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Tinjauan Ketepatan Pengodean Diagnosis Penyebab Dasar Kematian pada Pasien Diabetes Mellitus di RSU UKI Jakarta Dinda Nurmalasari; Lily Widjaja; Deasy Rosmala Dewi; Laela Indawati
Cerdika: Jurnal Ilmiah Indonesia Vol. 2 No. 4 (2022): Cerdika: Jurnal Ilmiah Indonesia
Publisher : Publikasi Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (3528.296 KB) | DOI: 10.59141/cerdika.v2i4.374

Abstract

Determination is a precaution and the accuracy of disease codes can be easily identified into correct and incorrect codes, Correct codes are adjusted in ICD-10 then incorrect codes are inappropriate codes in ICD-0. The cause of death was hospital reporting. The uncertainty of the diagnostic code consists of 5m (man, money, method, machine, material) based on the interview of the coding officer that the precision of the cause of death in the diabetes mellitus diabetes is not optimum because of poor doctors' writing, the use of abbreviations in the diagnosis, the lack of human resources in rmic education, no charge in coding, The method of conducting a death certificate from the medical certificate form is the cause of death at the point of immediate cause, the cause between and the underlying cause and the absence of a specialized chamber. Hence, the authors conducted a study on the correctness of the causes of death in diabetes patients mellitus according to the icd-10. The purpose of this study was to understand the precision of the diagnosis of the causes of death in the diabetes patient mellitus in Jakarta general hospital. Based on a study of the 72 medical records of patients dying of the precision of the cause of death in diabetes patients mellitus in Jakarta general in 2017-2020.
Tinjauan Kebutuhan Rak Penyimpanan Rekam Medis di Rumah Sakit Annisa Bogor Tahun 2022 Annisa Nur Salsabila; Wiwik Viatiningsih; Lily Widjaja; Laela Indawati
Cerdika: Jurnal Ilmiah Indonesia Vol. 2 No. 7 (2022): Cerdika: Jurnal Ilmiah Indonesia
Publisher : Publikasi Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (757.525 KB) | DOI: 10.59141/cerdika.v2i7.436

Abstract

Hospital is a health service institution by providing outpatient and inpatient services. Each hospital also has an obligation to have a Medical Record Unit. Medical records are files that contain records or documents such as patient identities, results of diagnoses, actions, and treatments as well as services that have been provided to patients. In the context of administering medical records, health service facilities are required to provide the necessary facilities. One of them is a medical record storage rack to store medical records. Based on the results of research at the Medical Record Unit of the Annisa Hospital, Bogor, it was found that the medical record storage rack was inadequate and some medical records were piled on the floor, making it difficult for officers to find medical records when needed and services at the polyclinic became hampered. The purpose of this study was to determine the need for medical record storage racks for the next 5 years at Annisa Hospital Bogor in 2022. The study was conducted using a quantitative descriptive method, using a non-random sampling method with saturated sampling technique. From the results of the study, the Annisa Bogor Hospital still lacks medical record storage rack facilities which currently have 12 wooden shelves and 3 Roll O'packs, an additional rack of 9 Roll O'packs is needed. The storage area at Annisa Hospital Bogor is sufficient because the area needed for the next 5 years is 61.3 m2. Meanwhile, the current room area is 120 m2 combined with the medical record officer's workspace.
Tinjauan Pelaksanaan Penyusutan Rekam Medis Inaktif di Rumah Sakit Islam Jakarta Cempaka Putih Tahun 2021 Hanum Milla Kurnia; Laela Indawati; Nanda Aula Rumana; Siswati Siswati
Cerdika: Jurnal Ilmiah Indonesia Vol. 2 No. 9 (2022): Cerdika: Jurnal Ilmiah Indonesia
Publisher : Publikasi Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (345.712 KB) | DOI: 10.59141/cerdika.v2i9.443

Abstract

Depreciation is an activity to reduce medical records from storage shelves by moving active medical records to inactive medical records. Depreciation of medical records needs to be done and considered, if the depreciation is not carried out with the addition of medical records that continues to increase, it will cause a buildup of medical record archives. This study aims to determine how the implementation of inactive medical record shrinkage at the Islamic Hospital Jakarta Cempaka Putih. This research method uses a descriptive method with a qualitative approach consisting of 3 informants, namely 1 head of medical records and 2 medical record officers. Based on the results of the study, it was found that the Islamic Hospital of Jakarta Cempaka Putih already had standard operating procedures related to shrinkage (retention) and destruction. The medical record unit depreciates medical records referring to the existing SOP. In carrying out the depreciation of the Jakarta Cempaka Putih Islamic Hospital, there were several things that had not been implemented, such as media transfer and extermination. The obstacle factors that occur in the implementation of depreciation are lack of human resources and there are still many medical records that accumulate because they have not been done entirely. Suggestions for the Islamic Hospital of Jakarta Cempaka Putih to make Standard Operating Procedures regarding the depreciation of inactive medical records, make decisions on medical records based on useful and not useful values, suggestions for Human Resources (HR) in the depreciation implementation section set a schedule so that the depreciation process can conducted.