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All Journal International Journal of Electrical and Computer Engineering International Journal of Evaluation and Research in Education (IJERE) Media Kesehatan Masyarakat Indonesia NUTRIRE DIAITA Jurnal Kebijakan Kesehatan Indonesia UNEJ e-Proceeding JIPI (Jurnal Ilmu Perpustakaan dan Informasi) Public Health of Indonesia Indonesian Journal of Artificial Intelligence and Data Mining Jurnal Kesehatan Medika Saintika Jurnal Ilmiah Bidan Jurnal Manajemen Kesehatan Yayasan RS.Dr. Soetomo Window of Health : Jurnal Kesehatan JOURNAL OF SCIENCE AND SOCIAL RESEARCH Jurnal Manajemen Informatika Jurnal Kesehatan Indonesia Jurnal Manajemen Informasi Kesehatan Indonesia (JMIKI) Indonesian of Health Information Management Journal (INOHIM) Health Information : Jurnal Penelitian PREPOTIF : Jurnal Kesehatan Masyarakat Jurnal JTIK (Jurnal Teknologi Informasi dan Komunikasi) Jurnal Ners Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Journal of Nursing and Public Health (JNPH) Indonesian Journal of Global Health research Infokes : Jurnal Ilmiah Rekam Medis dan Informasi Kesehatan Jurnal Health Sains Jurnal Kesehatan Tambusai J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan MAHESA : Malahayati Health Student Journal Health Publica : Jurnal Kesehatan Masyarakat International Journal of Science and Society (IJSOC) AKADEMIK: Jurnal Mahasiswa Ekonomi & Bisnis Jurnal Ilmu Komputer dan Teknologi (IKOMTI) Sehat Rakyat: Jurnal Kesehatan Masyarakat Malcom: Indonesian Journal of Machine Learning and Computer Science Jurnal Sosial dan Sains Indonesian Journal of Health Information Management Services (IJHIMS) Eduvest - Journal of Universal Studies Jurnal Penelitian Sistem Informasi International Journal of Health and Information System (IJHIS) Detector: Jurnal Inovasi Riset Ilmu Kesehatan Promotor: Jurnal Mahasiswa Kesehatan Masyarakat Al Makki Health Informatics Journal E-Amal: Jurnal Pengabdian Kepada Masyarakat Holistik Jurnal Kesehatan Jurnal Akuntansi, Ekonomi dan Manajemen Bisnis Jurnal Informatika Dan Tekonologi Komputer
Hosizah Hosizah
Universitas Esa Unggul
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Pengaruh Kepuasan Kerja terhadap Disiplin Kerja Perekam Medis Informasi Kesehatan (PMIK) di Wilayah DPD PORMIKI DKI Jakarta Nanda Dina Cahya; Husni Abdul Muchlis; Hosizah Hosizah; Nauri Anggita Temesvari
Jurnal Akuntansi, Ekonomi dan Manajemen Bisnis Vol. 5 No. 3 (2025): November : Jurnal Akuntansi, Ekonomi dan Manajemen Bisnis
Publisher : Lembaga Pengembangan Kinerja Dosen

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.55606/jaemb.v5i3.7149

Abstract

Problems related to work discipline among Medical and Health Information Recorders (PMIK) observed during fieldwork practice in hospitals include non-compliance with punctuality, delays in completing tasks, and ineffective use of break time. These conditions indicate that the level of work discipline among PMIK personnel is suboptimal, which may affect productivity and service quality. Job satisfaction is one of the factors presumed to influence work discipline. This study aimed to examine the effect of job satisfaction on work discipline among PMIK members within the DPD PORMIKI DKI Jakarta area. A quantitative approach with a cross-sectional design was employed. Using a quota sampling technique, 94 respondents were selected from a total population of 1,490. The results showed that job satisfaction had a positive and significant effect on work discipline (p-value = 0.000). The regression equation obtained was Y = 5.288 + 0.606X. Job satisfaction accounted for 75.1% of the variance in work discipline, while the remaining 24.9% was influenced by other factors not examined in this study. Therefore, efforts to enhance job satisfaction are essential to improve work discipline among PMIK professionals.
Analysis of the Factors Influencing the Coding Quality in East Java Hospital of Indonesia: Diabetes Mellitus as A Case Study Markam, Hosizah; Ningsih, Kori Puspita; Widjaja, Lily; Nisak, Umi Khoirun; Marzo, Roy Rillera; Siswati
Window of Health : Jurnal Kesehatan Vol 8 No 2 (April 2025)
Publisher : Fakultas Kesehatan Masyarakat Universitas Muslim Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33096/woh.v8i2.1702

