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ANALISIS KETEPATAN PENENTUAN KODE SEBAB DASAR KEMATIAN (UNDERLYING CAUSE OF DEATH) DI RSUD HAJI PROVINSI JAWA TIMUR Sabran Sabran; Lu'aily Munawaroh; Ervina Rachmawati
Jurnal Medika Malahayati Vol 7, No 1 (2023): Volume 7 Nomor 1
Publisher : Prodi Kedokteran Fakultas Kedokteran Universitas Malahayati

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33024/jmm.v7i1.9726

Abstract

One of the professional standards that must be mastered by medical recorders is coding the underlying cause of death (UCOD) and using the Medical Mortality Data Sheet (MMDS). MMDS along with ICD 10 assisted by the Guidebook for Determining the Cause of Death Code According to ICD-10 is used to determine the diagnosis code for the underlying cause of death. The purpose of this study was to analyze the accuracy of determining the basic cause of death code at the East Java Province Hajj Hospital. This study used a descriptive type of retrospective approach with the subject of 2 coding officers and the object of death reports in February and 56 cause of death certificates. The percentage of accuracy of UCOD determination at the East Java Province Hajj Hospital in February 2023, amounted to 21.4% accurate, and 44.6% inaccurate, and 33.9% unfilled. From the percentage results, it is known that the accuracy of code determination is still low, this is because there is no standard coding operational procedure and the guidelines for MMDS table tools have not been used. To assist in determining the basic cause of death code, coding training and socialization on how to determine the basic cause of death code and the provision of the Medical Mortality Data System (MMDS) table are needed.Keywords : Underlying Cause of Death, certificate, MMDS 
Disobedience in Medication and Opportunistic Infection as Lead Factors to HIV/AIDS Mortality at Kencong Public Health Center, Jember Santi, Maya Weka; Deharja, Atma; Rachmawati, Ervina
Jurnal Aisyah : Jurnal Ilmu Kesehatan Vol 6, No 1: March 2021
Publisher : Universitas Aisyah Pringsewu

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (496.095 KB) | DOI: 10.30604/jika.v6i1.440

Abstract

Acquired Immunodeficiency Syndrome (AIDS) is defined as a set of symptoms due to decreased immunity caused by the Human Immunodeficiency Virus (HIV). One of the sub-district in Jember which has the highest HIV/AIDS mortality is Kencong with the death number was 55.88% by January-July 2019. The purpose of this research was to analyze related factors to HIV/AIDS mortality at Kencong Public Health Center. Data were collected from HIV/AIDS patients’ medical record documents with 51 samples consisting of 17 samples from the case group and 34 samples from the control group. Analysis data conducted by Chi-Square test using a case-control approach. The results showed that there was a correlation between disobedience in medication and HIV/AIDS patients’ mortality, with p=0,000 and risk of death at 15,682 times OR (Odds Ratio). Likewise, there was a correlation between the patients’ opportunistic infection and the HIV/AIDS patients’ mortality, with p=0,004 and risk of death at 5,958 times OR. However, the variables of sex, age and level of education did not have any correlation with HIV/AIDS patients’ mortality. Kencong Public Health Office should encourage HIV/AIDS patients to improve medication adherence so can reduce the chance of opportunistic infections. Abstrak: Acquired Immunodeficiency Syndrome (AIDS) didefinisikan sebagai sekumpulan gejala akibat penurunan kekebalan yang disebabkan oleh Human Immunodeficiency Virus (HIV). Salah satu kecamatan di Kabupaten Jember yang memiliki angka kematian HIV / AIDS tertinggi adalah Kencong dengan angka kematian 55,88% pada Januari-Juli 2019. Tujuan penelitian ini adalah menganalisis faktor-faktor yang berhubungan dengan kematian HIV / AIDS di Puskesmas Kencong. Pengumpulan data dilakukan dari dokumen rekam medis pasien HIV / AIDS dengan 51 sampel yang terdiri dari 17 sampel dari kelompok kasus dan 34 sampel dari kelompok kontrol. Analisis data dilakukan dengan uji Chi-Square dengan menggunakan pendekatan case-control. Hasil penelitian menunjukkan bahwa ada hubungan ketidakpatuhan dalam pengobatan dengan kematian pasien HIV / AIDS, dengan p = 0,000 dan risiko kematian sebesar 15.682 kali OR (Odds Ratio). Demikian juga terdapat hubungan antara infeksi oportunistik pasien dengan kematian pasien HIV / AIDS, dengan p = 0,004 dan risiko kematian sebesar 5,958 kali OR. Namun variabel jenis kelamin, usia dan tingkat pendidikan tidak memiliki korelasi apapun dengan angka kematian penderita HIV / AIDS. Dinas Kesehatan Kencong harus mendorong pasien HIV / AIDS untuk meningkatkan kepatuhan minum obat sehingga dapat mengurangi kemungkinan terjadinya infeksi oportunistik.
Analisis Faktor Penyebab Rendahnya Bed Occupancy Rate (BOR) di Balai Besar Kesehatan Paru Masyarakat Makassar Agus Salim; Ervina Rachmawati; Maya Weka Santi; Indah Muflihatin
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 4 No 4 (2023): September
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v4i4.3322

