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ANALISIS KELENGKAPAN DAN KETEPATAN KODEFIKASI TERMINOLOGI MEDIS OBSTETRI DI PUSKESMAS JETIS BANTUL YOGYAKARTA Setiyawan, Hery; Rohman, Hendra; Nugraha, Faizqinthar Bima
Prosiding Seminar Informasi Kesehatan Nasional 2023 : SIKesNas 2023
Publisher : Fakultas Ilmu Kesehatan Universitas Duta Bangsa Surakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.47701/sikenas.vi.2830

Abstract

Latar belakang : Kompetensi perekam medis trampil dalam menganalisa terminologi medis, Kodifikasi Penyakit dan Masalah Kesehatan. Serta mampu menetapkan kode penyakit dan tindakan dengan tepat sesuai klasifikasi yang diberlakukan di Indonesia (ICD-10) tentang penyakit dan tindakan medis dalam pelayanan dan manajemen kesehatan. (Kemenkes, 2020). Pentingnya dilakukan analisis ketepatan pengisian kode diagnosis pada dokumen rekam medis karena apabila kode diagnosis tidak tepat atau tidak sesuai dengan ICD-10 maka dapat menyebabkan turunnya mutu pelayanan di rumah sakit serta mempengaruhi data, informasi laporan, dan ketepatan tarif INACBG’s yang pada saat ini digunakan sebagai metode pembayaran untuk pelayanan pasien (Mukhtadi, 2013). Tujuan penelitian untuk Mengidentifikasi kelengkapan dan ketepatan kodefikasi, menganalisa ketidaktepatan dan ketepatan, dampak ketidak tepatan dan ketepatan pada terminologi medis obstetri di Puskesmas Jetis. Metode penelitianya yaitu deskreptif kualitatif Penelitian ini memberikan gambaran tentang pelaksanaan kodefikasi diagnosa pada kasus obstetri berdasarkan ICD-10. Peneliti menghitung prosentase ketidaklengkapan dan ketidaktepatan kode serta mencari faktor permasalahan yang mempengaruhi ketidaklengkapan dan ketidaktepatan kodefikasi. Pelaksanaan pemberian kode diagnosis pasien obstetri di Puskesmas Jetis dilakukan oleh petugas rekam medis. Kegiatan pengkodean dilaksanakan setelah pasien mendapat pelayanan, pemberi pelayanan kesehatan menginput data pasien anamnesis dan diagnosis serta kode di sistem komputer SIMPUS DGS, kemudian pada sistem DGS otomatis akan muncul beberapa diagnosis pilihan. Keakuratan kode diagnosis sesungguhnya merupakan penentuan dan penulisan kode diagnosis yang sesuai dengan standar klasifikasi di dalam ICD- 10. Kode dinyatakan tepat atau akurat apabila mencerminkan kondisi riil pasien dengan segala tindakan dan pengobatan yang telah dilakukan.. Kesimpulan Kelengkapan kode pada metode persalinan fisiologis maupun patologis secara umum sudah baik (92%), kelengkpan kode kondisi persalinan patologis sudah baik (87%). Ketepatan kode pada persalinan fisiologis (spontan) maupun patologis ketepatannya kurang (37%). Ketepatan kondisi persalinan patologis kurang (32%).
ANALISIS KELENGKAPAN PENGISIAN FORMULIR RAWAT JALAN DI PUSKESMAS X Widowati, Vidya; Rohman, Hendra; Kristiyono, Eddy; Arsitaningrum, Annisa
Prosiding Seminar Informasi Kesehatan Nasional 2023 : SIKesNas 2023
Publisher : Fakultas Ilmu Kesehatan Universitas Duta Bangsa Surakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.47701/sikenas.vi.2834