Abstract

Code precision has received significant attention due to the increased utilization of encoded procedural data. Coding errors have been documented in multiple research investigations. This study aims to assess the variables that affect coding quality. The prevalence of diabetes has increased substantially in the past two decades and is a significant cause of morbidity and mortality. Method: This study was conducted in 2 hospitals in East Java, Indonesia, that were selected through simple random sampling from a population of hospitals meeting the predefined inclusion criteria. The bed capacities of these hospitals are 211, with details of 62 and 149, respectively, for the specialised ones. The sample in this study was 60 medical record files taken randomly in 2022 in the case of diabetes mellitus. The result showed coding quality testing uses six elements: reliability, accuracy, relevancy, timeliness, completeness, and legibility. Data analysis was carried out analytically using the Fisher Exact test. The results of the study from 60 samples showed that four elements were significant out of a total of 6 aspects of coding quality elements. The four essential elements consisted of Accuracy (p=0.001), Reliability (p=0.001), Completeness (p=0.046), and Legibility (p=0.046). Reliability elements also impact coding accuracy or vice versa (p=0.001); Completeness also affects Legibility and vice versa (p=0.046). The odds ratio value of each component shows that Reliability and Accuracy are 8.782, which means that Reliability can increase Accuracy 8 times and vice versa. Meanwhile, completeness and legibility are at 3.818, which means completeness also increases legibility by three times and vice versa. The Hospitals should consider four significant coding quality elements, including completeness, accuracy, reliability, and legibility, for use in coding audits. Timeliness and Relevance were insignificant.
PERANCANGAN USER INTERFACE DIGITALISASI ANALISIS KELENGKAPAN REKAM MEDIS MENGGUNAKAN METODE DESIGN THINKING DI RSUD PALEMBANG BARI Yuliani, Dian; Kurniawati, Anastasia Cyntia Dewi; Hosizah, Hosizah; Ichwan, Arief
JOURNAL OF SCIENCE AND SOCIAL RESEARCH Vol 8, No 2 (2025): May 2025
Publisher : Smart Education

