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Dampak Beban Kerja Coder yang Tinggi Terhadap Ketidakakuratan Kode Diagnosis Warsi Maryati; Indriyati Oktaviano Rahayuningrum; Niar Perdana Sari
Jurnal Manajemen Informasi Kesehatan Indonesia (JMIKI) Vol 8, No 1 (2020)
Publisher : Asosiasi Perguruan Tinggi Rekam Medis dan Informasi Kesehatan Indonesia- APTIRMIKI

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33560/jmiki.v8i1.252

Abstract

Rumah Sakit Umum Daerah Dr. Moewardi merupakan rumah sakit terakreditasi Paripurna. Berdasarkan berdasarkan hasil survei pendahuluan terhadap 10 dokumen rekam medis di bangsal Melati menunjukkan bahwa 40% tidak akurat. Penelitian ini bertujuan untuk mengetahui hubungan beban kerja coder dengan keakuratan kode diagnosis pada pasien rawat inap bangsal melati di Rumah Sakit Umum Daerah Dr. Moewardi   tahun 2018. Penelitian ini merupakan penelitian analitik dengan pendekatan cross sectional. Sampel dalam penelitian ini sebanyak 99 dokumen rekam medis rawat inap bangsal Melati dengan teknik pengambilan sampel proportionate stratified random sampling. Pengelolaan data dengan collecting, editing, coding, classification, tabulating, analisis dan penyajian data. Persentase beban kerja rendah sebesar 60% (59 dokumen) sedangkan yang beban kerja tinggi sebesar 40% (40 dokumen). Persentase keakuratan kode bangsal Melati 59% (58 dokumen) sedangakan ketidakakuratan sebesar 41% (41 dokumen). Data tersebut diolah dengan menggunakan uji statistik chi square dan menunjukkan bahwa p=0,01 sehingga p<0,01. Kesimpulan yang diambil adalah Ho ditolak dan Ha diterima, artinya ada hubungan antara beban keja coder dengan keakuratan kode diagnosis pasien rawat inap di Rumah Sakit Umum Daerah Dr. Moewardi Tahun 2018. Saran bagi rumah sakit sebaiknya merencanakan dan menganalisis beban kerja coder di masing-masing bangsal.
Accuracy of Outpatient Diagnosis Code Based on ICD – 10 Yeni Tri Utami; Muhammad Amin bin Sahari; Warsi Maryati; Dina Tri Wahyuni
Proceedings of the International Conference on Nursing and Health Sciences Vol 3 No 1 (2022): January-June 2022
Publisher : Global Health Science Group

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37287/picnhs.v3i1.1133

Abstract

The accuracy of the diagnostic code plays an important role in the accuracy of the INA-CBG's rates. Outpatient BPJS patient visits at the Astrini Wonogiri General Hospital reached 7,967 patients in 2020, which have superior polyclinics, namely Orthopedic poly and Cardiology poly. Based on a preliminary survey, the percentage of inaccurate in the diagnosis coding for outpatients in the Orthopedic poly reached 90% and the Cardiology poly 30%. The high inaccuracy of the diagnostic code can lead to a decrease in the quality of services in hospitals and affect the sources of reporting information and health service rates. This study aims to determine the accuracy of the outpatient diagnosis code based on ICD 10 at the Astrini Wonogiri General Hospital. This type of research is descriptive with a retrospective approach. The population in this study was 5284 documents, with a sample of 131 documents using the Simple Random Sampling technique. Methods of collecting data by means of observation and interviews. The analysis of the accuracy of this outpatient diagnosis code is interpreted as a percentage. The results of the research on the outpatient diagnosis coding procedure at the Astrini Wonogiri General Hospital in accordance with the SPO, by looking at the Participant Eligibility Letter, Certificate of Evidence of Service, CPPT form (Integrated Patient Progress Record) and Supporting Examination Sheets. The results of the percentage accuracy of the diagnostic code for outpatients in orthopedic poly are 89% (59 DRM) inaccurate codes, 11% (7 DRM) accurate, can be grouped into 2 inaccurate code classifications, namely incorrect code selection and lack of character code additions 5. The percentage accuracy of the diagnosis code for cardiac outpatients is an inaccurate score of 14% (9 DRM), 86% accurate (56 DRM) can be grouped into 2 classifications of inaccurate codes, namely, incorrect code selection and lack of character code additions 4. Factors causing the inaccuracy of the code include the doctor in writing the diagnosis that is not clear so it is difficult to read, the coder doubles as a casemix, assembling and reporting officer, causing a lack of accuracy in reading the sheets containing additional information that support the accuracy of the code. The conclusion from the results of the study is that the inaccuracy of the outpatient diagnosis code at RSU Astrini Wonogiri is still high, so it is necessary to re-socialize related to the SPO for writing diagnoses to doctors, and there is a clear division of job disks so that the coder burden is not too high and more thorough in coding to produce a accurate diagnosis code.
Hospital Tariff Gap With Final Claims in The Indonesian Case Base Groups (INA-CBGs) System Warsi Maryati; Indriyati Oktaviano Rahayuningrum; Vega Nevi Astuti
Proceeding of International Conference on Science, Health, And Technology Proceeding of the 1st International Conference Health, Science And Technology (ICOHETECH)
Publisher : LPPM Universitas Duta Bangsa Surakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (516.714 KB) | DOI: 10.47701/icohetech.v1i1.756

