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Tinjauan Keakuratan Kode External Cause Diagnosis Cedera Kepala Berdasarkan ICD-10 Pada Rekam Medis Pasien Rawat Inap Di RSUP Dr. Soeradji Tirtonegoro Reza Widiantoro; Astri Sri Wariyanti; Ninawati
Indonesian Journal of Health Information Management Vol. 3 No. 1 (2023)
Publisher : Sekolah Tinggi Ilmu Kesehatan Mitra Husada Karanganyar

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.54877/ijhim.v3i1.97

A preliminary survey was conducted, showing that 10 out of 10 external code medical records for the diagnosis of head injuries were inaccurate. The purpose of this study was to determine the accuracy of the external cause code for diagnosing head injuries based on the ICD-10 in the medical records of inpatients at dr. Soeradji Tirtonegoro. The research type was descriptive, with a retrospective approach. The study was conducted in the filing room. Time in May 2018. The total population of medical records for inpatients diagnosed with head injuries was 175 medical records. The sample size is 44 documents, with a systematic sampling technique. The instruments used were checklists, questionnaires, and observation guidelines. How to collect data from unstructured interviews and observation. Data analysis is descriptive in nature. The results of accuracy of the code external causes a diagnosis of head injury from 44 medical record documents 100% inaccurate code. Inaccuracy is incorrect code, there are 17 cases (39%) and there is incorect 5 categories code as many as 27 cases (61%). The conclusion is that inaccuracies occur because the officer has not carried out the inclusion and exclusion guidelines on the selected code, or the bottom of a chapter, block, category, or sub category in determining the selected code, directly coding without looking at the ICD when getting external cause information that often appear, and officers do not carry out coding up to 5 character digits because the standard for coding in hospitals is 15 minutes and officers still have to do an analysis of the completeness of medical records, code for claims, code in medical records, and still input into a computer.

Interactive ICD-10-Based Morbidity Dashboard Using BPJS Central Data: A Case Study of Karanganyar Regency Wahyu Wijaya Widiyanto; Ade Amallia; Astri Sri Wariyanti
Jurnal Ners Vol. 9 No. 3 (2025): JULI 2025
Publisher : Universitas Pahlawan Tuanku Tambusai

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31004/jn.v9i3.44415

The increasing complexity of disease trends in the post-pandemic era necessitates more accessible and data-driven decision-making tools, particularly in primary healthcare services. This study aims to develop an interactive morbidity dashboard based on ICD-10 classifications using secondary data from BPJS Kesehatan. The research focuses on outpatient visit records in Karanganyar Regency from 2020 to 2024. A descriptive quantitative approach was applied, accompanied by system development using Python. Data preprocessing involved standardizing ICD-10 codes, handling missing values, and grouping by year, gender, and age category. The resulting dashboard allows users to filter morbidity trends based on demographic variables and disease categories. The ten most prevalent disease groups include respiratory, digestive, endocrine, and circulatory disorders. This dashboard facilitates data-based decision-making and enables targeted promotive and preventive interventions in primary healthcare facilities.

LITERATURE REVIEW FAKTOR YANG MEMPENGARUHI KETEPATAN PETUGAS KODING DIAGNOSIS BERDASARKAN UNSUR 5M Vera Yulianti Budiyani; Astri Sri Wariyanti; Sri Wahyuningsih
Indonesian Journal of Health Information Management Vol. 1 No. 1 (2021)
Publisher : Sekolah Tinggi Ilmu Kesehatan Mitra Husada Karanganyar