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.54314/jssr.v8i2.3053

Abstract

Abstract: The mandatory of Electronic Medical Records (EMR) in Indonesia encourages Health Information Recorders (HIMs) to find the best solution to maintain the quality of EMR. Although EMR has been implemented, the electronic system in hospitals does not have enough features for effective quality assurance, resulting in difficulties for HIMs in quantitative and qualitative analysis. Based on KMK HK.01.07/Menkes/1128/2022 on Hospital Accreditation Standards, if the electronic system does not support service quality assurance operations, system development is required. This study aims to design a User Interface (UI) for digitizing the completeness analysis of Medical Records (MR). The method used is design thinking with five UI principles (proximity, similarity, continuity, figure and background and common fate). Design testing using heuristic evaluation by five evaluators. The result was a UI with features of MR completeness analysis, notification, MR completeness analysis report and activity log. The three highest heuristic principles were Help and Documentation score 2.80 (major), Recognition Rather Than Recall score 2.20 (minor) and Help Users Recognize, Diagnose and Recover from Errors score 1.60 (minor). These principles have been improved according to the evaluator's recommendations. It is recommended to improve the UI to achieve a score of 0 (no problem). Keyword: Heuristic Evaluation, Medical Record Completeness Analysis, User Interface Abstrak: Kewajiban Rekam Medis Elektronik (RME) di Indonesia mendorong para Perekam Medis dan Informasi Kesehatan (PMIK) mencari solusi terbaik untuk menjaga kualitas RME. Meskipun RME telah diterapkan, sistem elektronik di Rumah Sakit (RS) belum memiliki fitur yang cukup untuk penjaminan mutu yang efektif, mengakibatkan PMIK kesulitan dalam analisis kuantitatif dan kualitatif. Berdasarkan KMK HK.01.07/Menkes/1128/2022 tentang Standar Akreditasi RS, bila sistem elektronik tidak mendukung operasional penjaminan mutu pelayanan, pengembangan sistem diperlukan. Penelitian ini bertujuan merancang User Interface (UI) digitalisasi analisis kelengkapan Rekam Medis (RM). Metode yang digunakan adalah design thinking dengan lima prinsip UI (proximity, similarity, continuity, figure and background dan common fate). Pengujian desain menggunakan evaluasi heuristik oleh lima evaluator. Hasil penelitian adalah UI dengan fitur analisis kelengkapan RM, notification, report analisis kelengkapan RM dan log aktivitas. Diperoleh tiga prinsip heuristik tertinggi yakni Help and Documentation skor 2,80 (major), Recognition Rather Than Recall skor 2,20 (minor) dan Help Users Recognize, Diagnose and Recover from Errors skor 1,60 (minor). Prinsip-prinsip tersebut telah diperbaiki sesuai rekomendasi evaluator. Disarankan untuk menyempurnakan UI guna mencapai skor 0 (no problem). Kata Kunci: Analisis Kelengkapan Rekam Medis, Evaluasi Heuristik, User Interface  
PENGARUH MOTIVASI DAN PERSEPSI MAHASISWA TERHADAP PEMILIHAN PROGRAM STUDI MANAJEMEN INFORMASI KESEHATAN DI UNIVERSITAS ESA UNGGUL JAKARTA Sihombing, Apriliana; Hosizah, Hosizah
JOURNAL OF SCIENCE AND SOCIAL RESEARCH Vol 8, No 4 (2025): November 2025
Publisher : Smart Education

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.54314/jssr.v8i4.5086

Abstract

Abstract: The Health Information Management Study Program at Esa Unggul University, Jakarta, has been around for quite a long time, but public interest in choosing this study program has not yet met the expected target. This study aims to determine the influence of student motivation and perception on the selection of the Health Information Management Study Program at Esa Unggul University, Jakarta. The study was conducted from June to August 2022. The type of research was observational with a quantitative analytical approach using a cross-sectional design. The population was 241 with a sample size of 71 students taken by simple random sampling. Data collection was carried out through a questionnaire with a Likert scale, and analyzed using multiple linear regression. Of the 71 respondents, it was found that 84% were mostly female, 33.8% were aged between 21-23 years with a high school/equivalent education, and 33.8% came from DKI Jakarta. The selection of the Health Information Management Study Program at Esa Unggul University, Jakarta, was influenced by perception (0.442) and motivation (0.354). The results of multiple linear regression showed that there was a significant influence between motivation and perception on the Selection of the Health Information Management Study Program at Esa Unggul University Jakarta (p-value 0.000 <0.05) with the equation Selection of MIK Study Program = 7.167 + 0.354 (Motivation) + 0.442 (Perception). The selection of MIK Study Program was influenced by motivation and perception by 39.9%, the rest was other variables. Keyword: Selection, Motivation, Perception Abstrak: Program Studi Manajemen Informasi Kesehatan di Universitas Esa Unggul Jakarta sudah cukup lama, namun minat masyarakat untuk memilih program studi tersebut belum sesuai dengan target yang diharapkan. Penelitian ini bertujuan mengetahui pengaruh motivasi dan persepsi mahasiswa terhadap Pemilihan Program Studi Manajemen Informasi Kesehatan di Universitas Esa Unggul Jakarta. Penelitian dilakukan pada Juni - Agustus 2022. Jenis penelitian observasional dengan pendekatan kuantitatif analitik menggunakan desain cross sectional.  Populasi sebanyak 241 dengan besar sampel 71 mahasiswa yang diambil secara simple random sampling. Pengumpulan data dilakukan melalui kuesioner dengan skala likert, dan dianalisis menggunakan regresi linier berganda. Dari 71 responden diketahui bahwa 84% Sebagian besar berjenis kelamin perempuan, 33,8% berusia antara 21-23 tahun dengan Pendidikan terakhir SMA/Sederajat serta 33,8 % berasal dari DKI Jakarta. Pemilihan Program Studi Manajemen Informasi Kesehatan di Universitas Esa Unggul Jakarta dipengaruhi oleh persepsi 0,442 dan motivasi 0,354. Hasil regresi linier berganda diperoleh bahwa ada pengaruh signifikan antara motivasi dan persepsi terhadap Pemilihan Program Studi Manajemen Informasi Kesehatan di Universitas Esa Unggul Jakarta (p-value 0,000<0,05) dengan persamaan Pemilihan Prodi MIK =  7,167 + 0,354 (Motivasi) + 0,442 (Persepsi). Pemilihan Prodi MIK dipengaruhi oleh motivasi dan persepsi sebesar 39,9%, sisanya variabel lain. Kata kunci: Pemilihan, Motivasi, Persepsi 
Hubungan Ketepatan Penulisan Diagnosis Dengan Keakuratan Kode Diagnosis Obstetri Di RSIJ Sukapura Menna, Yasinta Rosalia; Muchlis, Husni Abdul; Hosizah, Hosizah; Yulia, Noor
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 7 No 2 (2026): March
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v7i2.5435

