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All Journal Dinamisia: Jurnal Pengabdian Kepada Masyarakat Logista: Jurnal Ilmiah Pengabdian Kepada Masyarakat Jurnal Kesehatan Saintika Meditory Ficco Public Health Journal
Sayati Mandia
Apikes Iris
Agriculture, Biological Sciences & Forestry Health Professions Medicine & Pharmacology Nursing Public Health Social Sciences Other

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SOSIALISASI DAN PRAKTEK RETENSI DAN PEMUSNAHAN BERKAS REKAM MEDIS di PUSKESMAS KURANJI Sayati Mandia
LOGISTA - Jurnal Ilmiah Pengabdian kepada Masyarakat Vol 4 No 1 (2020)
Publisher : Department of Agricultural Product Technology, Faculty of Agricultural Technology, Universitas Andalas Kampus Limau Manis - Padang, Sumatera Barat Indonesia-25163

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (713.456 KB) | DOI: 10.25077/logista.4.1.63-68.2020

Abstract

Puskesmas merupakan fasilitas pelayanan kesehatan yang menyelenggarakan upaya kesehatan masyarakat dan upaya kesehatan perseorangan tingkat pertama. Dalam melaksanakan tugasnya puskesmas berwenang untuk untuk melaksanakan pencatatan dan pelaporan kesehatan pasien serta melakukan evaluasi terhadap mutu dan cakupan pelayanan kesehatan. Pencatatan dan pelaporan pasien dapat dilihat dari berkas rekam medis pasien. Rekam medis pada sarana kesehatan non rumah sakit wajib disimpan sekurang-kurangnya untuk jangka waktu dua tahun terhitung dari tanggal terakhir pasien berobat. Setelah batas waktu penyimpanan dilampaui maka rekam medis dapat dimusnahkan. Puskesmas Kuranji merupakan salah satu puskemas di kota padang yang berlamat dikecamatan Kuranji. Berdasarkan hasil wawancara dengan petugas rekam medis, hingga saat ini Puskesmas Kuranji belum melakukan retensi dan pemusnahan berkas rekam medis sedangkan ruangan penyimpanan hanya ada satu. Berdasarkan pemaparan masalah di atas, maka pengabdi bermaksud untuk melakukan sosialisasi dan praktik langsung mengenai retensi dan pemusnahan berkas rekam medis di Puskesmas Kuranji Kota Padang. Target dan luaran dari pelaksanaan kegiatan pengabdian kepada masyarakat adalah kegiatan ini dapat dijadikan sebagai bahan pertimbangan untuk pelaksanaan retensi dan penghancuran berkas rekam medis. Target kedepannya agar sosialisi ini dapat digunakan sebagai dasar kegiatan retensi dan penghancuran berkas rekam medis. Kata Kunci: Puskesmas, Retensi, Pemusnahan, Rekam Medis ABSTRACT Public health center (PHC) is a health service facility that organizes public health efforts and first-level individual health efforts. In carrying out its duties PHC is authorized to carry out the recording and reporting of patient health and to evaluate the quality and scope of health services. Patient recording and reporting can be seen from the patient's medical record file. Medical records in non-hospital healthcare facilities must be kept for at least two years from the date the patient was treated. After the storage time limit is exceeded, the medical record can be destroyed. The Kuranji Community Health Center is one of the public health centers in the city of Padang which is well-known in the Kuranji sub-district. Based on the results of interviews with medical record officers, up to now the Kuranji Community Health Center has not retained and destroyed medical record files while there is only one storage room. Based on the explanation of the problem above, the service intends to conduct socialization and direct practice regarding the retention and destruction of medical record files at the Kuranji Health Center in Padang City. The target and output of the implementation of community service activities is that this activity can be used as consideration for the implementation of retention and destruction of medical record files. The future target is that this socialization can be used as a basis for retention and destruction of medical records. Keywords: Puskesmas, Retention, Destruction, Medical Record
BPJS Claims Pending Case Coding Training at AISYIYAH PADANG RSU: Pelatihan Pengodean Kasus Pending Klaim Bpjs Di RSU AISYIYAH PADANG Sayati Mandia
Dinamisia : Jurnal Pengabdian Kepada Masyarakat Vol. 7 No. 1 (2023): Dinamisia: Jurnal Pengabdian Kepada Masyarakat
Publisher : Universitas Lancang Kuning