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.54877/ijhim.v1i1.3

Abstract The inaccuracy of the results of the coding of the diagnosis and medical action produced by the inpatient coder. Percentage of coding accuracy was only 74.67% while coding imprecision reached 25.33%. It is still found that the coding accuracy in providing disease coding is still not accurate. The accuracy in coding the diagnosis is of course caused by several factors according to the conditions of each health service institution. The purpose of this study was to determine the factors that influence the accuracy of coding officers in providing disease codes based on 5M management elements. The method used in this research is literature review by examining journals with criteria, namely research that has been published, at least comes from accredited journals, and journals related to factors that affect the accuracy of the officer coding the diagnosis and then presented in the form of a conclusion. The results of this study were the factors that influenced the accuracy of the coding officer in giving disease codes based on theelement man , namely the qualifications of the coder, based on theelement, it money was not coding on the 4th or 5th characters, based on theelement material, there was a doctor's writing that was not clearly legible and the usage. Unusual abbreviations, based on theelements method are the inaccuracy of selecting the main diagnosis and the absence of SPO for determining the code, based on theelement machine is the absence of supporting coding books and SIMRS is not user friendly. It was found that the use of medical terminology that was not correct made the coders misperceived so that they were wrong in giving the diagnosis code. Keywords: Coding Officer, 5M Management Elements Abstrak Ketidaktepatan hasil koding diagnosis dan tindakan medis yang dihasilkan koder rawat inap. Presentase ketepatan koding hanya 74,67% sedangkan ketidaktepatan koding mencapai 25,33%. Masih ditemukan bahwa ketepatan pengkodean dalam pemberian kode penyakit masih kurang tepat. Ketepatan dalam pengkodean diagnosis tentunya disebabkan oleh beberapa faktor sesuai kondisi masing-masing institusi pelayanan kesehatan. Tujuan penelitian ini untuk mengetahui faktor yang mempengaruhi ketepatan petugas koding dalam pemberian kode penyakit berdasarkan unsur manajemen 5M. Metode yang digunakan dalam penelitian ini adalah literature review dengan mengkaji jurnal dengan kriteria yaitu penelitian yang telah dipublikasikan, minimal berasal dari jurnal terakreditasi, dan jurnal yang berkaitan dengan faktor yang mempengaruhi ketepatan petugas koding diagnosis kemudian disajikan dalam bentuk simpulan. Hasil penelitian ini adalah faktor yang mempengaruhi ketepatan petugas koding dalam pemberian kode penyakit berdasarkan unsur man adalah kualifikasi koder, berdasarkan unsur money adalah tidak melakukan pengkodean pada karakter ke 4 maupun ke 5, berdasarkan unsur material adalah adanya tulisan dokter yang tidak terbaca dengan jelas dan penggunaan singkatan yang tidak lazim, berdasarkan unsur method adalah ketidaktepatan pemilihan diagnosis utama dan belum adanya SPO penentuan kode, berdasarkan unsur machine adalah ketidaktersediaanya buku-buku penunjang koding dan SIMRS tidak user friendly. Ditemukan penggunaan terminologi medis yang tidak tepat membuat koder salah persepsi sehingga salah dalam pemberian kode diagnosis. Kata kunci: Petugas Koding, Unsur Manajemen 5M

Perbedaan Tingkat Kepuasan Pasien BPJS Dan Pasien Non BPJS Terhadap Pelayanan Pendaftaran Rawat Jalan Di RSU Indo Sehat Kebakkramat Febriyani Fauzi Marfuah; Astri Sri Wariyanti; Trismianto Asmo Sutrisno
Indonesian Journal of Health Information Management Vol. 3 No. 1 (2023)
Publisher : Sekolah Tinggi Ilmu Kesehatan Mitra Husada Karanganyar

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.54877/ijhim.v3i1.94

Rumah Sakit sebagai salah satu fasilitas pelayanan kesehatan yang kompleks dituntut untuk memberikan pelayanan dan informasi kesehatan yang tepat dan berusaha memenuhi segala aspek mutu kesehatan dengan selalu memberikan pelayanan sebaik mungkin dan memberikan jaminan kesehatan berupa BPJS kesehatan. Tingkat kepuasan pasien dianggap sebagai salah satu dimensi yang sangat penting, berkualitas dan merupakan salah satu indikator utama dari standar suatu fasilitas kesehatan. Tujuan penelitian ini untuk mengetahui perbedaan kepuasan pasien BPJS dan non BPJS terhadap pelayanan pendaftaran rawat jalan di Rumah Sakit Umum Indo Sehat Kebakkramat. Jenis penelitian ini adalah survei analitik. Populasi yang digunakan adalah pasien rawat jalan pasien BPJS dan pasien non BPJS yang terdaftar mendapat pelayanan di rumah sakit. Cara pengumpulan data menggunakan kuesioner dan analisis data menggunakan uji Chi Square Test. Dari penelitian tersebut diketahui kepuasan pasien BPJS sebesar 76,7% dan kepuasan pasien non BPJS sebesar 60%. Hasil penelitian didapat nilai p-value 0,259 (p>0,05) yang artinya tidak ada perbedaan yang signifikan. Kesimpulan dari penelitian ini adalah tidak ada perbedaan tingkat kepuasan pasien BPJS dan pasien non BPJS terhadap pelayanan pendaftaran rawat jalan di RSU Indo Sehat Kebakkramat. Saran Kepuasan Pasien BPJS dan non BPJS di RSU Indo Sehat Kebakkramat perlu dipertahankan dan terus ditingkatkan.

