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All Journal Jurnal Manajemen Pendidikan Jurnal Manajemen Informasi dan Administrasi Kesehatan Journal of Multidisciplinary Academic Jurnal Manajemen Informasi Kesehatan Indonesia (JMIKI) Indonesian of Health Information Management Journal (INOHIM) Surya Medika: Jurnal Ilmiah Ilmu Keperawatan dan Ilmu Kesehatan Masyarakat Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Jurnal Health Sains Jurnal Kesehatan Tambusai Jurnal Ilmiah Wahana Pendidikan Nusantara Hasana Journal Archives of The Medicine and Case Reports Arkus COMSERVA: Jurnal Penelitian dan Pengabdian Masyarakat Indonesian Journal of Health Information Management (IJHIM) Jurnal Ilmiah Kesehatan Masyarakat Sehat Rakyat: Jurnal Kesehatan Masyarakat Journal of Innovation Research and Knowledge Jurnal Rumpun Ilmu Kesehatan Jurnal Sosial dan Sains Journal of Hospital Management Cerdika: Jurnal Ilmiah Indonesia MEDICORDHIF Jurnal Rekam Medis Journal of Educational Innovation and Public Health Jurnal Medika Nusantara Vitamedica: Jurnal Rumpun Kesehatan Umum Vitalitas Medis : Jurnal Kesehatan Dan Kedokteran Vitamin: Jurnal Ilmu Kesehatan Umum Obat: Jurnal Riset Ilmu Farmasi dan Kesehatan Jurnal Rekam Medic
Widjaja, Lily
Universitas Esa Unggul
Religion Agriculture, Biological Sciences & Forestry Humanities Astronomy Computer Science & IT Dentistry Economics, Econometrics & Finance Education Engineering Environmental Science Health Professions Industrial & Manufacturing Engineering Law, Crime, Criminology & Criminal Justice Library & Information Science Medicine & Pharmacology Nursing Physics Public Health Social Sciences Veterinary Other

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Audit Kode Klinis Pasien Rawat Inap Jaminanan BPJS Kesehatan Di Rumah Sakit Tipe C Dan D Wilayah DIY Hosizah, Hosizah; Puspita Ningsih, Kori; Nisak, Umi Khoirun; Widjaja, Lily
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Vol. 9 No. 2 (2024): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Agustus
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v9i2.1707

Abstract

The quality of diagnosis codes is an important part of the hospital management level. The impact of a lack of quality diagnosis codes is the potential to reduce hospital income. A clinical coding audit needs to be conducted to review and analyze discovered errors and attempt to trace their source. The purpose of this research is to audit the code. The research approach was carried out through a quantitative descriptive approach. The research population was inpatient medical records of BPJS Health patients. Sample calculations use Slovin, with a margin of error of 10%. In this study, the clinical coding audit involved 3 coders in each hospital, coding experts from senior practitioners from Type B Hospitals and experts from academics. The results of the clinical code audit showed that the timeliness aspect was 100%, accuracy was 92.5%, completeness was 91.0%, relevance, and legitimacy were 87.5% each, while the lowest was in the reliability aspect at 80.0%. The results of the legibility aspect are in line with the results of relevance. This shows that determining clinical codes for case mix purposes must be supported by complete documentation of the patient's medical records.
ANALISIS FAKTOR YANG MEMPENGARUHI PERILAKU PENGGUNAAN SISTEM REKAM MEDIK ELEKTRONIK MENGGUNAKAN METODE UTAUT Bangun, Evi Vania; Suriyantoro, Suriyantoro; Widjaja, Lily
Journal of Hospital Management Vol 5, No 02 (2022): Journal of Hospital Management
Publisher : Lembaga Penerbitan Universitas Esa Unggul

