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<![CDATA[Ketersediaan Rekam Medis di Rumah Sakit Islam Jakarta Sukapura ]]>
<![CDATA[Gina Sonia]]>;
<![CDATA[Lily Widjaja]]>;
<![CDATA[Deasy Rosmala Dewi]]>;
<![CDATA[Puteri Fannya]]>
<![CDATA[ SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat Vol. 1 No. 2 (2022): April 2022 ]]>
Publisher : <![CDATA[Yayasan Literasi Sains Indonesia ]]>
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DOI: 10.55123/sehatmas.v1i2.110
<![CDATA[The medical record is an administration system that records all diagnoses and actions followed by the storage of medical records. Medical record retrieval is an important part to support the effectiveness of services in providing medical records for patients who return to the hospital. This research method uses quantitative descriptive and data collection techniques by observation, interviews and literature study. Based on the results of the research, the filing officer of the Islamic Hospital of Jakarta Sukapura often faced problems during retrieval, the results of the study found that 17 (3.4%) medical records were not found and 26 (5.2%) medical records were misplaced. Factors inhibiting the implementation of medical record retrieval include man factors such as the educational background of officers and the habitual factor of officers who do not use tracers when carrying out medical record retrieval that is not in accordance with SPO at the Islamic Hospital of Jakarta Sukapura. The money factor does not affect the implementation of medical record retrieval. The machine factor is the SMART system for medical record data entry that comes off the shelf. The method factor is that the standard operating procedure for retrieval of medical records is not fully appropriate. The material factor is the absence of loan receipts.]]>
<![CDATA[Tinjauan Pendokumentasian Yang Baik Pada Rekam Medis Pasien Rawat Inap Di Rumah Sakit Kanker Dharmais Jakarta ]]>
<![CDATA[Bayu Fajar Ilhami]]>;
<![CDATA[Lily Widjaja]]>;
<![CDATA[Deasy Rosmala Dewi]]>;
<![CDATA[Laela Indawati]]>
<![CDATA[ SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat Vol. 1 No. 2 (2022): April 2022 ]]>
Publisher : <![CDATA[Yayasan Literasi Sains Indonesia ]]>
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DOI: 10.55123/sehatmas.v1i2.167
<![CDATA[The contents of the Medical Record are not only data on the treatment of sick patients, but also overall health data so that it is more accurately called Health Records. In general, the Health Record is an overview of the patient's health provided by the service provider/doctor to the patient to become the patient's health record. The purpose of this study was to determine the quality of good documentation in inpatients at Dharmais Cancer Hospital. The research design is cross sectional, namely research conducted at a certain time. Data sources: article searches conducted on Google Scholar to use articles that are in accordance with the research.research method Descriptiveis to describe directly the object under study using a quantitative approach. The results of the study obtained the number of completeness of medical records reached 89.13%. The sample obtained 92 medical record files, with the results of the Initial Medical Assessment Form getting a completeness score of 88.77%, CPPT Form 87.68%, Shift Handover 90.58%, and Consultation Sheets 89.49%. Medical Record Documentation still needs to be improved. Dharmais Cancer Hospital, the number of completeness of medical records needs to be increased so that the documentation of medical records is of higher quality.]]>
<![CDATA[Tinjauan Kelengkapan Berkas Persyaratan Klaim Pasien Rawat Inap Covid-19 di Rumah Sakit Sumber Waras ]]>
<![CDATA[Bahlani]]>;
<![CDATA[Lily Widjaja]]>;
<![CDATA[Deasy Rosmala Dewi]]>;
<![CDATA[Laela Indawati]]>
<![CDATA[ SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat Vol. 1 No. 2 (2022): April 2022 ]]>
Publisher : <![CDATA[Yayasan Literasi Sains Indonesia ]]>