Abstract

Mutu pelayanan didukung oleh kelengkapan pengisian formulir rawat jalan, yang bisa dianalisis secara kuantitatif dan kualitatif. Perekam medis dan informasi kesehatan sudah melaksanakan analisis setelah pelayanan, namun masih didapatkan ketidaklengkapan pada formulir rawat jalan. Tujuan: mengetahui hasil analisis kelengkapan pengisian formulir rawat jalan di Puskesmas X. Metode penelitian yang digunakan adalah deskriptif pendekatan kualitatif. Teknik pengambilan sampel subjek menggunakan teknik purposive sampling. Hasil penelitian dari 95 berkas diketahui kelengkapan identifikasi pada item nomor rekam medis, nama, umur dan alamat 100%, laporan penting pada item anamnesa 100%, pendokumentasian pada pembetulan kesalahan 7%, autentikasi nama terang 74%, kelengkapan dan kekonsistenan diagnosa 100%, informed consent yang sesuai dengan tindakan yang dilakukan 100%, praktek pencatatan pada keterangan waktu 99%. Faktor penyebab ketidaklengkapan pengisian formulir rawat jalan yaitu profesional pemberi asuhan terburu-buru dalam mengisi, belum ada anggaran untuk beralih ke elektronik, belum maksimal sosialisasi standar operasional prosedur. Kesimpulan: rata-rata kelengkapan identifikasi pada formulir rawat jalan sebanyak 79%, laporan penting 98%, pendokumentasian yang benar 7%, autentikasi 73%, kelengkapan dan kekonsistenan diagnosa 100%, informed consent sebanyak 73%, praktek pencatatan 73%. Ketidaklengkapan pengisian formulir rawat jalan disebabkan oleh profesional pemberi asuhan terburu-buru dalam mengisi, belum ada anggaran untuk beralih ke elektronik, belum maksimal sosialisasi standar operasional prosedur.
PEMBERDAYAAN PEREMPUAN MELALUI PEMBUATAN COVERALL MEDIS DAN GOWN PADA MASA PANDEMI COVID-19 Rohman, Hendra; Sari, Ana Dewi Lukita
ADIMAS Jurnal Pengabdian Kepada Masyarakat Vol 6 No 1 (2022): Maret
Publisher : Universitas Muhammadiyah Ponorogo

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.24269/adi.v6i1.3419

Abstract

Terpuruknya kegiatan ekonomi dirasakan pengusaha, karyawan dan wirausaha. Salah satunya adalah pabrik garmen di wilayah Bantul yang gulung tikar sehingga banyak karyawan pabrik di PHK secara sepihak. Program pengabdian masyarakat diberikan untuk menggerakan roda ekonomi masyarakat terutama bagi perempuan. Melihat kondisi tersebut kami tergerak untuk melatih sebagian karyawan garmen tersebut agar tetap berkarya memproduksi Alat Pelindung Diri (APD) seperti coverall medis dan gown baik dari bahan spunbond, parasut waterproof, taslan, dan microphorus. Pada awal pandemi COVID-19 antara kebutuhan APD dengan jumlah produksi tidak seimbang. Sehingga pemesanan APD yang masuk sangat banyak, permintaan dari Jawa, Sumatera, Kalimantan, Sulawesi bahkan sampai Papua. Kegiatan ini mampu memproduksi 5000 gown maupun coverall dalam 1 bulan. Kelompok kami berjumlah 10 penjahit yang beralamat di Randubelang, Semail dan Bangunjiwo Bantul. Pengabdian masyarakat ini dilakukan dengan metode pelatihan pembuatan APD, pembagian kerja dan membangun jaringan market. Pada proses pelatihan meliputi cara pembuatan desain APD, cara menjahit yang benar sesuai syarat sebagai alat pelindung diri, proses pengemasan dan pengiriman paket yang efektif dan murah. Hasil yang dirasakan oleh para penjahit adalah adanya pemasukan finansial yang lebih banyak dibandingkan saat mereka bekerja di pabrik. Banyak waktu untuk mengurus keluarga karena produksi dikerjakaan di rumah masing-masing, dan peluang resiko tertular virus COVID-19 lebih kecil. Diharapkan tetap berkarya dan produktif pada masa pandemi covid-19. Situasi ini dibutuhkan kerjasama yang terkoordinasi baik antar masyarakat dan pemerintah, sehingga UMKM tetap bertahan demi kelangsungan produksi. Perlu kemampuan beradaptasi dengan cepat, tepat dan benar untuk bertahan hidup baik terutama dari segi ekonomi.
Development of a WEBGIS-Mapping Information System of Tuberculosis (MISS TB) For Plotting Tuberculosis Cases: A Case Study in Sleman District, Yogyakarta Province, Indonesia Rohman, Hendra; Nurrochman, Alwhan
Procedia of Engineering and Life Science Vol. 6 (2024): The 3rd International Scientific Meeting on Health Information Management (3rd ISMoHI
Publisher : Universitas Muhammadiyah Sidoarjo

