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<![CDATA[Tinjauan Kelengkapan Penulisan dan Ketepatan Kode External Cause Kasus Kecelakaan Lalu Lintas di Siloam Hospital Kebon Jeruk ]]>
<![CDATA[Uli Shalatiya uli]]>;
<![CDATA[Lily Widjaja lily]]>;
<![CDATA[Laela Indawati laela]]>;
<![CDATA[Noor Yulia noor]]>
<![CDATA[ COMSERVA : Jurnal Penelitian dan Pengabdian Masyarakat Vol. 2 No. 3 (2022): COMSERVA : Jurnal Penelitian dan Pengabdian Masyarakat ]]>
Publisher : <![CDATA[Publikasi Indonesia ]]>
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DOI: 10.59141/comserva.v2i3.249
<![CDATA[In giving a code to a traffic accident case, it must be equipped with an external cause code, these external factors need attention because they are the cause of problems that need intervention in preventing, overcoming injuries, poisoning, or certain diseases. The purpose of this study is to identify the SOP for giving external cause codes for traffic accidents, calculate the completeness of external causes, measure the accuracy of the external cause code, find out the factors causing the inaccuracy of the external cause code. The research method is a quantitative descriptive method. The results showed that Siloam Hospital Kebon Jeruk did not yet have a special SOP for external causes for traffic accidents and from 64 samples of medical records it was known that the completeness of writing external causes was 57.81% and 42.19% were incomplete. The accuracy of the diagnostic code and the external cause is 64.96% and the incorrect is 35.04%. The factors causing the code inaccuracy are the lack of accuracy of the coder officer when giving the external cause code, the unclear writing of the doctor and the incomplete writing of the external cause, the absence of a special SPO for special coding for traffic accidents, and the SIMRS being inadequate to use the activity code which is a character code for traffic accidents. 5. The conclusion of this study is that the hospital does not have a special SOP for giving external cause codes to traffic accident patients, writing completeness is 57.81%, coding accuracy is 64.96%.]]>
<![CDATA[Tinjauan Kelengkapan Laporan Operasi Sectio Caesarea Di Rsud Kembangan 2022 ]]>
<![CDATA[Adil Hidayat]]>;
<![CDATA[Lily Widjaja]]>;
<![CDATA[Deasy Rosmala Dewi]]>;
<![CDATA[Puteri Fannya]]>
<![CDATA[ Jurnal sosial dan sains Vol. 2 No. 12 (2022): Jurnal Sosial dan Sains ]]>
Publisher : <![CDATA[Green Publisher Indonesia ]]>
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DOI: 10.59188/jurnalsosains.v2i12.590
<![CDATA[Latar Belakang : Laporan Operasi merupakan catatan dokter terkait langkah langkah yang dilakukan saat pembedahan pasien. Laporan operasi harus segera dibuat setelah pembedahan dan dimasukkan dalam rekam kesehatan. Tujuan : Tujuan dari penelitian ini adalah mengetahui kelengkapan pengisian laporan operasi pasien operasi caesar di RSUD Kembangan. Metode : Metode penelitian yang dilakukan adalah metode deskriptif dengan analisis kuantitatif, untuk menggambarkan kelengkapan pengisian laporan operasi di RSUD Kembangan. Hasil : Berdasarkan hasil penelitian mengenai Standar Prosedur Operasional pengisian lembar laporan operasi caesar di RSUD Kembangan Jakarta sudah ada, dimana sudah terdapat Standar Prosedur Operasional (SPO) yang mengatur tentang pengisian laporan operasi di RSUD Kembangan tetapi belum semua prosedur terlaksana, 2 point prosedur yang belum terlaksana dimana belum adanya buku catatan yang mencatat laporan operasi yang belum diisi dan pengisian laporan operasi masih dilaksanakan di ruang rawat inap, belum tersedianya buku catatan yang mencatat laporan operasi yang belum diisi. Hasil analisis kuantitatif dari 79 laporan operasi didapatkan kelengkapannya dengan persentase 96,3%. Kesimpulan: Dampak dari ketidaklengkapan laporan operasi yaitu ada beberapa berkas yang tidak lengkap yang tidak dapat dipakai sebagai barang bukti yang sah bila dibutuhkan dipengadilan, menggangu proses keberlanjutan proses pengobatan, bagi pasien bpjs klaim menjadi terhambat, membuat proses kelanjutan pengobatan terganggu karna riwayat pengobatan pasien tidak lengkap, tidak lengkapnya laporan operasi juga berpengeraruh terhadap akreditasi rumah sakit.]]>