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DOI: 10.55123/sehatmas.v1i2.237
<![CDATA[Every hospital organizes a health insurance program, the implementation of the national health insurance program is operated by the Health Office, before the hospital collects payments to the Health Office, a complete inpatient claim requirement file is required, if the inpatient claim requirement file is incomplete it will hamper the process. the health office's claim to the hospital, causing a pending claim. The purpose of this study was to get an overview of the completeness of the claim file requirements for Covid-19 inpatients at Sumber Waras Hospital. The research was conducted using a quantitative descriptive method. The sample in this study was taken from the claim requirements file for Covid-19 inpatients at the Sumber Waras Hospital. Sampling using systematic random sampling. Data was collected using a checklist and interview guidelines submitted to Casmiex officers at Sumber Waras Hospital. Based on the results of a study of 87 files for claim requirements for Covid-19 inpatients, 75.90% were obtained. The factors causing the incompleteness of the Covid-19 inpatient claim file requirements are the Covid-19 inpatient claim requirement file provided by the service officer in hardcopy, the service officer does not provide all the files that exist at the patient's discharge date in that month, the occurrence of errors in inputting patient data and medical support officers do not directly enter the results of laboratory tests. Therefore, it is necessary to disseminate information to service personnel so that they can complete the claim requirements for inpatients in a timely manner.]]>
<![CDATA[Inactive Medical Record Governance at St. Carolus Hospital Jakarta ]]>
<![CDATA[Yasinta Rosalia Menna]]>;
<![CDATA[Lily Widjaja]]>;
<![CDATA[Muniroh Muniroh]]>;
<![CDATA[Daniel Happy Putra]]>
<![CDATA[ Indonesian Journal of Health Information Management Vol. 2 No. 2 (2022) ]]>
Publisher : <![CDATA[Sekolah Tinggi Ilmu Kesehatan Mitra Husada Karanganyar ]]>
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DOI: 10.54877/ijhim.v2i2.62
<![CDATA[Medical record depreciation is an activity of reducing archives from storage shelves by moving inactivated medical records archives from active shelves to inactivated shelves according to the year of visit. Preliminary observation results show the process of media transfer in the medical record unit has not reached the target of a minimum number of 50 medical records per day. This research aims to find out the governance of inactivated medical records at St. Carolus Hospital Jakarta. The research methodology used is a descriptive method. It can be concluded that the standard operating procedure for shrinking medical records in St. Carolus Jakarta already exists but is not complete because the depreciation stage related to transfer, value assessment, media transfer has not been listed in the standard operating procedure. The medical records unit has carried out the depreciation process with the male medical record officer as its executor but the implementation is not based on the assessment of the value for medical records due to the absence of an assessment team. The constraint factors in the medical record unit are related to the man, money, material, method, and machine.]]>
<![CDATA[Analisis Kuantitatif Kelengkapan Formulir Pengkajian Medis Awal Dokter Pada RM Pasien Rawat Inap Di RS Vertikal Jakarta Timur ]]>
<![CDATA[Sarah Khonsa]]>;
<![CDATA[Lily Widjaja]]>;
<![CDATA[Muniroh Muniroh]]>;
<![CDATA[Puteri Fannya]]>;
<![CDATA[Yenni Syafitri]]>
<![CDATA[ Indonesian Journal of Health Information Management Vol. 2 No. 2 (2022) ]]>
Publisher : <![CDATA[Sekolah Tinggi Ilmu Kesehatan Mitra Husada Karanganyar ]]>
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DOI: 10.54877/ijhim.v2i2.64