Tinjauan Keakuratan Kode External Cause Diagnosis Cedera Kepala Berdasarkan ICD-10 Pada Rekam Medis Pasien Rawat Inap Di RSUP Dr. Soeradji Tirtonegoro Reza Widiantoro; Astri Sri Wariyanti; Ninawati
Indonesian Journal of Health Information Management Vol. 3 No. 1 (2023)
Publisher : Sekolah Tinggi Ilmu Kesehatan Mitra Husada Karanganyar

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.54877/ijhim.v3i1.97

A preliminary survey was conducted, showing that 10 out of 10 external code medical records for the diagnosis of head injuries were inaccurate. The purpose of this study was to determine the accuracy of the external cause code for diagnosing head injuries based on the ICD-10 in the medical records of inpatients at dr. Soeradji Tirtonegoro. The research type was descriptive, with a retrospective approach. The study was conducted in the filing room. Time in May 2018. The total population of medical records for inpatients diagnosed with head injuries was 175 medical records. The sample size is 44 documents, with a systematic sampling technique. The instruments used were checklists, questionnaires, and observation guidelines. How to collect data from unstructured interviews and observation. Data analysis is descriptive in nature. The results of accuracy of the code external causes a diagnosis of head injury from 44 medical record documents 100% inaccurate code. Inaccuracy is incorrect code, there are 17 cases (39%) and there is incorect 5 categories code as many as 27 cases (61%). The conclusion is that inaccuracies occur because the officer has not carried out the inclusion and exclusion guidelines on the selected code, or the bottom of a chapter, block, category, or sub category in determining the selected code, directly coding without looking at the ICD when getting external cause information that often appear, and officers do not carry out coding up to 5 character digits because the standard for coding in hospitals is 15 minutes and officers still have to do an analysis of the completeness of medical records, code for claims, code in medical records, and still input into a computer.

Analisis Kepuasan Pasien Terhadap Sistem Pendaftaran Online Dibanding Sistem Pendaftaran Onsite di RSUD Pandan Arang Boyolali Analysis Of Patient Satisfaction On Online Registration System Compared To Onsite Registration Systemat Pandan Arang Boyolali H: Analisis Kepuasan Pasien Terhadap Sistem Pendaftaran Online Dibanding Sistem Pendaftaran Onsite di RSUD Pandan Arang Boyolali Analysis Of Patient Satisfaction On Online Registration System Compared To Onsite Registration Systemat Pandan Arang Bo Nur’aini Uswatun Chasanah; Trismianto Asmo Sutrisno; Astri Sri Wariyanti
Indonesian Journal of Health Information Management Vol. 4 No. 2 (2024)
Publisher : Sekolah Tinggi Ilmu Kesehatan Mitra Husada Karanganyar

