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All Journal J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan
Mahardika Nugraha
Politeknik Negeri Jember
Health Professions Public Health

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EVALUASI KETIDAKTEPATAN PEMBERIAN KODE REKAM MEDIS RAWAT JALAN DI RS PHC SURABAYA Mahardika Nugraha; Dony Setiawan Hendyca Putra; Efri Tri Ardianto
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 2 No 2 (2021): March
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v2i2.2176

Abstract

Codification is an activity to transform a diagnosis into a code consisting of letters and numbers.Inaccuracies of coding can slow the process of insurance claims and decrease the quality of medicalrecords. Preliminary study results showed a percentage of inaccuracy in the diagnostic code of 4documents of a total of 10 outpatient medical record documents at PHC Surabaya Hospital. This researchaims to evaluate the correctness of an outpatient medical record file in Surabaya's PHC Hospital. This typeof research used qualitative research. The samples were 44 documents of the outpatient medical record inJanuary 2020. Data collection techniques using observation and documentation. The results of the studyshow that the code inaccuracies in an outpatient medical record document of 13 (29.5%) improper codeand 21 (70.5%) of the right code. The cause of its absence was an error in the code-granting suspect of15.4%, a mistake in giving control code and therapy of 61.5%, and an error in giving the fourth character inthe case of diabetes mellitus by 23.1%. Factors that lead to inaccuracy in the coding of an outpatientmedical record were the less thorough officers in conducting medical record reviews as well as mistakes indetermining the old case and new cases. The suggestions provided by researchers are to conduct routinecoding audits, repair SOP, socialization about the correct encoding procedures, and make a note for thecode which is often to be used.
Perancangan dan Pembuatan Sistem Informasi Apotek di Puskesmas Banjarsengon Mahardika Nugraha; Niyatul Muna; Andri Permana Wicaksono; Demiawan Rachmatta Putro Mudiono
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 2 No 4 (2021): September
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v2i4.2447

Abstract

Banjarsengon public health center is one of the health agencies that deal with patient care and treatment. The pharmacy section of the Banjarsengon Health Center in carrying out registration, recording medical records, drug data collection and managing reports is still done manually. In addition, data collection errors are often encountered which can lead to inaccurate reporting data. The purpose of this research is to solve problems in drug data collection by designing a pharmacy information system at the Banjarsengon health center. The making of pharmacy information system application was using Microsoft Visual Studio 2019. System development was using waterfall method. Data collections consist of observation, interviews and documentation. The result of black box testing showed that this pharmacy information system can operate properly. The advantages are the pharmacy information system been integrated with the operation of pharmacists and management that can reduce the possibility of errors that affect the service to patients, improve the efficiency of the drug recording system quickly and accurately, facilitate pharmacists in recording, reduce and add drug stock automatically and also print reports in pdf form.
Co-Authors Andri Permana Wicaksono Demiawan Rachmatta Putro Mudiono dony setiawan hendyca putra Efri Tri Ardianto Niyatul Muna