<![CDATA[Rekam medis wajib dibuat oleh rumah sakit dan diisi lengkap dan jelas baik secara tertulis maupun elektronik. Formulir pengkajian medis awal dokter pasien rawat inap merupakan isi dari bagian rekam medis. Di RS Vertikal Jakarta Timur, pengisian formulir pengkajian medis awal dokter pasien rawat inap masih belum lengkap sehingga nilai gunanya menjadi kurang maksimal. Data yang dianalisis adalah formulir pengkajian medis awal dokter rm pasien rawat inap bulan desember 2020. Tujuan dilakukan penelitian ini adalah untuk mengidentifikasi SPO pengisian pengkajian medis awal dokter pasien rawat inap, menghitung kelengkapan pendokumentasian lembar pengkajian medis awal dokter pasien rawat inap berdasarkan analisis kuantitatif, mengidentifikasi faktor-faktor yang menghambat kelengkapan pengkajian medis awal dokter pasien rawat inap. Analisis kuantitatif merupakan melihat keseluruhan isi dari rekam medis untuk mengidentifikasi terjadinya kekurangan. Penelitian menggunakan metode secara deskriptif kuantitatif dan pengambilan sampel menggunakan simple random sampling. Berdasarkan hasil penelitian SPO pengisian pengkajian medis awal dokter pasien rawat inap sudah ada. Hasil analisis kuantitatif terhadap 90 formulir pengkajian medis awal dokter pasien rawat inap didapat rata-rata kelengkapan sebesar 81%. Faktor penyebab ketidaklengkapan pengisian formulir pengkajian medis awal dokter pasien rawat inap adalah kurangnya tingkat kepatuhan dokter dalam mengisi formulir pengkajian medis awal rawat inap, sehingga banyak formulir tidak terisi secara lengkap. Oleh karena itu, disarankan agar meningkatkan sosialisasi SPO pengisian formulir pengkajian medis awal dokter rawat secara lengkap terutama kepada dokter dan tenaga kesehatan terkait.]]>
<![CDATA[Gambaran Ketepatan Waktu Penyediaan Rekam Medis Rawat Jalan Di RSUP Fatmawati Tahun 2021 ]]>
<![CDATA[Arip Budiana]]>;
<![CDATA[Deasy Rosmala Dewi]]>;
<![CDATA[Laela Indawati]]>;
<![CDATA[Lily Widjaja]]>
<![CDATA[ Sehat Rakyat: Jurnal Kesehatan Masyarakat Vol. 1 No. 1 (2022): Februari 2022 ]]>
Publisher : <![CDATA[Yayasan Pendidikan Penelitian Pengabdian Algero ]]>
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DOI: 10.54259/sehatrakyat.v1i1.890
<![CDATA[The hospital as a public health service institution is an important part that provides complete individual health services and provides inpatient, outpatient, and emergency services. Provision of medical records is a process of providing medical records starting from searching for medical records to sending medical records to the intended polyclinic for health services in accordance with health service standards. The purpose of this study was to get an overview of the timeliness of providing outpatient medical records at Fatmawati Hospital. In this study the authors decided to use a qualitative descriptive method which aims to describe the situation or field conditions regarding the occurrence of inaccuracies in the provision of outpatient medical records at Fatmawati Hospital. Based on Standard Operating Procedures, the provision of outpatient medical records at Fatmawati Hospital is <30 minutes (maximum 30 minutes), in this study it was found that the timely provision was 75.55%. With an average delivery time of 27,96 minutes. From this it is known that there is a gap related to the time delay in the process of providing medical records. Delays in the process of providing outpatient medical records are caused by factors including factors in the 5M management element which include man, machine, material, money, method. The staff's knowledge factor needs to be improved, the discipline of the supply officer is good but not optimal, the officer has not attended training on the timeliness of providing good medical records. The machine factor is the lack of number of outpatient medical record storage racks, and the lack of a trolley for the provision of medical records. The method factor is the need for periodic socialization of SOPs to remind officers' performance. The matherial factor requires trolly rejuvenation and good maintenance in order to function as it should. The money factor is that the budget should always be a priority that can be a support for the creation of good health services.]]>