Abstract

The Bed Occupancy Rate (BOR) at the Makassar Community Lung Health Center in the last 3 years has decreased in 2018 by 64%, in 2019 by 62% and in 2020 by 52%. BOR is an indicator of health services that can be used to determine the level of quality, level of utilization of facilities and efficiency of health services. The impact of the decrease in BOR causes a decrease in economic income for the Hospital. The purpose of this study was to analyze the factors causing the low BOR at the Makassar Community Lung Health Center with (human resources), (facilities and infrastructure), (discipline of health care providers) and (problem improvement efforts. This study used qualitative research methods, with the intention of digging deeper into the factors causing the low BOR by using interview, observation, documentation and brainstorming techniques involving 3 informants including HRD, head of facilities and infrastructure and head of nursing.The results of this study indicate that the factor causing low BOR is the lack of resources. human nurses, facilities and infrastructure are not adequate, the discipline of health service providers is not consistent. The solution is that human resources need to be added to facilities and infrastructure that are immediately improved and complete the facilities and infrastructure that are not yet available.
Electronic Medical Records Implementation at Soeradji Tirtonegoro Hospital, Klaten, Indonesia atma deharja; Dito Yogo Waskito; Ervina Rachmawati; Veronika Vestine
Unnes Journal of Public Health Vol 12 No 2 (2023): Unnes Journal of Public Health
Publisher : Universitas Negeri Semarang (UNNES) in cooperation with Association of Indonesian Public Health Experts (Ikatan Ahli Kesehatan Masyarakat Indonesia (IAKMI))

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.15294/ujph.v12i2.67972

Abstract

Soeradji Tirtonegoro Hospital uses Electonic Medical Records (EMRs) to transform health technology. EMR filling completeness in the outpatient clinic was only 74.3% in June 2022, below the 100% service standard. This study aimed to analyze the factors causing the implementation problem of EMR in Soeradji Tirtonegoro Hospital—a quantitative analysis with a cross-sectional study was conducted, adapted from Mandatory Use of Software Technologies (MMUST) Model. The respondents totaled 108 people, including doctors, nurses, midwives, and medical recorders. Data analysis was performed using SmartPLS 3.2.9 with the SEM-PLS technique. This study showed a significant relationship between the variable's information quality and information satisfaction with a T-statistic value of 10.377. Furthermore, information satisfaction towards performance expectations (5,711) and performance expectations towards attitude (6,063). Social influence also affects performance expectations (2.660). Facility conditions affect attitude (2.145), attitudes towards overall satisfaction (26,209), and overall satisfaction with net benefits (10,876). However, there are two insignificant variable relationships: attitude towards use (0,367) and use towards net benefits (1.393). Based on the study, it is concluded that all exogenous variables influence the endogenous variable. However, there are two insignificant variable relationships. Hopefulness, future research can modify the model by adding control variables using the effect of confounding factors such as officer work schedules.
Prediksi Kunjungan Pasien Rawat Jalan Dengan Metode Analisis Trend Linear di RSUD Haji Provinsi Jawa Timur Tahun 2023-2025 Sabran, Sabran; Azizah, Sandi Nur; Rachmawati, Ervina
Jurnal Manajemen dan Administrasi Rumah Sakit Indonesia (MARSI) Vol 8, No 1 (2024): Jurnal Manajemen dan Administrasi Rumah Sakit Indonesia (MARSI)
Publisher : LPPM Universitas Respati Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52643/marsi.v8i1.4046