Abstract

Accurate documentation of diagnoses in medical records is essential, as inaccurate diagnostic statements may lead to incorrect diagnostic coding. Preliminary observations indicated that among 18 medical records, 61% of diagnoses were written accurately, while 78% of diagnostic codes were accurate. This study aimed to examine the relationship between the accuracy of diagnostic documentation and the accuracy of obstetric diagnostic coding at RSIJ Sukapura Hospital. This quantitative study employed a cross-sectional design and utilized the Chi-square test, with Fisher’s exact test applied as appropriate. Based on the analysis of 92 medical records, 77.2% of diagnoses were documented accurately and 88.0% of diagnostic codes were accurate. The results revealed a statistically significant association between the accuracy of diagnostic documentation and the accuracy of obstetric diagnostic coding (p = 0.002 < 0.05; OR = 8.375). This indicates that accurate diagnostic documentation increases the likelihood of producing accurate obstetric diagnostic codes by 8.375 times. Physicians in charge are therefore expected to pay closer attention to appropriate medical terminology when documenting diagnoses to ensure greater accuracy.
Forecasting Kapasitas Tempat Tidur di Rumah Sakit Islam Jakarta Pondok Kopi Sinlae, Andrey Reynaldi Devada; Hosizah, Hosizah; Nurmalasari, Mieke
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 7 No 2 (2026): March
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v7i2.5727

Abstract

In 2022–2023, bed utilization at RSIJ Pondok Kopi was inefficient according to the Barber–Johnson (GBJ) standard, with Bed Occupancy Rates (BOR) of 53% in 2022 and 74% in 2023, both below the ideal range. This inefficiency was partly due to the absence of bed capacity adjustments based on accurate forecasting. This study aimed to conduct bed capacity forecasting at RSIJ Pondok Kopi. This applied retrospective study employed data mining techniques using Tableau with the Exponential Smoothing algorithm. Data on inpatient days and discharged patients from 1992 to 2023 were collected and processed following the Knowledge Discovery in Databases (KDD) framework. One optimal forecasting model was selected for each variable. Bed capacity projections were calculated using BOR assumptions of 75% and 85%, and Turnover Interval (TOI) assumptions of 1 and 3 days, with the Barber–Johnson chart used for evaluation. Forecasted bed requirements were estimated at 183–192 units (2024), 185–194 (2025), 187–196 (2026), 189–197 (2027), and 190–199 (2028). Compared with actual data through May 2024, the hospital had 10 excess beds. Therefore, more intensive promotional strategies are recommended to improve bed utilization.
PERANCANGAN APLIKASI SISTEM ANTRIAN PASIEN POLIKLINIK PENYAKIT DALAM DI RSUD BUDHI ASIH CAWANG JAKARTA TIMUR Rospita, Ida Putri S; Hosizah, Hosizah; Uddin, Badie
JOURNAL OF SCIENCE AND SOCIAL RESEARCH Vol 9, No 1 (2026): February 2026
Publisher : Smart Education

