Yati Maryati Yenni Syafitri Yulia, Noor