Abstract

National Health Insurance is a health program organized by the Social Security Organizing Agency with a prospective payment system or package system. Payment for health services with this package system is based on a diagnosis and procedure grouping that has similar resource needs. This study is an analytical study by examining differences in hospital tariff with final claims on the INA-CBG system. Data collection was carried out by observing 100 INA-CBGs claim files in five hospitals in Central Java Province, Indonesia. Data were analyzed by Paired Sample T-test. The results of the study showed that there was a significant difference with p value < 0.001. The total hospital tariff is IDR 582,373,996.00 compared to the total claim rate in the INA-CBG system of IDR 526,431,595.00, resulting in a negative difference of IDR 55,942,371.00. The difference in tariffs reached 9.6% of the total hospital tariff. The percentage of negative difference between hospital tariff and the tariff in the INA-CBGs system is 53%, slightly more than the 47% positive difference. Most hospitals already have efficient health service management by referring to the established clinical pathway. Financial management with cross subsidies between cases with positive and negative tariff differences can help hospital operations to continue to run well. Compliance of health workers with clinical pathways and effective and efficient management of health services can help hospitals overcome losses in the National Health Insurance system.
Disparities in hospital cost and INA-CBGs tariff with unit cost analysis of inpatient services Warsi Maryati; Muhammad Faiz Othman; Siti Musyarofah; Puguh Ika Listyorini; Fhahrul Dwi Aryanti; Miftakhul Jannah
Proceeding of International Conference on Science, Health, And Technology 2021: Proceeding of the 2nd International Conference Health, Science And Technology (ICOHETECH)
Publisher : LPPM Universitas Duta Bangsa Surakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (604.723 KB) | DOI: 10.47701/icohetech.v1i1.1097

Abstract

The National Health Insurance Program, a form of health insurance that has been implemented since 2014, which uses the Indonesian Case Based Groups (INA-CBGs) system. The implementation of this system ensures that patients get good service and hospitals get standard tariff. The intended tariff is in the form of a package which includes all components of hospital costs. This study aims to determine the relationship between the unit cost of all health service cost components and the INA-CBGs tariff and how the gap is. The research sample was taken from the INA-CBGs claim document in the second quarter of 2020 as many as 4,833. Data were analyzed using linear regression to find a relationship between hospital health service costs and the INA-CBGs tariff. Hospital service costs are calculated based on unit cost analysis. The average unit cost of laboratory was IDR 853,500 (7.91%), radiology IDR 366,198 (3.39%), treatment IDR 2,031,850 (18.82%), Examination IDR 4,205,745 (38.95%), Consumables IDR 345,092 (3.17%), and Drugs IDR 3,022,694 (27.76%). The results of the analysis showed Laboratory (b = 1.639; 95% CI = 1.177 to 2.100; p <0.001), Treatment (b = 0.915; 95% CI = 0.852 to 0.978; p <0.001), Examination and Accommodation (b = 1.211; 95% CI = 1.138 to 1.285; p <0.001), and Drug (b = 0.015; 95% CI = 0.007 to 0.024; p <0.001) had a significant relationship with the INA-CBGs tariff. Other variables such as Radiology (b = -0.141; 95% CI = -0.629 to 0.347; p <0.001) and Consumable Costs (b = -0.343; 95% CI = -696 to 0.009; p <0.001) had no significant relationship with INA-CBGs Tariff. However, all cost components have a significant effect (p <0.001) of 42.7% on the INA-CBG tariff with a strong influence category (R = 0.654). Hospitals must be wiser in managing finances with the INA-CBGs pattern, because the tariff may look small because there are some treatment that are not cost effective or there are still unnecessary treatment for patients taking a large portion of the cost of the package.
Hospital Patient Loyalty: In terms of Brand Image, Service Quality, Patient Satisfaction, and Trust Puguh Ika Listyorini; Warsi Maryati; Sylvia Anjani
Proceeding of International Conference on Science, Health, And Technology 2021: Proceeding of the 2nd International Conference Health, Science And Technology (ICOHETECH)
Publisher : LPPM Universitas Duta Bangsa Surakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (469.94 KB) | DOI: 10.47701/icohetech.v1i1.1103