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.54314/jssr.v9i1.5772

Abstract

Abstract: Budhi Asih Regional General Hospital in Cawang, East Jakarta is a type B+ referral and teaching hospital with a high number of outpatient visits, particularly in the Internal Medicine Polyclinic, which serves an average of 200–250 patients daily. This condition often leads to queue congestion, long waiting times, and patient discomfort. This study aims to design a digital-based queue system application to improve service efficiency, reduce patient congestion, and provide real-time queue information. The research method applied was prototyping, consisting of user requirement identification, initial design, system testing using black box testing, followed by evaluation and revision. Data were collected through observation, interviews with three registration officers, and questionnaires. The results showed that the application performed according to user needs with minor improvements required in the user interface design. The implementation of this system is expected to reduce waiting times, enhance the regularity of service schedules, and support the achievement of hospital minimum service standards in accordance with Ministry of Health regulations. Keywords: Queue System, Prototyping, Black Box Testing, Healthcare Services, Budhi Asih Cawang Regional Hospital Abstrak: RSUD Budhi Asih Cawang Jakarta Timur merupakan rumah sakit rujukan tipe B+ pendidikan dengan jumlah kunjungan rawat jalan yang tinggi, khususnya pada Poliklinik Penyakit Dalam yang rata-rata melayani 200–250 pasien perhari. Kondisi ini kerap menimbulkan kepadatan antrean, lamanya waktu tunggu, serta ketidaknyamanan pasien. Penelitian ini bertujuan merancang aplikasi sistem antrian berbasis digital untuk meningkatkan efisiensi layanan, meminimalkan penumpukan pasien, dan menyediakan informasi antrean secara real-time. Metode penelitian menggunakan pendekatan prototyping dengan tahapan identifikasi kebutuhan (user requirement), perancangan desain awal, pengujian sistem menggunakan black box testing, serta evaluasi dan revisi. Data diperoleh melalui observasi, wawancara dengan tiga petugas pendaftaran, dan kuesioner. Hasil pengujian menunjukkan bahwa aplikasi berjalan sesuai kebutuhan pengguna dengan beberapa perbaikan minor pada tampilan antarmuka. Implementasi sistem ini diharapkan mampu mengurangi waktu tunggu, meningkatkan keteraturan jadwal pelayanan, serta mendukung pencapaian standar pelayanan minimal rumah sakit sesuai regulasi Kementerian Kesehatan. Kata kunci: Sistem Antrian, Prototyping, Black Box Testing, Pelayanan Kesehatan, RSUD Budhi Asih
PENGUKURAN BEBAN KERJA PEREKAM MEDIS DAN INFORMASI KESEHATAN PASCA PENERAPAN REKAM MEDIS ELEKTRONIK DI INSTALASI REKAM MEDIS RSUD KABUPATEN TANGERANG Ikaningsih, Kurnia Tisna; Pertiwi, Tria Saras; Hosizah, Hosizah; Temesvari, Nauri Anggita
JOURNAL OF SCIENCE AND SOCIAL RESEARCH Vol 9, No 1 (2026): February 2026
Publisher : Smart Education