<![CDATA[Literature Review : Kelengkapan Kode Topography dan Morphology pada Kasus Neoplasma ]]>
<![CDATA[Dian Nur Muslimah]]>;
<![CDATA[Deasy Rosmala Dewi]]>;
<![CDATA[Laela Indawati]]>;
<![CDATA[Lily Widjaja]]>
<![CDATA[ SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat Vol. 2 No. 1 (2023): Januari 2023 ]]>
Publisher : <![CDATA[Yayasan Literasi Sains Indonesia ]]>
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DOI: 10.55123/sehatmas.v2i1.1000
<![CDATA[In the Medical Record for determining the cancer diagnosis code (Neoplasm), there are 2 codes, namely the topographic code and the morphology code. These two codes are very important because the topographic code is a code that shows the location of the tumor, while the morphology code is a code that shows the nature of the tumor. If the two codes are not included, it will not determine the level of malignancy of the tumor. The aim of the study was to identify the completeness of the topographic and morphological codes in neoplasm cases. Literature study conducted on 7 journals uploaded online in the span of 2011-2021. Search journals in this study using the keywords "completeness", "Topography and Morphology code" obtained through Google Scholar. The results of the literature review show that the completeness of topographic and morphological codes in neoplasm cases has not yet reached 100%. The highest completeness of topographic codes is 98% at Aisyiyah Hospital Malang in 2018. While the lowest percentage is 0% at MRCCC Siloam Semanggi Hospital in 2020 and Karanganyar District Hospital in 2011. The highest completeness of morphology codes is 82.4% at Santa Elisabeth Hospital Medan while The lowest percentage was 0% at MRCCC Siloam Semanggi Hospital in 2020, Bhayangkara Hospital, Aisyiyah Hospital, Dr Moewardi Hospital, and Karanganyar District Hospital. The incompleteness is due to 2 factors Man: Coder inaccuracy in coding, officers have not implemented coding procedures in neoplasm cases. Method: there is no SOP for coding neoplasms, there is no PA result sheet, and the doctor's writing is not clear and complete. In assigning codes to neoplasm cases, officers should code according to the SOP, so that the resulting code is complete and accurate.]]>
<![CDATA[Tinjauan Lama Waktu Pendistribusian Rekam Medis Rawat Jalan di Rumah Sakit Umum Bhakti Asih ]]>
<![CDATA[Adinda Pratiwi]]>;
<![CDATA[Lily Widjaja]]>;
<![CDATA[Muniroh Muniroh]]>;
<![CDATA[Daniel Happy Putra]]>
<![CDATA[ Cerdika: Jurnal Ilmiah Indonesia Vol. 2 No. 4 (2022): Cerdika: Jurnal Ilmiah Indonesia ]]>
Publisher : <![CDATA[Publikasi Indonesia ]]>
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DOI: 10.59141/cerdika.v2i4.362
<![CDATA[Medical record is written or recorded information regarding identity, history taking, physical determination, laboratory, diagnosis of all medical services and actions provided to patients and treatment, whether inpatient, outpatient or receiving emergency services. Distribution in the health sector, especially medical records, has the meaning of a process of distributing medical records to each polyclinic addressed by the patient according to the medical record number. Minimum Service Standards (SPM) are provisions regarding the type and quality of basic services in the speed of providing medical records, the standard time for providing medical records for outpatient services is 10 minutes. This research was conducted at Bhakti Asih Hospital located at Jalan Raden Saleh No. 10, Karang Tengah, Tangerang City, Banten 15157. The purpose of this study was to determine the length of time for the distribution of outpatient medical records at Bhakti Asih General Hospital. This type of research uses descriptive quantitative methods. Data collection techniques used are observation and interviews. In this study, the population was all outpatient medical records in the period June 2021 with a sample of 96 outpatient medical records, using the Incidental/Convenience sampling technique. The results of this study can be seen that 52 medical records (54.16%) have met the SOP 10 minutes, while 44 medical records (45.83%) have not met the SOP 10 minutes. The time of calculating the distribution of outpatient medical records with 96 samples for 10 days with a total time of 984 minutes obtained an average time of distribution of outpatient medical records of 10.25 minutes.]]>