Abstract

The success of a hospital if it has loyal patients. Patient loyalty depends on the brand image of the hospital, the quality of service to patients, patient satisfaction, and patient trust in the hospital. This study aims to determine whether there is a relationship between brand image, service quality, satisfaction, and patient trust on patient loyalty. This type of research is analytic observational research with a cross-sectional approach. Samples were taken by accidental sampling with a total of 156 patients. The results showed that there was a relationship between brand image, service quality, satisfaction, and patient trust on patient loyalty.
THE Identification Pending Claim of Healthcare and Social Security Agency Insurance at Nirmala Suri Hospital. Linda Widyaningrum; Warsi Maryati; Rizki Nurul Wulandari
Proceeding of International Conference on Science, Health, And Technology Proceeding of the 3rd International Conference Health, Science And Technology (ICOHETECH)
Publisher : LPPM Universitas Duta Bangsa Surakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (649.308 KB) | DOI: 10.47701/icohetech.v3i1.2251

Abstract

A pending claim is a claim that is returned by the BPJS (Social Security Administering Agency) Health verifier to the hospital for revision which can later be resubmitted. This study aims to determine the causes of pending BPJS claims for inpatients at Nirmala Suri Sukoharjo Hospital in 2020. This study is a descriptive study, with a retrospective approach. Samples of 685 claims are pending with the saturated sample technique. The research instrument was in the form of observation guidelines and interview guidelines. Data processing with classification, editing, and presentation of data in text form. Data processing with data analysis is done descriptively. The implementation of BPJS patient claims at the Nirmala Suri Sukoharjo Hospital has been implemented and has implemented the existing SPO (Standard Operating Procedures). There are 14 classifications of pending BPJS claims for inpatients at Nirmala Suri Sukoharjo Hospital. The causes of pending BPJS claims for inpatients at the Nirmala Suri Sukoharjo Hospital in 2020 include: completeness of medical record documents, clarity of doctor's writing, and application system updates. Coordinate with related units such as medical records and registration units, inpatient installations, emergency units, cashier units, and pharmacy installations regarding matters that affect pending claims so that they do not happen again. It is better if the coder requires updating the latest knowledge and rules related to coding rules or BPJS Health rules and it takes the accuracy of the coder and grouper in the coding and input process
OPTIMALISASI MUTU PELAYANAN KESEHATAN DI KLINIK DENGAN IMPLEMENTASI SISTEM INFORMASI REKAM MEDIS BERBASIS WEB Warsi Maryati; Yeni Tri Utami
Jurnal LINK Vol 19, No 1 (2023): MEI 2023
Publisher : Pusat Penelitian dan Pengabdian kepada Masyarakat, Poltekkes Kemenkes Semarang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31983/link.v19i1.9387