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.54314/jssr.v9i1.5874

Abstract

Abstract: Workload is the accumulation of tasks and responsibilities that must be carried out by employees or staff in accordance with the targets set by their supervisors within a specific period of time. The transition from a manual system to an electronic system has the potential to affect the workload of Medical Record and Health Information (MRHI) personnel. This study aims to measure the workload of MRHI staff after the implementation of Electronic Medical Records (EMR) in the Medical Records Department, using job analysis and workload analysis methods based on Regulation of the Ministry of Administrative and Bureaucratic Reform (KEMENPAN RB) No. 1 of 2020. This is a descriptive study with a purposive sampling approach, involving 10 out of 34 MRHI staff with a D3-level education. Data were collected through interviews and direct observation.The results show that the workload for new outpatient registration is 4 minutes, returning outpatients 3 minutes, inpatients 13.4 minutes, and self-registration via APM 5 minutes—requiring 16 staff. Assembling takes 10 minutes per medical record, requiring 2 staff; outpatient coding takes 1 minute and inpatient coding 3.5 minutes per record, requiring 3 coders. Filing and distribution take 6 and 5 minutes per record respectively, requiring 6 staff. Retention and digitization of active and inactive records take 10 minutes per record, requiring 5 staff. Reporting requires 15,240 minutes in total, with 3 reporting staff. Analysis of EMR completeness requires 15 minutes per record, needing 2 expert MRHI staff, while EMR monitoring requires 3 expert MRHI staff. The total workforce required is 35 skilled MRHI personnel and 5 expert MRHI professionals. Keyword: Electronic Medical Records, Workload, Medical Record and Health Information, Job Analysis Abstrak: Beban kerja merupakan akumulasi tugas dan tanggung jawab yang harus dilaksanakan oleh karyawan atau petugas sesuai dengan target yang telah ditentukan oleh atasan dalam periode waktu tertentu. Transisi dari sistem manual ke sistem elektronik berpotensi mempengaruhi beban kerja Perekam Medis dan Informasi Kesehatan (PMIK) Penelitian ini bertujuan untuk mengukur beban kerja PMIK pasca penerapan RME di Instalasi Rekam Medis menggunakan metode analisis jabatan dan analisis beban kerja sesuai Peraturan KEMENPAN RB No. 1 Tahun 2020. Penelitian ini merupakan penelitian deskriptif dengan pendekatan purposive sampling, melibatkan 10 orang dari total 34 petugas di instalasi rekam medis dengan pendidikan D3 PMIK. Pengumpulan data dilakukan melalui wawancara dan observasi. Hasil pengukuran menunjukkan bahwa beban kerja pendaftaran rawat jalan pasien baru 4 menit,pasien lama 3 menit untuk pasien rawat inap 13,4 menit sedangkan APM 5 menit dibutuhkan sebanyak 16 petugas, Beban kerja assembling 10 menit/BRM dibutuhan 2 tenaga assembling, Beban kerja koding pasien rawat jalan 1 menit , koding rawat inap 3,5 menit/BRM di butuhkan 3 tenaga koding, beban kerja filling 6 menit/ BRM dan distribusi 5 Menit/BRM memerlukan 6 petugas, Beban kerja petugas retensi dan alih media berkas rekam medis in akif dan aktif 10 menit/BRM dan dibutuhkan 5 tenaga, Beban kerja pelaporan 15.240 menit kebutuhan tenaga pelaporan 3 petugas , beban kerja analisa kelengkapan rekam medis elektronik 15 menit/RME di butuhkan 2 tenaga PMIK ahli dan monitoring rekam medis elektroni k sebanyak 3 tenaga PMIK ahli, total kebutuhan tenaga PMIK adalah 35 tenaga PMIK terampil dan 5 orang PMIK ahli. Kata Kunci: Rekam Medis Elektronik, Beban Kerja, Perekam Medis dan Informasi Kesehatan, Analisis Jabatan
Perancangan Buku Saku Elektronik Penggunaan Kode Diagnosis JKN Rumah Sakit Soeharto Heerdjan Purba, Andrea Krisler; Muchlis, Husni Abdul; Hosizah, Hosizah; Ambarwati, Ambarwati; Muzdalifah, Ifah
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Vol. 11 No. 1 (2026): 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.v11i1.2072