<![CDATA[Tinjauan Kebutuhan Rak Penyimpanan Rekam Medis di RSUD Bangka Selatan ]]>
<![CDATA[Ferina Ferina]]>;
<![CDATA[Muniroh Muniroh]]>;
<![CDATA[Daniel Happy Putra]]>;
<![CDATA[Lily Widjaja]]>
<![CDATA[ Cerdika: Jurnal Ilmiah Indonesia Vol. 2 No. 4 (2022): Cerdika: Jurnal Ilmiah Indonesia ]]>
Publisher : <![CDATA[Publikasi Indonesia ]]>
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DOI: 10.59141/cerdika.v2i4.373
<![CDATA[Medical record is a collection of facts or evidence of the patient's condition, past and current medical history and treatment written by the health professional who provides services to the patient. Medical records require sufficient storage shelves and storage space is needed to maintain confidentiality, avoid damage and make it easier for officers to retrieve and return medical records in the long term. If the medical record storage is adequate and meets the standards to support maximum patient care, it is necessary to adjust the need for medical record storage racks at the South Bangka Hospital. The purpose of this study was to determine the need for medical record storage racks for the next 5 years at RSUD South Bangka. This type of research uses a descriptive method with a quantitative approach. Data collection techniques used are observation and interviews. The results of this study are the number of medical record storage racks in the South Bangka Hospital currently amounts to 17 shelves and the South Bangka Hospital currently has a medical record storage area of 25m². It is recommended that the South Bangka Hospital need to provide 49 storage shelves for the next 5 (five) years so that the shelf needs can be met and can accommodate all medical records and it is hoped that the hospital will add an area of medical record room with an additional area of 11.96m² to adjust the addition of medical record racks.]]>
<![CDATA[Tinjauan Ketepatan Pengodean Diagnosis Penyebab Dasar Kematian pada Pasien Diabetes Mellitus di RSU UKI Jakarta ]]>
<![CDATA[Dinda Nurmalasari]]>;
<![CDATA[Lily Widjaja]]>;
<![CDATA[Deasy Rosmala Dewi]]>;
<![CDATA[Laela Indawati]]>
<![CDATA[ Cerdika: Jurnal Ilmiah Indonesia Vol. 2 No. 4 (2022): Cerdika: Jurnal Ilmiah Indonesia ]]>
Publisher : <![CDATA[Publikasi Indonesia ]]>
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DOI: 10.59141/cerdika.v2i4.374
<![CDATA[Determination is a precaution and the accuracy of disease codes can be easily identified into correct and incorrect codes, Correct codes are adjusted in ICD-10 then incorrect codes are inappropriate codes in ICD-0. The cause of death was hospital reporting. The uncertainty of the diagnostic code consists of 5m (man, money, method, machine, material) based on the interview of the coding officer that the precision of the cause of death in the diabetes mellitus diabetes is not optimum because of poor doctors' writing, the use of abbreviations in the diagnosis, the lack of human resources in rmic education, no charge in coding, The method of conducting a death certificate from the medical certificate form is the cause of death at the point of immediate cause, the cause between and the underlying cause and the absence of a specialized chamber. Hence, the authors conducted a study on the correctness of the causes of death in diabetes patients mellitus according to the icd-10. The purpose of this study was to understand the precision of the diagnosis of the causes of death in the diabetes patient mellitus in Jakarta general hospital. Based on a study of the 72 medical records of patients dying of the precision of the cause of death in diabetes patients mellitus in Jakarta general in 2017-2020.]]>
<![CDATA[Tinjauan Kebutuhan Rak Penyimpanan Rekam Medis di Rumah Sakit Annisa Bogor Tahun 2022 ]]>
<![CDATA[Annisa Nur Salsabila]]>;
<![CDATA[Wiwik Viatiningsih]]>;
<![CDATA[Lily Widjaja]]>;
<![CDATA[Laela Indawati]]>
<![CDATA[ Cerdika: Jurnal Ilmiah Indonesia Vol. 2 No. 7 (2022): Cerdika: Jurnal Ilmiah Indonesia ]]>
Publisher : <![CDATA[Publikasi Indonesia ]]>
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DOI: 10.59141/cerdika.v2i7.436