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.54877/ijhim.v4i2.123

Latar Belakang. Rumah Sakit Umum Daerah Pandan Arang Boyolali merupakan rumah sakit rujukan type B dengan rata-rata kunjungan pasien 250 per hari. Tergolong padat di setiap harinya. Pada tahun 2019 di RSUD Pandan Arang Boyolali telah menerapkan sistem pendaftaran secara online yang diberi nama aplikasi BAPER ( Booking Antrian Periksa ), yang dapat diakses dari rumah oleh pasien, sistem pendaftaran online ini ditujukan untuk meningkatkan mutu pelayanan di rawat jalan, akan tetapi sistem tersebut masih memiliki banyak kendala. Tujuan Mengetahui Kepuasan Pasien Terhadap Sistem Pendaftaran Online Dibanding Sistem Pendaftaran Onsite di RSUD Pandan Arang Boyolali Metode Jenis penelitian yang digunakan dalam penelitian ini adalah kuantitatif. Rancangan penelitian yang digunakan adalah komparatif. Populasi dalam penelitian adalah pasien rawat jalan yang berkunjung pada bulan November 2022 sebanyak 1.034. Teknik sampling purposive sampling. Analisa data chi square. Hasil Gambaran kepuasan pasien terhadap system pendaftaran online Sebagian besarpuassebanyak 24 responden (52,2%) Gambaran kepuasan pasien terhadap system pendaftaran onsite Sebagian besar cukup puas sebanyak 23 responden (50%). Kesimpulan. Ada perbedaan kepuasan antara sistem pendaftaran online dan onsite dengan nilai p value = 0,008

HUBUNGAN KELENGKAPAN INFORMASI PENUNJANG CT SCAN DENGAN KEAKURATAN KODE DIAGNOSIS CEREBRAL INFARCTION PADA PASIEN BPJS DI RUMAH SAKIT UMUM DAERAH KABUPATEN TEMANGGUNG UMI KHOLIFAH; ASTRI SRI WARIYANTI; ERNA ADITA KUSUMAWATI
Indonesian Journal of Health Information Management Vol. 3 No. 3 (2023)
Publisher : Sekolah Tinggi Ilmu Kesehatan Mitra Husada Karanganyar

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.54877/ijhim.v3i3.147

One of the factors that affects the accuracy of the Cerebral Infarction diagnosis code is the availability of medical information i.e the supporting result completeness of the CT Scan. The study was aimed at determining the relationship between the completeness of CT Scan supporting information and the accuracy of the Cerebral Infarction diagnosis code for BPJS patients at the Temanggung Regional Public Hospital in 2022. This type of research was analytic observational with a cross-sectional approach. The population were 115 medical record documents and that of 89 were taken as the sample by using simple random sampling. Statistical test used was Chi Square by using SPSS. The results of the study: The characteristic of the patient's age was mostly between 45 to 64 years and that of mostly were female. The length of patients’ treatment was mostly between 4 to 6 days and mostly the discharge patients by the the doctor approval. The completeness of CT Scan results was obtained 71 medical record documents which were complete (79.78%) and that of 18 (20.22%) which were incomplete. Coding accuracy resulted in 64 medical record (71.91%) which were accurate and that of 25 documents (28.09%) which were inaccurate. There was a relationship between the supporting information completeness of CT Scan and the accuracy of the Cerebral Infarction diagnosis code.

Analysis Of Patient Satisfaction On Online Registration System Compared To Onsite Registration Systemat Pandan Arang Boyolali Hospital Nur'aini -; Trismianto Asmo Sutrisno; Astri Sri Wariyanti
Indonesian Journal of Health Information Management Vol. 3 No. 3 (2023)
Publisher : Sekolah Tinggi Ilmu Kesehatan Mitra Husada Karanganyar

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.54877/ijhim.v3i3.157

Background. Pandan Arang Boyolali Regional General Hospital is a type B referral hospital with an average of 250 patient visits per day. In 2019 the Pandan Arang Boyolali Hospital has implemented an online registration system called the BAPER application (booking check queue), which can be accessed from home by patients, this online registration system is intended to improve service quality in outpatient care, but the system still has many obstacles. Objective. Knowing the Patient Satisfaction of the Online Registration System Compared to the Onsite Registration System at Pandan Arang Boyolali Hospital. Method. The type of research used in this research is quantitative. The research design used is comparative. The population in the study were 1,034 outpatients who visited in Nopember 2022. Purposive sampling technique. chi square data analysis, Results. Description of patient satisfaction with the online registration system Most of them are satisfied as many as 24 respondents (52,2%) Description of patient satisfaction with the onsite registration system Most of them are quite satisfied as many as 23 respondents (50%) Conclusion. There is a difference in satisfaction between the online and onsite registration systems with a p value = 0.008.