Abstract

Hospitals frequently encounter challenges in the BPJS Kesehatan claims process, such as diagnostic coding errors, data discrepancies, and incomplete medical record documentation. These issues result in claims delays, financial disruptions, and a decline in service quality. This study aims to design an electronic pocketbook of National Health Insurance (JKN) diagnosis codes as a guide for healthcare workers to expedite and simplify the claims process. The study was conducted at Soeharto Heerdjan Hospital from October to December 2024 using the Research and Development (R&D) method with the ADDIE model in three stages: analysis, design, and development. Six informants from the analysis and coding unit and the patient verification and assurance unit were involved as data sources. Data collection techniques included in-depth interviews, questionnaires, and document reviews, followed by descriptive analysis. The results showed that the 34-page electronic pocketbook, designed in PDF format, contains diagnoses, ICD-10 codes, severity levels, and management procedures, with hyperlinks for easy information retrieval. The feasibility test showed a validity level of 95.8% for content and 91.6% for media. Therefore, this pocketbook is highly valid and suitable for use as a guide in the BPJS claims process, and can support work efficiency and improve the quality of hospital services.
PERANCANGAN INSTRUMEN AUDIT KUALITAS DOKUMENTASI KLINIS KASUS NON BEDAH DI RUMAH SAKIT UKRIDA Ayuningtyas, Meta; Muchlis, Husni Abdul; Hosizah, Hosizah; Temesvari, Nauri Anggita
PREPOTIF : JURNAL KESEHATAN MASYARAKAT Vol. 10 No. 1 (2026): APRIL 2026
Publisher : Universitas Pahlawan