<![CDATA[Hospital is a health service institution by providing outpatient and inpatient services. Each hospital also has an obligation to have a Medical Record Unit. Medical records are files that contain records or documents such as patient identities, results of diagnoses, actions, and treatments as well as services that have been provided to patients. In the context of administering medical records, health service facilities are required to provide the necessary facilities. One of them is a medical record storage rack to store medical records. Based on the results of research at the Medical Record Unit of the Annisa Hospital, Bogor, it was found that the medical record storage rack was inadequate and some medical records were piled on the floor, making it difficult for officers to find medical records when needed and services at the polyclinic became hampered. The purpose of this study was to determine the need for medical record storage racks for the next 5 years at Annisa Hospital Bogor in 2022. The study was conducted using a quantitative descriptive method, using a non-random sampling method with saturated sampling technique. From the results of the study, the Annisa Bogor Hospital still lacks medical record storage rack facilities which currently have 12 wooden shelves and 3 Roll O'packs, an additional rack of 9 Roll O'packs is needed. The storage area at Annisa Hospital Bogor is sufficient because the area needed for the next 5 years is 61.3 m2. Meanwhile, the current room area is 120 m2 combined with the medical record officer's workspace.]]>
<![CDATA[Literature Review Ketepatan Pengodean ICD-10 External Cause di Rumah Sakit ]]>
<![CDATA[Maulidiah Rizki Harahap]]>;
<![CDATA[Laela Indawati]]>;
<![CDATA[Lily Widjaja]]>
<![CDATA[ Cerdika: Jurnal Ilmiah Indonesia Vol. 2 No. 9 (2022): Cerdika: Jurnal Ilmiah Indonesia ]]>
Publisher : <![CDATA[Publikasi Indonesia ]]>
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DOI: 10.59141/cerdika.v2i9.445
<![CDATA[External cause is classifying disease with cases of injury, poisoning, and accidents, from external causes. Therefore, medical officers must be competent in coding according to ICD-10 and are required to provide precise and accurate codes. The purpose of this study was to determine the percentage accuracy of the external cause ICD-10 coding and to find out the obstacles to the inaccuracy of external cause coding. using the literature review method. The results of a literature review of 12 journals related to the coding accuracy of ICD-10 external causes in several hospitals found that the highest percentage of code accuracy was 82% with the lowest percentage of code accuracy being 0%, while the highest percentage of coding inaccuracy was 100% and for the percentage of inaccuracy. the lowest code as much as 18 %. The 10 journals above use 5M elements, namely the obstacles that are often obtained from the Man factor which consists of coders who are not careful in determining the code, the competence of medical recorders needs to be honed, and lack of effective communication between coders and officers regarding the contents. medical records. It is recommended for coders who do not understand coding to conduct seminars to learn how to do good coding, so that the percentage of inaccuracies in the hospital is reduced to a lower level.]]>
<![CDATA[Tinjauan Ketepatan Kode Diagnosis Pada Kasus Bedah Pasien Rawat Inap di RSKD Duren Sawit ]]>
<![CDATA[Ririn Rahayu]]>;
<![CDATA[Laela Indawati]]>;
<![CDATA[Lily Widjaja]]>;
<![CDATA[Nanda Aula Rumana]]>
<![CDATA[ Cerdika: Jurnal Ilmiah Indonesia Vol. 2 No. 11 (2022): Cerdika: Jurnal Ilmiah Indonesia ]]>
Publisher : <![CDATA[Publikasi Indonesia ]]>
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DOI: 10.59141/cerdika.v2i11.455
<![CDATA[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.]]>
<![CDATA[Analisis Ketepatan Kode Diagnosis Kasus Persalinan Secara Sectio Caesarea Di Rumah Sakit Pelabuhan Jakarta ]]>
<![CDATA[Adelia Anggraini]]>;
<![CDATA[Lily Widjaja]]>;
<![CDATA[Laela Indawati]]>;
<![CDATA[Deasy Rosmala Dewi]]>
<![CDATA[ Cerdika: Jurnal Ilmiah Indonesia Vol. 3 No. 1 (2023): Cerdika: Jurnal Ilmiah Indonesia ]]>
Publisher : <![CDATA[Publikasi Indonesia ]]>
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DOI: 10.59141/cerdika.v3i1.505
<![CDATA[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.]]>