ANALISIS PERBEDAAN KELENGKAPAN REKAM MEDIS CONCURENT DENGAN RETROSPECTIVE DI RUMAH SAKIT ORTOPEDI PROF DR R SOEHARSO SURAKARTA RIZKA SIWI MARGIANTI; Astri Sri Wariyanti; Erna Adita Kusumawati
Indonesian Journal of Health Information Management Vol. 4 No. 1 (2024)
Publisher : Sekolah Tinggi Ilmu Kesehatan Mitra Husada Karanganyar

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.54877/ijhim.v4i1.170

Rekam medis yang lengkap akan memberikan kemudahan bagi penyediaan informasi di rumah sakit. Penelitian ini bertujuan untuk membandingkan kelengkapan rekam medis concurent dengan retrospective. Jenis penelitian yaitu metode kuantitatif observasional analitik dengan pendekatan komparatif. Populasi yaitu seluruh rekam medis pasien rawat inap pada bulan Oktober - Desember 2023. Pengambilan sampel dengan rumus Lemeshow dengan jumlah 100 yaitu 50 rekam medis concurrent dan 50 rekam medis retrospective. Teknik pengambilan sampel dengan teknik simple random sampling. Persentase kelengkapan rekam medis yang di review secara concurrent yaitu formulir Catatan Perkembangan Pasien Terintegrasi (CPPT) kelengkapannya 34%, formulir Rencana Pelayanan dan Discharge Planing 60%, serta Laporan Operasi sebesar 18%. Persentase Kelengkapan rekam medis yang di review secara retrospective yaitu formulir Catatan Perkembangan Pasien Terintegrasi (CPPT) kelengkapannya 50%, formulir Rencana Pelayanan dan Discharge Planing 80%, serta Laporan Operasi sebesar 32%. Analisis data bivariate dilakukan dengan Uji Mann Whitney U Test dengan hasil analisis perbandingan kelengkapan rekam medis concurent dan retrospective dengan uji statistik p-value yaitu 0,011, sehingga 0,011< 0,05 maka Ho ditolak dan Ha diterima yang berarti ada perbedaan kelengkapan rekam medis concurent dengan retrospective di RS Ortopedi Prof Dr R Soeharso Surakarta. Berdasarkan hasil penelitian disarankan sebaiknya pada aplikasi rekam medis saat pengguna menginput data diberi pesan peringatan sebelum proses simpan (validasi) sehingga jika ada poin yang belum terisi tidak bisa disimpan.

The The Relationship between Completeness of Medical Information and Accuracy of Diabetes Mellitus Diagnosis Codes in Inpatient Medical Record Documents in RSUD Ajibarang: The Relationship between Completeness of Medical Information and Accuracy of Diabetes Mellitus Diagnosis Codes in Inpatient Medical Record Documents in RSUD Ajibarang Rosita Nur Istiqomah; Astri Sri Wariyanti; Trismianto Asmo Sutrisno
Indonesian Journal of Health Information Management Vol. 5 No. 3 (2025)
Publisher : Sekolah Tinggi Ilmu Kesehatan Mitra Husada Karanganyar

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.54877/ijhim.v5i3.173

Completeness of medical information is very important in supporting the accuracy of diabetes mellitus diagnosis codes. This study aims to determine the relationship between completeness of medical information and the accuracy of Diabetes Mellitus diagnosis codes in inpatient medical record document. This research uses analytical observasional with a cross sectional approach. The sample used was 105 document using a simple random sampling technique. Data analysis used the Chi-Square test. The percentage of complete medical information was 81%, while incomplete was 19%. The highest incompleteness in diagnosis was 13 documents (12%). The percentage accuracy of the diagnosis code is 50%, while the percentage of accuracy is 50%. The most inaccuracies were due to not using dagger and asterisk codes in 18 documents (35%). The Chi-Square statistical test shows that p=0,042. The conclusion is that there is a relationship between the completeness of medical information and the accuracy of diabetes mellitus diagnosis codes. The author suggests that doctors and PPA should immediately complete incomplete medical record documents, especially important sheets relating to the classification and coding of diseases to support accurate coding, and koders should not only refer to ICD 10 volume 3, but must also refer to ICD volume 1 and volume 2.

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