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All Journal Jurnal Health Sains Cerdika: Jurnal Ilmiah Indonesia
Lily Widjaja
Universitas Esa Unggul, Jakarta, Indonesia
Humanities Dentistry Economics, Econometrics & Finance Education Health Professions Medicine & Pharmacology Nursing Public Health Social Sciences Veterinary

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Analisis Pengaruh Rekam Medis Elektronik Berdasarkan Teori TAM Firmansye Ika Panggulu; Rokiah Kusumapradja; Lily Widjaja
Jurnal Health Sains Vol. 3 No. 2 (2022): Jurnal Health Sains
Publisher : Syntax Corporation Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.46799/jhs.v3i2.429

Abstract

Electronic medical records are computerized health information systems that provide detailed records of patient demographic data, medical history, allergies, and history of laboratory examination results and some of which are also equipped with decision support systems. The purpose of the study was to analyze the influence of organizational contextual factors, attitudes and social influences simultaneously and respectively on the application of electronic medical records. Method: The model used to test the acceptance of technology is the Technology Acceptance Model (TAM). This study uses a quantitative approach with explanatorical causality research design with a sample of 65 with individual analysis units. Tenik data retrieval with questionnaires and tested with path analysis. Results: Based on the results of the above research can be summarized that the findings in this study are in line with TAM theory with variables of contextual factors of organization, attitudes and social influences affect the perception of benefits and perception of ease in electronic medical records both individually and simultaneously. In addition, contextual factors of the organization affect social influence but attitudes do not affect social influence. Implication: This research assists hospital management in developing this electronic medical record system to be easier to use by creating a network of systems that can be accessed on mobile phones by the PPA even if they are not in the hospital. recognize the importance of management support and training in the application of electronic medical records
Tinjauan Ketepatan Kode Diagnosis Pada Kasus Bedah Pasien Rawat Inap di RSKD Duren Sawit Ririn Rahayu; Laela Indawati; Lily Widjaja; Nanda Aula Rumana
Cerdika: Jurnal Ilmiah Indonesia Vol. 2 No. 11 (2022): Cerdika: Jurnal Ilmiah Indonesia
Publisher : Publikasi Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (254.166 KB) | DOI: 10.59141/cerdika.v2i11.455

Abstract

Based on Kenmenkes RI in 2014, it explains about coding which has the meaning as an activity of providing main diagnosis codes and secondary diagnoses in accordance with ICD-10 and providing procedure codes in accordance with ICD-9CM. Coding inaccuracies can affect the financing of health services, this study was conducted to see the accuracy of the main and secondary diagnosis codes of surgical cases of inpatients at Duren Sawit Hospital using descriptive research methods with a quantitative approach, namely writing aims to describe the results obtained on the accuracy of diagnosis codification. Informants in this study were inpatient coders at RSKD Duren Sawit, data collection in this study using interviews and observation methods. The results of this study indicate that the coding SPO uses the latest procedures based on an electronic system, the educational background of the coder at RSKD Duren Sawit has an important role in the quality of the correct code. The competence of the coder at RSKD Duren Sawit still has to undergo deeper learning, in the results of coding research on surgical cases of inpatients, it was found that the average dignosis code that had accuracy was 58 (63.74%) and 33 (36.26%) were inappropriate, and it was also found that the results of the accuracy of the secondary diagnosis were 84 (92.30%) and 7 (7.70%) were inappropriate. Based on the 4 characters, the inaccuracy occurred in the main diagnosis of the majority in the 4th character as many as 31 (34.7%). There are factors that become obstacles to the identification of 5M, namely the man factor, the lack of accuracy of doctors in inputting diagnoses and the lack of accuracy of officers in re-examining incorrect diagnosis codes and having to undergo learning related to coding more deeply for diagnosis coding officers who are not from academic graduates of medical records.
Analisis Ketepatan Kode Diagnosis Kasus Persalinan Secara Sectio Caesarea Di Rumah Sakit Pelabuhan Jakarta Adelia Anggraini; Lily Widjaja; Laela Indawati; Deasy Rosmala Dewi
Cerdika: Jurnal Ilmiah Indonesia Vol. 3 No. 1 (2023): Cerdika: Jurnal Ilmiah Indonesia
Publisher : Publikasi Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (300.233 KB) | DOI: 10.59141/cerdika.v3i1.505

Abstract

Salah satu aspek terpenting dalam pelayanan rekam medis adalah kegiatan klasifikasi dan kodefikasi diagnosis serta tindakan. Dalam melakukan pemberian kode diagnosis pasien, petugas koding mengacu pada aturan ICD-10. Berdasarkan aturan ICD-10 kasus persalinan terdiri atas tiga komponen yaitu kondisi atau penyulit (O00-O99), metode persalinan (O80-O84), dan outcome of delivery (Z37.-) yang digunakan sebagai kode tambahan untuk mengetahui hasil persalinan. Tujuan dalam penelitian yaitu untuk mengetahui ketepatan kode diagnosis kasus persalinan secara sectio caeasrea di Rumah Sakit Pelabuhan Jakarta. Penelitian menggunakan analisis deskriptif dengan pendekatan kuantitatif. Dengan sampel sebanyak 70 rekam medis kasus persalinan secara sectio caesarea di Rumah Sakit Pelabuhan Jakarta. Pada penelitian ini didapati hasil komponen atau penyulit ibu dengan ketepatan 90% (63 RM), lalu metode persalinan dengan ketepatan 11,43% (8 RM).  Serta outcome of delivery  yang memiliki ketepatan 0% (70 RM). Berdasarkan hasil wawancara dan observasi terhadap kepala rekam medis dan koder bahwa ketepatan pengodean dapat dipengaruhi oleh faktor 5M (man, money, material, method, machine), yaitu ketelitian koder dalam melakukan pengodean, kejelasan pada tulisan dokter, serta tersedianya SPO yang memiliki catatan khusus mengenai pengodean kasus persalinan sehingga proses pengodean dapat terstruktur dengan baik.
Co-Authors Adelia Anggraini Deasy Rosmala Dewi Firmansye Ika Panggulu Indawati, Laela Nanda Aula Rumana Ririn Rahayu Rokiah Kusumapradja