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31849/dinamisia.v7i1.12032

Abstract

Hospital health facilities are required to complete BPJS claim documents before submitting them to BPJS Health to get reimbursement for treatment costs according to the Indonesian Case Base Groups (INA-CBG's) rates. The BPJS claim process already uses the INA-CBGs program. With this payment method, the accuracy of clinical and procedure code data determines the financing of health services. Service of Community Activities (PKM) aim to provide education regarding ICD-10 coding regulations in minimizing cases of pending claims that occur at Aisyiyah General Hospital, Padang. This PKM did at Aisyiyah Hospital Padang on 06-07 October 2022 Service of Community in the form of outreach regarding the urgency of using the ICD-10 then followed up in the form of practicing ICD-10 coding cases of pending claims to partners. This activity was attended by 18 participants from the medical team and case-mix. Result of pre-test and post-test showed, increasing the team's understanding of ICD-10 coding regulations and cases pending claims.
Analysis of Medical Record Document Management Based on The Assessment Elements of MRMIK 3 LAM-KPRS at Mutiara Bunda Mother and Child Hospital Dewi Oktavia; Sayati Mandia
Ficco Public Health Journal Vol. 2 No. 03 (2025): December 2025
Publisher : Ficco Scientific Corner

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.5281/zenodo.18147215

Abstract

Background: Accreditation is recognition given to hospitals for their efforts to continuously improve the quality of service. One of the accreditation institutions for hospital quality and patient safety is LAM-KPRS. The implementation of MRMIK 3 focuses on document management and hospital policies. RSIA Bunda Padang has specific needs in implementing this system, particularly in recording patient data related to pregnancy, childbirth, and neonatal care, thus requiring a system capable of supporting real-time data access. The aim of the study was to determine the results of the analysis of medical record document management based on the MRMIK 3 LAM-KPRS Assessment Elements at Mutiara Bunda Mother And Child Hospital. Methods: This study used a qualitative design and was conducted from March to April 2025. The sampling method used purposive sampling with a total of 3 people. The data collection technique used observation with research instruments, namely checklists based on the MRMIK3 LAM-KPRS accreditation assessment and conducted in-depth interviews with informants. Data analysis was carried out in three main steps: data reduction, data presentation, and drawing conclusions. Results: The results of the study showed that the hospital had implemented document management according to the criteria with a partially met assessment, had and implemented a uniform format for similar documents with a met assessment, and had documents with a partially met assessment. Conclusion: from the three assessment indicators, some were fulfilled and some were partially fulfilled.
ANALISIS PENGELOLAAN REKAM MEDIS BERDASARKAN ELEMEN PENILAIAN LAM-KPRS MRMIK 9 DI RSIA MUTIARA BUNDA PADANG Sayati Mandia; Dewi Oktavia; Anggie Trie Utami
Jurnal Kesehatan Saintika Meditory Vol 8, No 2 (2025): November 2025
Publisher : STIKES Syedza Saintika Padang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.30633/jsm.v8i2.30590

Abstract

Akreditasi rumah sakit sebagai sistem penilaian independen untuk menjamin mutu pelayanan dan keselamatan pasien. Pada standar LAM-KPRS, elemen MRMIK 9 menekankan kepatuhan terhadap penggunaan kode diagnosis, kode prosedur, serta singkatan dan simbol baku terstandarisasi sebagai bagian penting dari tata kelola rekam medis. Penelitian ini bertujuan untuk menganalisis implementasi elemen tersebut di RSIA Mutiara Bunda Padang. Penelitian menggunakan desain deskriptif kuantitatif dengan observasi langsung terhadap 80 dokumen rekam medis pasien rawat inap, yang dipilih melalui teknik simple random sampling. Hasil menunjukkan bahwa pengodean diagnosis telah dilakukan pada 85% dokumen, sedangkan 15% belum dikodekan. Pada pengodean prosedur 78,75% telah dikodekan, 18,75% tidak dikode, dan 2,5% tidak terdapat prosedur. Penggunaan singkatan dan simbol belum terdapat pedoman atau SOP tertulis. Evaluasi penggunaan kode, singkatan, dan simbol memang dilaksanakan secara rutin, tetapi belum terdokumentasi dengan baik serta tidak diikuti tindak lanjut yang konsisten. Penelitian ini menegaskan perlunya penguatan regulasi internal melalui SOP dan pedoman resmi agar pengelolaan rekam medis lebih terstandar, akurat, dan berdaya guna. Penerapan standar tersebut esensial tidak hanya untuk pemenuhan akreditasi, tetapi juga bagi peningkatan mutu data kesehatan serta efektivitas pengambilan keputusan klinis.
Co-Authors Anggie Trie Utami Dewi Oktavia Dewi Oktavia