Abstract

Teknologi informasi berkembang sangat pesat, tidak terkecuali di bidang pelayanan kesehatan. Rekam Medis Elektronik merupakan salah satu faktor penting untuk meningkatkan kualitas dan keamanan layanan kesehatan, mengurangi kejadian buruk bagi pasien, mengurangi biaya, mengoptimalkan pelayanan, meningkatkan penelitian klinis, dan memperoleh luaran klinis yang lebih baik. Pengabdian kepada masyarakat ini bertujuan untuk mengimplementasikan sistem informasi rekam medis berbasis website untuk meningkatkan mutu pelayanan Kesehatan di klinik. Metode yang dilakukan dalam pengabdian kepada masyarakat di klinik ini yaitu penyediaan perangkat keras (hardware), implementasi perangkat lunak (software) berupa aplikasi pelayanan pendaftaran dan pengelolaan rekam medis berbasis website, serta pelatihan penggunaan aplikasi aplikasi pelayanan pendaftaran dan pengelolaan rekam medis berbasis website kepada petugas. Hasil kegiatan pengabdian kepada masyarakat ini yaitu rekam medis elektronok mampu mengurangi waktu tunggu pelayanan kepada pasien sehingga kepuasan pasien terhadap pelayanan di klinik meningkat. Pengetahuan dan penerimaan petugas kesehatan di klinik juga meningkat setelah mengikuti kegiatan pelatihan dan pendampingan, sehingga dapat menjamin keberlanjutan program ini.
Ketepatan Kode Diagnosis Chronic Kidney Disease Dalam Mendukung Kelancaran Klaim BPJS Di Rumah Sakit Warsi Maryati; Indriyati Oktaviano Rahayuningrum; Hestiana Hestiana
Indonesian of Health Information Management Journal (INOHIM) Vol 11, No 1 (2023): INOHIM
Publisher : Lembaga Penerbitan Universitas Esa Unggul

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.47007/inohim.v11i1.497

Abstract

AbstractAn accurate diagnosis code is crucial to support the smooth submission of health service fee claims. In Indonesia, kidney disease is ranked as the second largest financing from BPJS. The preliminary study results show that of the 30% of claims submitted by patients with chronic kidney disease (CKD) that were not approved, 10% of them were due to inaccurate diagnosis codes. This study aimed to prove the relationship between the accuracy of the CKD diagnosis code and the approval of BPJS claims. This research is a quantitative study with a cross-sectional study design. A sample of 97 CKD patient claim files was taken at a hospital in Surakarta. There are two variables: the accuracy of the diagnosis code and the approval of BPJS claims. Researchers used observation guidelines and ICD-10 to analyze the accuracy of the diagnosis code and observe the reasons for returning BPJS claims. Analysis of the relationship between the two variables using the Fisher Exact test. The results showed 93 (95.9%) valid CKD diagnosis codes and 4 (4.1%) inaccurate codes. Claim files were approved by 79 (81.5%) and not approved by 18 (18.5%). The analysis showed that the accuracy of the CKD diagnosis code had a significant relationship with the approval of BPJS claims (b=6.643; 95% CI=4.099-10.765; p=0.001). An Accurate CKD diagnosis code that is accurate has a 6.643 times greater chance of increasing claim approval than one that is inaccurate. Hospitals should try to improve the accuracy of the diagnosis code through regular training, monitoring and evaluation to minimize the occurrence of claims return.Keyword: code, diagnosis, claim, accuracy, CKD AbstrakKode diagnosis yang akurat sangat penting untuk mendukung kelancaran pengajuan klaim biaya pelayanan kesehatan. Di Indonesia, penyakit ginjal menduduki ranking kedua pembiayaan terbesar dari BPJS. Hasil studi pendahuluan menunjukkan bahwa dari 30% pengajuan klaim pasien dengan chronic kidney disesase (CKD) yang tidak disetujui, 10% diantaranya disebabkan karena ketidakakuratan kode diagnosis. Tujuan penelitian ini untuk membuktikan hubungan antara keakuratan kode diagnosis CKD dengan persetujuan klaim BPJS. Penelitian ini menggunakan desain studi cross sectional dengan sampel sebanyak 97 dokumen klaim pasien CKD. Terdapat dua variabel yaitu keakruratan kode diagnosis dan persetujuan kliam BPJS. Peneliti menggunakan pedoman observasi dan ICD-10 untuk menganalisis keakuratan kode diagnosis serta mengamati penyebab pengembalian klaim BPJS. Analisis hubungan antara variabel bebas dengan variabel terikat dengan menggunakan uji Fisher Exact. Hasil penelitian didapatkan kode diagnosis CKD yang akurat sebanyak 93 (95,9%) dan tidak akurat sebanyak 4 (4,1%). Berkas klaim yang disetujui sebanyak 79 (81,5%) dan tidak disetujui sebanyak 18 (18,5%). Hasil analisis menunjukkan bahwa keakuratan kode diagnosis CKD memiliki hubungan yang signifikan dengan persetujuan klaim BPJS (b=6,643; 95% CI=4,099-10,765; p=0,001). Setiap kode diagnosis CKD yang akurat memiliki peluang sebesar 6,643 kali lebih besar dalam meningkatkan persetujuan klaim dibandingkan yang tidak akurat. Rumah sakit sebaiknya melakukan upaya peningkatan keakuratan kode diagnosis melalui pelatihan, pengawasan dan evaluasi secara berkala sehingga meminimalisir terjadinya pengembalian klaim.Kata Kunci: kode, diagnosis, klaim, kekauratan, CKD 
Review Of The Medical Record Document Storage System At UPT Puskesmas Karanganyar Liss Dyah Dewi Arini; Warsi Maryati; Maulana Charisma Ardiansyah
International Journal of Medicine and Health Vol. 2 No. 4 (2023): December : International Journal of Medicine and Health (IJMH)
Publisher : Pusat Riset dan Inovasi Nasional