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.21070/pels.v6i0.1954

Abstract

Geographic information system for health information management and public health to analyze the spatial disease distributions in surveillance has increasingly applied in the last few decades. The programming skills needed to utilize the software appropriately in contact tracing and follow up control measures for tuberculosis (TB) patients. This study aimed to develop a more user friendly application by applying XAMPP application to create WEBGIS localhost, PHP My Admin for MySQL database management, MySQL server as a database management system (DBMS), Visual Studio Code application for creating programming. The system development method uses a waterfall model. These data were collected from infectious disease prevention and control officers at the Sleman District Health Service and tuberculosis reporting programmer officers at community health centers. Data on rainfall, humidity, altitude, temperature, area, population and population density were obtained from the Central Statistics Agency of Sleman Regency. Data visualization in mapping for 17 sub-districts in Sleman Regency. The geographic menu contains information on rainfall, humidity, altitude and temperature for each month in tabular form. The demographics menu contains information on the area, population and population density of each sub-district in tabular form. The distribution location input menu is used to add data on tuberculosis cases. The distribution list menu contains a table that contains a database stored from the location input. The account menu on the administrator user contains a list of accounts created or registered in system. The website-based geographic information system (GIS) application is expected to improve case data reporting, case monitoring, support data availability, and visualize the distribution of tuberculosis cases in Sleman Regency through the mapping menu. The application developed should assist health information management and public health experts to utilize medical record data and spatial data for the surveillance purposes comprehensively.
Evaluation of Core Security Principles in Electronic Medical Records: Evaluasi Prinsip Keamanan Dasar dalam Catatan Medis Elektronik Rohman, Hendra; Lauma, Alfia Salsabilah; Pambudi, Sukma Dian; Narendra, Indra
Procedia of Engineering and Life Science Vol. 9 (2025): Proceedings of the 2025 Annual Meeting of APTIRMIKI
Publisher : Universitas Muhammadiyah Sidoarjo

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

Abstract

EMR access in one of health centers in Yogyakarta City are given to all health service officers using username and password. In registration, there are 2 username while 5 registration officers use them. This can pose a risk of data and patient information leakage. This study aims to evaluate 6 aspects of information security in EMR in health center. This type of research is qualitative. The population is 51 EMR users and sample is 7 users. Privacy, on access rights, login process to EMR uses a username and password, automatic log out feature does not yet exist. Integrity, on accuracy data and timeliness in filling out forms, accuracy of data is accurate but timeliness in filling is sometimes less timely due to system downtime in form of network problems and power outages, edit and delete features are already available but not all users can use these features. Authentication, on electronic signatures has not been implemented but manual signatures that are carried out can still guarantee authentication from users, on application of signatures to guarantee validity of users made using electronic certification provider services has not been implemented. Availability, data transfer to the health office is not done at health center, as health office can retrieve the necessary data using a superadmin user. Access control, access are set using a username and password, in accordance with user access settings, duties, and authorities. Non-repudiation, a history of access and edits is maintained for users using EMR
PERANCANGAN SISTEM INFORMASI PELAPORAN POSYANDU LANSIA Rohman, Hendra
Jurnal Manajemen Informasi dan Administrasi Kesehatan Vol. 1 No. 2 (2018): JMIAK
Publisher : Program Studi D3 Rekam Medis dan Informasi Kesehatan

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.32585/jmiak.v1i02.158

Abstract

The health centre Gondokusuman II was a Yogyakarta Primary Health Centre with two assisted villages, namely Terban and Kotabaru, which has sixteen integrated health post groups for the elderly. Each group of integrated health post sends the results of the patient's health activities once a month to the health centre Gondokusuman II. During this time the reporting used to manage patient data using microsoft excel, but in reporting management found deficiencies namely incomplete reporting, access rights processing elderly patient data can be used by all staff, and in the age column was still filled manually. The purpose of the study was to design a microsoft access 2010 integrated health post based elderly information reporting system in the health centre Nutrition Consultant Unit Gondokusuman II. This study uses a prototype design method as a method of developing management information systems based on microsoft access. The subject of this research was the integrated health post officers of the elderly in the nutrition consultant unit of the health Gondokusuman II. In this study started from the needs of users, applications and information system prototypes that are used as microsoft based desktop access. This prototypes was approved by users, complete filling becomes more complete, access rights can be set, and the age calculation was automatic.Keywords: primary health centre, medical record, electronic
SISTEM RETENSI BERKAS REKAM MEDIS TERINTEGRASI: PERANCANGAN SISTEM INFORMASI BERBASIS WEB DI KLINIK PRATAMA Rohman, Hendra
Jurnal Manajemen Informasi dan Administrasi Kesehatan Vol. 2 No. 2 (2019): JMIAK
Publisher : Program Studi D3 Rekam Medis dan Informasi Kesehatan