Abstract

Prediksi kunjungan pasien dapat digunakan untuk mengetahui kenaikan jumlah pengunjung dan membantu manajemen rumah sakit dalam melakukan perencanaan baik dari sumber daya manusia maupun fasilitas yang tersedia guna memelihara kualitas pelayanan terhadap pasien. Berdasarkan data kunjungan pasien rawat jalan di RSUD Haji Provinsi Jawa Timur pada tahun 2020-2022 mengalami peningkatan, hal ini dapat mempengaruhi kinerja pelayanan terhadap pasien terutama pada bagian pendaftaran yang menjadi sasaran utama saat pasien datang. Tujuan penelitian ini untuk mengetahui prediksi kunjungan pasien rawat jalan 2023-2025. Jenis penelitian yang digunakan adalah deskritif dengan pendekatan retrospektif dengan subjek penelitian 2 orang petugas rekam medis. Objek dalam penelitian ini merupakan data kunjungan pasien rawat jalan pada tahun 2020-2022. Analisis data menggunakan analisis statistik deskriptif dan perhitungan prediksi menggunakan metode trend linear. Prediksi jumlah kunjungan pasien rawat jalan pada tahun 2023 sejumlah 183.901 kunjungan, pada tahun 2024 menjadi 206.911 kunjungan dan pada tahun 2025 meningkat lagi menjadi 229.921 kunjungan pasien. Oleh karena itu perlunya dilakukan inovasi dan evaluasi guna mempertahankan maupun meningkatkan jumlah kunjungan pasien rawat jalan.
Analisis Faktor Penyebab Ketidaklengkapan Ringkasan Masuk dan Keluar Rawat Inap di RS X Febriyani, Kharishma Dyah; Rachmawati, Ervina; Alfiansyah, Gamasiano; Yunus, Muhammad
Jurnal Penelitian Kesehatan SUARA FORIKES 2023
Publisher : FORIKES