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.55606/ijmh.v2i4.2349

Abstract

UPT Karanganyar Health Center Karanganyar Regency is a type urban non-inpatient health centers, so they only serve outpatient care and emergency. Based on the results of the survey and introduction of researchers, at UPT Karanganyar Health Center found a medical record document missfile. The Missfile was due to a lack of non-RMIK officers in the filing department careful in returning medical record documents in place, and amount the medical record staff in the filing is inadequate. This research aims to find out the medical record document storage system at UPT Puskesmas Karanganyar.This type of research uses descriptive research methods, with approach. The subjects in this study were medical record filing officers. The object of this study is a medical record document storage system in UPT Karanganyar Health Center. This research instrument uses guidelines interviews and observations. Data processing by collecting, editing, and data presentation.The result of this research is based on record numbering system medical uses UNS (Unit Numbering System) with Family Numbering, for alignment using SNF (Straight Numerical Filling) and storage using centralization with personal folders. Factor the cause of the missfile is the inaccuracy of the clerk in returning the document medical records to the filing rack, the impact of the missfile is service delays and duplication of medical records efforts made namely socialization with color coding.The author suggests that a tracer should always be used when retrieval of medical record documents, so that they are stored again medical record documents faster, and avoid missfiles. It is necessary control by medical record officers when non medical record officers put DRM back on the shelf. Conduct HR recruitment with competence and qualifications from D3 Medical Records.
Management of Cancer in the Digestive System Liss Dyah Dewi Arini; Warsi Maryati; Puguh Ika Listyorini; Devi Pramita Sari
International Journal of Health and Medicine Vol. 1 No. 3 (2024): July : International Journal of Health and Medicine
Publisher : Asosiasi Riset Ilmu Kesehatan Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.62951/ijhm.v1i3.33

Abstract

Cancer is a non-communicable disease characterized by the presence of abnormal cells/tissues that are malignant, grow quickly and uncontrollably and can spread to other places in the patient's body. Cancer cells are malignant and can invade and damage the function of the tissue. Digestive cancer, also called gastrointestinal cancer, attacks the organs of the digestive system. Digestive cancer also includes gastrointestinal cancer, liver cancer, stomach cancer, colorectal cancer, and pancreatic cancer. Risk factors for digestive cancers are varied because many different organs can be affected. Some factors that contribute to cancer throughout the digestive system include age, heavy drinking (alcohol), smoking, and diabetes sufferers. This type of liver cancer is cancer that grows in liver cells. Liver cancer is a type of cancer that ranks second as the cancer that causes the most deaths in the world. Gastric cancer is a group of malignant diseases that have multifactorial causes, namely genetic, lifestyle and environmental factors. The symptoms caused by stomach cancer are initially not as typical as the symptoms of general digestive complaints. The diagnosis of colorectal cancer can be carried out in stages, including through an appropriate history, physical examination, and supporting examinations in the form of laboratory examinations, both from clinical laboratories and anatomical pathology laboratories. The etiology of colorectal cancer is currently still unknown. Symptoms of colorectal cancer are varied and non-specific. The main complaints of patients with colorectal cancer relate to the size and location of the tumor. Tumors in the right colon, where the contents of the colon are fluid, tend to remain hidden until they are very advanced.