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.32585/jmiak.v2i02.452

Abstract

PKU Muhammadiyah Cangkringan Primary Clinic serves outpatient and inpatient services. The patient service process was still using microsoft excel, from patient registration to reporting. The problem that occurs was the accumulation of files due to not implemented the medical record file retention process, and the medical record file retention information system does not yet exist. This study aims to design a web based medical record file retention information system. The prototype design method was used as a method for developing web based information systems. The design using visual studio code editorial text and interface design with the help of a bootstrap framework, the system uses the laravel framework, and the database uses mysql. The result, a web based medical record file retention information system that can facilitate officers and doctors in viewing patient forms that have been retained, can save scans of medical record forms before they are destroyed, and can display scan results forms that have been uploaded into the information system. This information system requires patient data to see a list of visits of the last 2 years which is used to determine the medical record file that will be carried out the retention process.
Co-Authors Abdillah, Asmi Rizal Adelia, Dinda Agung Kurniawan Agustin Wijayanti Alwhan Nurrochman Amin Kiswantoro Ana Dewi Lukita Sari Ana dewi lukita sari Ana Herlina Andhy Sulistyo Andrias Feri Sumadi Andy Muharry Anggia Meianti Anisa Aulia Anna Mayretta Annisa Kusuma Wati Ari Natalia Probandari Aris Wintolo Arsitaningrum, Annisa Astuti, Risa Mei Azizah, Sabella Nur Bayu Ari Wibowo Putra Dahlia Ayu Pri Irani Denny Noor Septyawan Denta, Wahyu Dewi Tri Astuti Dinda Adelia Dona Wening Kusumastuti Dwiyono Rudi Susanto Dyah Evanka Nur Ikhsani Eka Setiawati Elmy Agnia Endang Susilowati Endang Susilowati Enjang, Hieronymus Kidung Erina Septin Prihaningtyas Erlina Meidyawati Evrithia Chatarina Fadia Sulaiman Fadia, Fadia Fardana Nur Rachma Febrianty Lestari Fikram S. Sumangan Fitria Latupono Fitriana Yulianti Haerudin Haerudin Hamida Ismaqonita Hariyono, Widodo Hariyono, Widodo Hartono Hartono Hery Setiyawan Hery Setiyawan Hery Setiyawan Hery Setiyawan Himawan Adventayudha Ibnu IMardiyoko Ibnu Mardiyoko Ibnu Mardiyoko Ibnu Mardiyoko Indar Puspita Latarissa Iramie Duma Kencana Irianto Kristiyono, Eddy Kusuma, Oni Noviandi Lauma, Alfia Salsabilah Lilik Edi Saputro Lusi Fitriah Sari M. Imron Mawardi Marsilah Marsilah Melisa Wulandari Nabila Rizki Putri Utami Narendra, Indra Nida Priastiti Nugraha, Faizqinthar Bima Nur Annisa Rimadanti Nur Fajarini Nur Ismiyati Nur Ismiyati Nur Rohman Nur Rohman Nurhidayati Nurhidayati Nurrochman, Alwhan Nurwijayanti Pambudi, Sukma Dian Prasetyo, Rizki Adi Prawirya, Ais Pri Irani, Dahlia Ayu Puji Laksmini Purwanto Purwanto Qhoiriyah, Anisa Risqi Rahmatullah, Widia Rangga Pramudya Saputra Resmi Aini Riki Dwi Saputra Rina Widiastuti Widiastuti Rina Widiastuti, Rina Rohmat Dipo Darmawan Ronggo Nurcahyo Rosyidah Rosyidah Sahda Aulia Khairunnisa Salsabila, Amalia Sari, Ana Dewi Lukita Selin Sheralinda Shinta Sulaiman Sulaiman Sulistyo, Andhy Susanto, Dwiyono Rudi Tetha Normalitha Tivani, Khoirun Nisa’ Tri Handoko Ulfah Maulida Nur Sholihah Vesty Yuli Istichanah Widhi Sulistyo Widodo Hariyono Widowati, Vidya Widya Safitri Dano Jafar Wiji Wahyuningsih Wimasa, Yoga Adi Zharifa, Ibnata Nasywa