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33846/sf.v14i0.3221

Abstract

Formulir ringkasan masuk dan keluar berisi informasi identitas pasien, cara penerimaan pasien melalui, cara masuk, dikirim oleh, serta berisi ringkasan data saat pasien dipulangkan. Berdasarkan hasil studi pendahuluan di Rumah Sakit X, dapat diketahui jika masih terdapat ketidaklengkapan pengisian formulir ringkasan masuk dan keluar sebesar 20,30%. Tujuan penelitian yaitu untuk menganalisis faktor penyebab ketidaklengkapan pengisian ringkasan masuk dan keluar. Jenis penelitian yaitu kualitatif, dengan subjek penelitian yaitu 4 admisi rawat inap dan 4 DPJP. Pengumpulan data menggunakan wawancara mendalam (in-depth interview), observasi, dan dokumentasi. Hasil penelitian pada faktor individu yaitu usia admisi dan DPJP termasuk kategori usia produktif, sebagian informan memiliki masa kerja lama, tingkat pendidikan yang belum sesuai kualifikasi dan berpengetahuan kurang terkait kelengkapan pengisian ringkasan masuk dan keluar. Faktor psikologi yaitu admisi dan DPJP memiliki persepsi yang baik, sebagian informan memiliki sikap yang kurang terkait kelengkapan pengisian ringkasan masuk dan keluar, seluruh informan belum mengikuti pelatihan pengisian rekam medis dan tidak adanya sistem reward serta punishment. Faktor organisasi yaitu sudah terdapat SPO  dan  dilaksanakan sosialisasi namun masih berjalan kurang maksimal serta pelaksanaan monitoring dan evaluasi yang kurang optimal. Kesimpulan dari penelitian ini yaitu pendidikan yang belum sesuai kualifikasi, pengetahuan dan sikap yang masih kurang, tidak dilakukannya pelatihan, tidak adanya sistem reward/punishment, pelaksanaan sosialisasi, serta monitoring dan evaluasi yang kurang optimal sehingga disarankan untuk melakukan penempatan petugas sesuai dengan kualifikasinya, memberikan pelatihan, reward, dan punishment kepada petugas, melakukan sosialisasi secara periodik serta lebih meningkatkan pelaksanaan monitoring dan evalusi terhadap kinerja admisi dan DPJP.Kata kunci: ketidaklengkapan; rawat inap; ringkasan masuk dan keluar
Faktor Penyebab Ketidaklengkapan Pengisian Resume Medis Pasien Rawat Inap di Rumah Sakit Alifah, Safira Nur; Santi, Maya Weka; Rachmawati, Ervina; Sabran, Sabran
Jurnal Penelitian Kesehatan SUARA FORIKES 2022
Publisher : FORIKES

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33846/sf13nk408

Abstract

Incomplete medical resumes are one of the factors that influence hospital quality and service improvement, which can have an impact on reducing the quality of hospital services, administrative needs and fulfilling patient rights and safety. So a study is needed that aims to find out the factors that cause incomplete medical resume filling for inpatients at the hospital. The method in this study is a literature review using the Google Scholar database, Crossreff, Garuda Portal and Directory of Open Access Journal as many as 20 articles that meet the criteria. The results of the review show that the incomplete filling out of medical resumes is caused by the implementation of standard operating procedures that has not been maximized, doctors' time is tight, monitoring and evaluation has not been maximized, socialization of standard operating procedures has not been maximized, attitudes and behavioral problems of doctors, lack of understanding and knowledge of doctors, lack of understanding and knowledge medical recorders, shortage of medical recorders, no assembly room available, standard operating procedures not yet available, standard operating procedures not yet detailed, lack of reward/punishment, no incomplete recapitulation, and limited funding sources. The dominant factor causing incomplete medical resumes is the implementation of standard operating procedures that has not been maximized.Keywords: medical resume; incompleteness; inpatient; hospital ABSTRAK Ketidaklengkapan resume medis merupakan salah satu faktor yang berpengaruh terhadap menaikkan mutu dan pelayanan rumah sakit, yang dapat berdampak pada penurunan mutu pelayanan rumah sakit, keperluan administrasi serta pemenuhan hak dan keselamatan pasien. Maka diperlukan studi yang bertujuan untuk mengetahui faktor penyebab ketidaklengkapan pengisian resume medis pasien rawat inap di rumah sakit. Metode pada studi ini adalah literature review menggunakan database Google Scholar, Crossreff, Portal Garuda dan Directory of Open Access Journal sebanyak 20 artikel yang memenuhi kriteria. Hasil review menunjukkan bahwa ketidaklengkapan pengisian resume medis disebabkan oleh pelaksanaan standar operasional prosedur belum maksimal, waktu dokter padat, monitoring dan evaluasi belum maksimal, sosialisasi standar operasional prosedur belum maksimal, sikap dan masalah perilaku dokter, kurangnya pemahaman dan pengetahuan dokter, kurangnya pemahaman dan pengetahuan perekam medis, kekurangan perekam medis, tidak tersedia ruang assembling, standar operasional prosedur belum ada, standar operasional prosedur belum rinci, kurangnya reward/punishment, belum ada rekapitulasi ketidaklengkapan, dan sumber dana terbatas. Faktor dominan penyebab ketidaklengkapan resume medis adalah pelaksanaan standar operasional prosedur belum maksimal.Kata kunci: resume medis; ketidaklengkapan; rawat inap; rumah sakit
Design of Food Ordering Application in Teaching Factory Nutrition Care Center in Supporting Zero Stunting Santi, Maya Weka; Husin, Husin; Rachmawati, Ervina
International Journal of Healthcare and Information Technology Vol. 2 No. 1 (2024): July
Publisher : P3M Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/ijhitech.v2i1.4577