<![CDATA[Tinjauan Faktor Penyebab Pengembalian Klaim BPJS Pasien Rawat Inap di RSKD Duren Sawit Jakarta Timur Tahun 2021 ]]>
<![CDATA[Alex Sander]]>;
<![CDATA[Laela Indawati]]>;
<![CDATA[Lily Widjaja]]>;
<![CDATA[Nanda Aula Rumana]]>
<![CDATA[ Sehat Rakyat: Jurnal Kesehatan Masyarakat Vol. 1 No. 4 (2022): November 2022 ]]>
Publisher : <![CDATA[Yayasan Pendidikan Penelitian Pengabdian Algero ]]>
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DOI: 10.54259/sehatrakyat.v1i4.1180
<![CDATA[BPJS claim returns have 2 types of returns, the first is a purification failure or a return that occurs due to incompatibility and incompleteness of patient administration, such as patient eligibility letter number (SEP), class of care, and way of returning the patient. The second is pending, this return occurs due to discrepancies and incomplete diagnoses, diagnosis codes and service files received by inpatient BPJS patients submitted to BPJS. Therefore, officers must have thoroughness and understanding when carrying out their duties. This study was conducted to determine the factors causing the return of BPJS claims for inpatients at the Duren Sawit Hospital, East Jakarta in 2021 using a descriptive quantitative approach, by providing an overview and results regarding the factors causing the return of BPJS claims for inpatients. The results of the study used 227 samples of claim files that were returned by the BPJS verifier and obtained 2 (two) types of claim returns. 54 (23.8%) failed to be purified and 173 (76.2%) pending claim files. The most reason for returning claims is that the diagnosis is not supported by treatment and supporting results. There are 2 factors hindering the identification of 5M. Man factor: human error, competence of officers, and the absence of a casemix team. Material: inaccuracy of diagnosis in electronic medical resume so that there is inaccuracy when coding patient diagnosis. There are no barriers to the Money, Method, Machine factors. To get maximum results when submitting BPJS claims for inpatients, hospitals should pay attention to the competence of officers and socialize policies that are in accordance with the system run by the hospital.]]>
<![CDATA[KETEPATAN KODE DIAGNOSIS PENYEBAB DASAR KEMATIAN DI RUMAH SAKIT DI INDONESIA : LITERATUR REVIEW ]]>
<![CDATA[Fredrika Welhelmina]]>;
<![CDATA[Wiwik Viatiningsih]]>;
<![CDATA[Lily Widjaja]]>;
<![CDATA[Noor Yulia]]>
<![CDATA[ Jurnal Kesehatan Tambusai Vol. 3 No. 3 (2022): September 2022 ]]>
Publisher : <![CDATA[Universitas Pahlawan Tuanku Tambusai ]]>
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DOI: 10.31004/jkt.v3i3.7693
<![CDATA[Pelaporan mortalitas dilakukan sebagai upaya untuk pencegahan penyakit yang mematikan dan sebagai evaluasi fasilitas pelayanan kesehatan. Dalam memilih kode pada sertifikat medis penyebab kematian perlu diperhatikan agar pelaporan dapat terlaksana secara optimal. Kode yang tepat adalah kode yang sesuai dengan ICD-10 serta dibantu dengan Tabel MMDS. Tujuan dari review ini melihat melihat ketepatan kode diagnosis penyebab dasar kematian dan untuk mengetahui faktor penyebab ketidaktepatan pengodean diagnosis dan pengisian sertifikat medis penyebab kematian di rumah sakit. Metode penelitian ini menggunakan metode literatur review terhadap sejumlah artikel penelitian yang dipublikasikan rentang waktu tahun 2011-2021 dan ditemukan sebanyak 13 artikel jurnal memenuhi kriteria penelitian. Hasil menunjukkan presentasi ketepatan kode diagnosis sebesar 83% dan presentase ketidaktepatan kode diagnosis sebesar 90%. Hasil studi literatur ini juga membahas faktor penyebab ketidaktepatan pengodean diagnosis dan pengisian sertifikat penyebab dasar kematian yaitu faktor Man, Method, Material, Machine, dan Money.]]>
<![CDATA[ANALISIS KUALITATIF KEKONSISTENSIAN PENCATATAN DAN JUSTIFIKASI PENGOBATAN PADA REKAM MEDIS KASUS DEMAM BERDARAH DENGUE DI RUMAH SAKIT MEKAR SARI BEKASI TAHUN 2021 ]]>