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31004/prepotif.v10i1.57516

Abstract

Pendokumentasian berkualitas harus memenuhi kriteria kelengkapan, akurasi, ketepatan waktu, konsistensi, sehingga diperlukan audit rekam medis melalui analisis kualitatif. Hasil Observasi periode Oktober-November 2024 terhadap 80 berkas rekam medis kasus bedah menggunakan Medical Record Quality Scoring Tool (MeReQ) menunjukan Completeness 64%, Operative Procedures 78%, Acuracy 100%, Tracking 50%, Informed Consent 89%. Beberapa komponen mencapai 100% tanda vital, ringkasan pulang, catatan terapi. Selain itu komponen riwayat kesehatan keluarga 6%, pelacakan instrumen operasi 0%, alternatif 61%, data ini menunjukan kualitas dokumentasi perlu ditingkatkan. Penelitian bertujuan merancang instrumen audit kualitas dokumentasi klinis kasus non bedah di rumah sakit. Penelitian menggunakan metode Research and Development (R&D) model ADDIE, meliputi tahap analisis, perancangan, pengembangan, dan uji coba. Penelitian bulan Desember 2025. Tahap analisis melalui wawancara dengan 10 informan Dokter Spesialis, Perawat, Kepala Instalasi Rekam Medis, Tim Mutu, Verifikator Internal. Tahap perancangan dan pengembangan dengan mengintegrasikan indikator kualitas dokumentasi klinis (legible, reliable, precise, complete, consistent, clear, timely) dan Standar Akreditasi Rumah Sakit (STARKES 2024). Uji coba instrumen pada 50 berkas rekam medis kasus non bedah periode September–Oktober 2025 oleh 5 orang Perekam Medis dan Informasi Kesehatan dengan pengalaman kerja minimal 6 bulan. Uji validitas menggunakan Content Validity Index (CVI). Hasil penelitian sebagian besar item memperoleh nilai I-CVI 1,00, dua item nilai I-CVI 0,80, dan nilai S-CVI/Ave 0,98, menunjukkan validitas isi sangat baik. Instrumen audit layak digunakan sebagai alat evaluasi kualitas dokumentasi klinis kasus non bedah di Rumah Sakit UKRIDA
Co-Authors Agustin, Karisna Agustin Alita Sandy Putriani Alumni STIKES Husada Borneo Amanda Ambarwati Ambarwati Ambarwati Anastasia Cyntia Dewi Kurniawati Andani, Evi Andry Arief Ichwan Aris Susanto Atmojowati, Fitria Ayuningtyas, Meta Azza, Azizatul Badie Uddin Basuki Hari Brian Jodi Darmawan, Lusiana Davina Afifah Zahra Dedy Kurniawan Desi Aryani desi aryani Desviyanti Eka Saputri Dewi Krismawati Dewi, Sukmala Dhiar Niken Larasati Dian Yuliani Dita Manisha Amrina Putri Ditya Pratama Duta Liana Dyah Kurniawati Endang Titi Amrihati, Endang Titi Eva Rahmawati Fachmi Tamzil Firdayana Firdayana Gita Fitrisia Hari Basuki Harna, Harna Hera Adrianti Herey, Peter Herlina Afrelina Herliza Husni HILHAMI, HILHAMI Husni Abdul Muchlis Husni, Herliza Ichwan, Arief Ichwani, Arief Ida Putri S Rospita Ifah Muzdalifah Ifah Muzdalifah Ikaningsih, Kurnia Tisna Indah Cahyani Buana Irmawan, - Ismi Azizah Jayanti Aswinasih Jayanti Lestari Jihan Saskia Salsabilla Julianti, Anissa Julita D. L. Nainggolan JUS’AT, IDRUS Kholida Syiah Nasution Krismawati, Dewi Kuntoro Kuntoro Kuntoro Kuntoro Kurnia Tisna Ikaningsih Kurniawati, Anastasia Cyntia Dewi Larasati , Dhiar Niken Latumapina, Stella Florence Imanuela Lazuardy, Achmad Sirri Lepong, Maria Lestari, Jayanti Lisda Novilia Lusiana Darmawan maria Hiasinta Meo Marzo, Roy Rillera Mauren Michaela, Sarah Menna, Yasinta Rosalia Meo, maria Hiasinta Michaela, Sarah Mauren Mitha Mandasary Mulyo Wiharto Munggaran, Rahayu Putri Mustikawati, Intan Silviana Muzdalifah, Ifah Nadri Aulia Fathia Nanda Dina Cahya Nauri Anggita Temesvari Nisa Rafilda Khafidah Nofierni Nofierni Novi Mulyani Putri Nungky Nurkasih Kendrastuti Nurhasanah, Raden Nurmalasari, Mieke Oktavianti, Putri Panutun, Satria Bagus Peter Herey Peter Herey Purba, Andrea Krisler Purwanti, Amalia Indah Puspita, Kori Putri, Tacyah Kholifah Qomarania, Witri Uama Rafidah, Arlien Rona Rahmawati Rahmawati Rahmawati, Danisa Ocha Rahmayani, Kamila Zainab Ramadhani, Rizky Ramdhan, Yanuar Regy Permata Sari Resia Perwirani Rina Anindita Rina Mutiara Rina Mutiara, Rina Rina Yuliana Rischa Zahra Bellanisa Rosida, Putri Lailatul Rospita, Ida Putri S Rubina, Tirzhana Jean Rusman Efendi Salsabilla, Jihan Saskia Salshabila, Andini Dwi Sansy Dua Lestari Putri Azah Saqil Ahmad Saragih, Pestaria Sari Dewi Lamsir Seiswati, Siswati Sella Yossiant Selviani, Selviani Sihombing, Apriliana Silalahi, Rani Gartika Holivia Sinlae, Andrey Reynaldi Devada Siswati Siswati Seiswati Sri Jumiati Agustina Sri Rahayu STIKES Husada Borneo Sulistianingsih Sulistianingsih Sunarti Susi Arianti Sutanto, Imam Temesvari, Nauri Anggita Tita Ardianti Tria Saras Pertiwi Umi Khoirun Nisak Widjaja, Lily Widodo, Agus Widodo Witri Uama Qomarania Witri Zuama Witri Zuama Qomarania Witri Zuama Qomarania Wittri, Zalipa Yani Haida Shanti Yati Maryati Yati Maryati Yoga Utomo Yosi Siti Nur Azizah Yulia, Noor Yuliani, Dian Yuniana Eka Pratiwi Yunita Fauzia A. Yunita Fitri Widiyawati Yusnaeni Yusnaeni Yusnaeni Yusnaeni, Yusnaeni Zuama, Witri