Abstract

Jember Regency was in the spotlight because the prevalence of stunted toddlers has reached the highest rank in East Java with a figure of 34.9% in 2022. Teaching Factory Nutrition Care Center (NCC) has nutritional catering services with Managed Health Meal and Kids Meal packages. However, the ordering process was still done via telephone or chat from social media groups. The research objective was to generate the online application for ordering food at the Teaching Factory NCC to accelerate zero stunting program. It used waterfall method contains of system investigation, system analysis, system design, system implementation, and system maintenance. Meanwhile, this article limited to system design. The results showed that NCC Food facilitates clients/ patients to order nutritious food online according to nutritional adequacy rate needs, particularly for stunted toddlers.
The Factors Associated with Inaccurate Inpatient Diagnosis Code at Health Information System Ibnu Sina Hospital Gresik Regency Hasan, Khumaidah; Santi , Maya Weka; Rachmawati , Ervina; Setiawan, Dony
International Journal of Healthcare and Information Technology Vol. 2 No. 1 (2024): July
Publisher : P3M Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/ijhitech.v2i1.5072

Abstract

Inaccuracies in disease diagnosis codes result in inaccurate reports. The results of the preliminary study showed a high rate of code inaccurate (73%). The research aimed to determine the relationship between ability, leadership, reward, motivation and attitude factors on inaccurate inpatient diagnosis codes at HIS Ibnu Sina Hospital, Gresik Regency. This research method uses a cross-sectional approach with the chi-square test. The population used was nurses who coded diagnoses as many as 42 people with a sample of 39 people. The results of observations of inaccurate inpatient diagnosis codes at HIS Ibnu Sina Hospital, Gresik Regency were 49% inaccurate. The results of the attitude factor analysis have a relationship with the inaccurate of inpatient diagnosis codes with P value 0.00 < α (0.05), while the Ability, Leadership, Reward, and Motivation there is no significant relationship with inaccurate inpatient diagnosis codes with P value > α (0.05) at Hospital Information System Ibnu Sina Regional Hospital, Gresik Regency. The suggestion this research is the Hospital Director needs to create a policy regarding the diagnosis input must be carried out by medical recorders, a clear reward and punishment mechanism, monitoring and evaluation by audit team for the number of inaccurate disease diagnosis codes
Keterlambatan Retensi dan Pemusnahan Rekam Medis di Puskesmas Maron Probolinggo Alfiansyah, Gamasiano; Himma, Alifiah Faiqotul; Rachmawati, Ervina; Roziqin, Mochammad Choirur; Swari, Selvia; Mudiono, Demiawan Rachmatta Putro
Jenggala : Jurnal Riset Pengembangan dan Pelayanan Kesehatan Vol 3 No 1 (2024): JUNI 2024
Publisher : Fakultas Teknologi dan Manajemen Kesehatan

