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Ida Wahyuni
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Faktor-Faktor Yang Mempengaruhi Kecepatan Pengambilan Dokumen Rekam Medis Rawat Jalan RSUD dr. Soekardjo Kota Tasikmalaya 2014 Eka Rahman Rahmah; Ida Wahyuni
Jurnal Persada Husada Indonesia Vol 2 No 5 (2015): Jurnal Persada Husada Indonesia
Publisher : STIKes Persada Husada Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (277.9 KB) | DOI: 10.56014/jphi.v2i5.63

Abstract

The speed of service is one thing that can shows good quality of service, as well as the provision ofmedical record documents. Medical record documents mandatory to be available at any time. Surveys conductedin dr. Soekardjo Hospital Kota Tasikmalaya found that the extraction of outpatient medical record documentsstill found some factor that affecting the speed of documents retrieval outpatient medical record. The purpose ofthis research is to determine the factors that affecting the speed of document retrieval in the outpatient medicalrecord dr. Soekardjo Hospital Kota Tasikmalaya. This research is descriptive qualitative study with aphenomenological approach. Data collected through in-depth interviews and observations. Informants are fourworkers filing outpatient and head of medical record taken by purposive sampling techniques.The resultsshowed that the factors that affected the retrieval of documents including outpatient medical record are: limitedhuman resources filing outpatient section, lack of development of ambulatory ability filing officer, limitedfacilities and infrastructure are appropriate in the outpatient filing, and discrepancy between impmentation andSOP. It is Suggested that Hospital would make an effort sto improve these factors so that the speed of documentretrieval service outpatient medical record can be improved.Keywords: factors, medical record document retrieval.
Analisis Ketepatan Kode External Cause Kasus Kecelakaan Lalu Lintas (KLL) Berdasarkan ICD-10 di RSUD dr. Soekardjo Kota Tasikmalaya Tahun 2014 Amalia Wulandari; Ida Wahyuni
Jurnal Persada Husada Indonesia Vol 2 No 6 (2015): Jurnal Persada Husada Indonesia
Publisher : STIKes Persada Husada Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (141.342 KB) | DOI: 10.56014/jphi.v2i6.72

Abstract

Codefication Diagnosis should be done precisely, accurate and appropriate, considering the data diagnosis is authentic law evidence and data required in morbidity reports and insurance interests. External cause code used as secondary code to describe external causes of a disease. Coding of external cause in RSUD dr. Soekardjo not optimally implemented in accordance provision applicable based on Standard Operating Procedure (SOP). This research purpose to analyze the accuracy of external cause code four-digit and five-digit and the contributing factors. The type of this research is mix methodes. The method was used for 94 patients medical record documents, which were taken by total sampling and indepth interview with two informants. The data analysis is using univariate analysis using frequency distribution formula and also qualitative analysis. The results obtained the percentage of external cause four-digit code 24,5% accurate and 75,5 % not accurate. While the code external cause five-digit not found the accurate code. Accuracy and optimally coding in RSUD dr. Soekardjo influenced by diagnosis of external cause that is not written, procedures for coding, human resources and all aplication process. Suggestions for hospital should do socialization about the complete recording of the traffic accidents information according to the rules of coding and standard applications.
Kesesuaian Istilah Tindakan Medis Berdasarkan ICD-9-CM Pada Dokumen Rekam Medis Rawat Inap Non-PBI Triwulan I Di Rumah Sakit Umum Pusat Hasan Sadikin Tahun 2015 Fahri Ramdan Hariri; Ida Wahyuni
Jurnal Persada Husada Indonesia Vol 2 No 7 (2015): Journal Persada Husada Indonesia
Publisher : STIKes Persada Husada Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (297.058 KB) | DOI: 10.56014/jphi.v2i7.81

Abstract

The Regulation of the Minister of Health of the Republic of Indonesia Number 27 Year 2014 on theIndonesian Systems Case Base Groups (INA-CBGS) Technical Guidelines that charging medical action terms,and action code refers to ICD-9cm. Based on preliminary studies in dr. Hasan Sadikin Central GeneralHospital, coders have difficulty in determining leadterm to define actions based on ICD-9-CM, giving rise to theassumption that resulted in inaccurate code determination. The study was conducted to determine the percentagelevel of medical procedures term conformity based on ICD -9-CM. This study is a descriptive study that seeks tolook back by re-reviewing or review back the use of the medical action term on NON-PBI inpatient medicalrecord document in the first quarter of 2015. Data obtained through observation using observation sheet andinterviews as supportive descriptives. The results showed that the use of medical action term is largely inaccordance ICD-9-CM with the corresponding percentage at 78% and in non-accordance of 22%. However, inorder to homogenize the perceptionof the medical action term usage, efforts should be made to address theimpact caused, by further enhancing the cooperation that has existed between physicians, nurses and otherhealthcare practitioners with medical records clerk about writing medical term measures appropriately basedon ICD- 9-CM.Keywords: Suitability, medical action term, ICD-9-CM.
Co-Authors Amalia Wulandari Eka Rahman Rahmah Fahri Ramdan Hariri