<![CDATA[Jeillia Jihan Swaradwibhagia]]>;
<![CDATA[Lily Widjaja]]>;
<![CDATA[Laela Indawati]]>;
<![CDATA[Muniroh Muniroh]]>
<![CDATA[ Journal of Innovation Research and Knowledge Vol. 2 No. 4: September 2022 ]]>
Publisher : <![CDATA[Bajang Institute ]]>
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<![CDATA[Kelengkapan rekam medis dapat diukur secara analisis kuantitatif maupun kualitatif. Namun untuk melihat kekonsistensian pendokumentasian dilakukan secara analisis kualitatif. Permasalahan terjadi pada rendahnya kekonsistensian pencatatan dan justfikasi pengobatan. Penelitian ini bertujuan untuk menganalisis kekonsistensian pencatatan dan justifikasi pengobatan di Rumah Sakit Mekar Sari Bekasi tahun 2021. Metode penelitian ini deskriptif dengan pendekatan kuantitatif dan teknik pengumpulan data melalui observasi dan wawancara. Populasi penelitian ini adalah 343 rekam medis dan sampel sebanyak 85 rekam medis. Hasil dari penelitian ini adalah ketidak-konsistensian pada subkomponen skrining risiko cedera/jatuh sebesar 91,76%, instruksi pemberian obat dalam pencatatan waktu instruksi, nama, jenis dan dosis obat serta waktu pemberian obat sebesar 94,11%, instruksi penghentian/penggantian obat dalam pencatatan waktu instruksi, nama, jenis dan dosis obat serta waktu pemberhentian/penghentian obat sebesar 61,17% dan instruksi pemeriksaan penunjang sebesar 89,41%. Belum ada standar prosedur operasional kegiatan analisis kualitatif, faktor-faktor penyebab ketidak-konsistensian ditinjau dari unsur sumber daya antara lain petugas analisis bukan lulusan rekam medis, tenaga kesehatan yang tidak melakukan autentikasi dengan baik serta desain formulir skrinning risiko jatuh dan formulir pemberian obat pasien yang tidak sesuai standar. Kekonsistensian rekam medis dari awal pasien masuk, dalam perawatan hingga diperbolehkan pulang menjadi penting untuk diperhatikan agar terjalin kesinambungan dalam pelayanan kesehatan yang diberikan.]]>
<![CDATA[Della Rati Saputri Tinjauan Lama Waktu Ketersediaan Rekam Medis Rawat Jalan Di RSUD Kota Depok ]]>
<![CDATA[Della Rati Saputri della]]>;
<![CDATA[Lily Widjaja lily]]>;
<![CDATA[Laela Indawati laela]]>;
<![CDATA[Nanda Aula Rumana nanda]]>
<![CDATA[ COMSERVA : Jurnal Penelitian dan Pengabdian Masyarakat Vol. 2 No. 5 (2022): COMSERVA : Jurnal Penelitian dan Pengabdian Masyarakat ]]>
Publisher : <![CDATA[Publikasi Indonesia ]]>
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DOI: 10.59141/comserva.v2i5.235
<![CDATA[Medical records are files in which there are documents about the patient's identity and records of the results of examinations, actions, treatment, and other services that have been provided to patients. Medical records are very useful in providing services to patients because they contain written evidence in paper form for the services provided by doctors and other health workers. Therefore, medical records must be stored in appropriate storage places so that they can be obtained and made available quickly when needed again. Minimum Service Standards are the quality of basic services used in providing medical records with a minimum service standard time of providing outpatient medical records, which is ?10 minutes. This research was conducted at the Depok City Hospital, West Java. This study aims to determine the length of time the availability of outpatient medical records at the Depok City Hospital. This study uses a descriptive method with a quantitative approach by conducting interviews and observations. The population in this study was outpatient visits for 1 month in March 2022. The sample in this study was 106 requests for outpatient medical records using incidental sampling technique. The results of the study showed that ?10 minutes was 51 (48%), and the retrieval time of medical records >10 minutes was 55 (52%) divided into categories for retrieval time of 11 - 20 minutes by 25 (23,6%), 21 - 30 minutes by 8 (7,6%), and > 30 minutes by 22 (20,8%). With an average availability time of 17,42 minutes.]]>