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

Abstract

Dari studi awal di Puskesmas Maron, disimpulkan bahwa proses retensi rekam medis terlambat dan pemusnahan rekam medis belum dilaksanakan. Penelitian ini bertujuan untuk mengidentifikasi faktor-faktor yang menyebabkan keterlambatan tersebut di Puskesmas Maron Kabupaten Probolinggo, dengan menggunakan variabel personal factor, team factor, dan system factor. Penelitian ini menggunakan metode kualitatif dengan tenggunakan wawancara, observasi, dan dokumentasi sebagai cara pengumpulan data. Informan dalam penelitian ini terdiri dari kepala TU, penanggung jawab UKP, koordinator rekam medis, dan petugas rekam medis. Temuan penelitian menunjukkan bahwa keterlambatan dalam retensi dan pemusnahan rekam medis disebabkan oleh faktor-faktor personal seperti tingkat pendidikan, pengetahuan, dan pelatihan, faktor tim seperti kekurangan SDM, dan faktor sistem seperti kurangnya fasilitas yang dibutuhkan. Rekomendasi diberikan kepada Puskesmas untuk meningkatkan kompetensi petugas, melengkapi fasilitas, dan mengembangkan SOP khusus mengenai pemusnahan rekam medis dan mengadakan sosialisasi kepada petugas rekam medis agar pemahaman tentang prosedur tersebut menjadi lebih baik.
Co-Authors Adi Prasetyo Adlien Rizqo Fadillah Agni Candramawa Sholikha Agus Salim Aldo Daffa Daniswara Alfiansyah, Gamasiano Alfiansyah, Gamasiano Ali Chamid Alia Chaerunisa Alifah, Safira Nur Andri Permana Wicaksono Ani Nuraini Atma Deharja Atma Deharja Atma Deharja Atma Deharja avan fadholi Azizah, Sandi Nur Bakhtiyar Hadi Prakoso Dara Ayu Nirwana Datik Lestari Deharja, Atma Delvia NB, Azza Ferista Demiawan Rachmatta Putro Mudiono Dito Yogo Waskito Donny Adhasari Hasan Dony Setiawan Dwi Rizky Permatasari Efri Tri Ardianto Fahirah Tamara Salim Fajria Nur Rahmah Fatika Laily Novitasari Febriyani, Kharishma Dyah Feby Erawantini Feby Erawantini Firdaus Sholehah Fitri, Zilvanhisna Emka Fitriani Fitriani Gamasiano Alfiansyah Gandu Eko Julianto Suyoso Gandu Eko Julianto Suyoso Harningsih, Dewi Hasan, Khumaidah Hayu Ning Widyastuti Hikmah, Faiqatul Himma, Alifiah Faiqotul Husin Husin, Husin Ida Nurmawati Ikha Nurjihan Indah Muflihatin Istianingsih, Noviana Jabal Nur Hamdani Jannah, Siti Elatul Lu&#039;aily Munawaroh Maemunah Maemunah Maya Weka Santi Maya Weka Santi Maya Weka Santi maya weka santi, maya weka Melati Ayu Pratiwi Miftahul Jannah Mudafiq Riyan Pratama Mudiono, Demiawan Rachmatta Putro Muhammad Yunus Muhammad Yunus Muna, Niyalatul Niyalatul Muna Ni’mah, Khomsatun Novita Nuraini Nugroho Setyo Wibowo Nuraini, Novita nurmawati, ida Puspitasari, Trismayanti Dwi Rahagiyanto, Angga Rohman, Nur Cholis Abdul Rossalina Adi Wijayanti Roziqin, Mochammad Choirur Sabran Sabran Sabran, Sabran Santi , Maya Weka Santi, Maya Weka Sedyo Pinerdi Selvia Juwita Swari Selvia Juwita Swari Selvia Juwita Swari Silfiatul Mukaromah Sitti Fa’Isil Karomah Sulandari Sulandari Sustin Farlinda Suyoso, Gandu Eko Julianto Swari, Selvia Syahbaniar, Desi Tamami Alifia Annisa Veronika Vestine Vestine, Veronika Virda Hardiana Wicaksono, Kurniawan Erman Wijayanti, Rossalina Wijayanti, Rossalina Adi Yusfa Ike Rustiana