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.47007/.v5i02.5862

Abstract

Latar Belakang dan Tujuan Rekam medis elektronik adalah sistem informasi kesehatan berbasis komputerisasi yang menyediakan dengan rinci catatan tentang data demografi pasien, riwayat kesehatan, alergi, dan riwayat hasil pemeriksaan laboratorium serta beberapa diantaranya juga dilengkapi dengan sistem pendukung keputusan. Tujuan penelitian adalah untuk menganalisis pengaruh faktor ekspektasi kinerja, ekspektasi usaha, pengaruh sosial, dan kondisi fasilitas dengan variabel intervening niat perilaku yang dimoderasi faktor umur dan pengalaman terhadap perilaku penggunaan sistem rekam medis elektronik. Metode: Model yang digunakan untuk menguji penerimaan dan penggunaan teknologi adalah Unified Theory of Acceptance and Use of Technology (UTAUT).  Penelitian ini menggunakan pendekatan kuantitatif dengan desain  penelitian explanatoris causalitas dengan sampel sebanyak 109 orang. Tehnik pengambilan data dengan kuesioner dan wawancara, diuji dengan analisis jalur. Hasil: Berdasarkan hasil penelitian diatas dapat dirangkum bahwa temuan pada penelitian ini adalah sejalan dengan teori UTAUT dengan variabel faktor ekspektasi kinerja, ekspektasi usaha, pengaruh sosial dan kondisi fasilitas berpengaruh terhadap perilaku penggunaan rekam medis elektronik melalui niat perilaku yang dimoderasi faktor umur baik secara masing-masing maupun simultan. Selain itu, faktor moderasi umur berpengaruh terhadap perilaku penggunaan sistem rekam medis elektronik namun faktor moderasi pengalaman tidak berpengaruh terhadap perilaku penggunaan sistem rekam medis elektronik.  Implikasi: Penelitian ini membantu manajemen rumah sakit menyadari pentingnya dukungan manajemen dalam implementasi penerapan sistem yaitu penyediaan fasilitas dan tenaga pendukung IT yang akan membantu user jika mengalami kendala, juga membantu manajemen dalam mengembangkan fitur dan aplikasi sistem rekam medis elektronik ini untuk lebih mudah digunakan sesuai kebutuhan professional pemberi asuhan. 
Pemanfaatan Personal Health Record Dalam Mengontrol Kesehatan Individu (Literature Riview) Regina Yulianti T. S; Laela Indawati; Lily Widjaja; Daniel Happy Putra
Jurnal Medika Nusantara Vol. 2 No. 2 (2024): Mei : Jurnal Medika Nusantara
Publisher : Stikes Kesdam IV/Diponegoro Semarang, Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.59680/medika.v2i2.1126

Abstract

Individuals are authorized to access, maintain, and share their Personal Health Record (PHR), which is an electronic application, in a private, secure, and confidential setting. Using PHR will facilitate patient-provider communication. PHR has two-way communication that allows patients and providers to communicate with each other. The main effect of using PHR is that patients will be involved and take an active role in their health and disease prevention. The act of recording health information in PHR will increase patient awareness, such as weight, diet and glucose, and other health checks. Through PHR which stores health information, and consultations, patients feel safe knowing their health. The purpose of this writing is to determine the Utilization of Personal Health Record in controlling individual health. This study uses the Literature Review method. The results of this study are seen from the utilization and features of the Personal Health Record. Utilization of the Personal Health Record in controlling individual health can assist patients in accessing patient personal health information such as knowing blood sugar, blood pressure, laboratory results, and so on. The features used in the PHR have a main menu including health records, medical records, test results, medication reminders, health contacts, and education.
Analisis Kualitatif Konsistensi Pencatatan Rekam Medis Rawat Inap Kasus Penyakit Dalam di Rumah Sakit Pelabuhan Jakarta Putri Nurindahsari; Dina Sonia; Lily Widjaja; Daniel Happy Putra
SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat Vol. 2 No. 4 (2023): Oktober 2023
Publisher : Yayasan Literasi Sains Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.55123/sehatmas.v2i4.2352

Abstract

Qualitative analysis is an activity that examines the filling of medical records for inconsistent and incomplete contents, which indicates that the medical records are inaccurate and incomplete. The purpose of this study was to find out a qualitative analysis of the reliability of recording medical records of inpatient cases of internal medicine for the year 2022. This type of research uses a descriptive method with a quantitative approach and data collection by observation and interviews. Of the 99 medical records, the results obtained were 96% consistent and 4% inconsistent. And the results of the 4 subcomponents include: At the time of admission, namely the consistency of the initial assessment of nurses and inpatient doctors, the results were 98% consistent. On the subcomponent during hospitalization, namely the consistency of progress notes between doctors and nurses, obtaining results of 99% consistency, Consistency of Doctor's Instructions with delivery notes the drug gets 93% consistent results, when going home, namely the consistency of the doctor's return summary and the nurse gets 94% consistency results. Of the 4 sub-components that have the highest consistency, the consistency between the doctor's and nurse's developmental records obtains 99% consistent results. While the lowest was the consistency of the Doctor's Instructions with a record of drug administration obtaining 93% consistent results. The conclusion is that the qualitative analysis of medical record recording is not 100% consistent. It is recommended that the Jakarta Harbor Hospital make standard operating procedures and implement related qualitative analysis of medical records.
Tinjauan Penyebab Pengembalian Berkas Klaim Biaya Pelayanan Pasien Rawat Inap BPJS Kesehatan di Rumah Sakit Pelabuhan Jakarta Tahun 2022 Siti Rahmawati Handayani; Lily Widjaja; Daniel Happy Putra; Dina Sonia
SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat Vol. 2 No. 4 (2023): Oktober 2023
Publisher : Yayasan Literasi Sains Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.55123/sehatmas.v2i4.2617

Abstract

In the process of submitting a BPJS Health Claim, some requirements must be completed by the Health Facility. Of these requirements, the BPJS Health party will know that the claim submission can be paid or returned/delayed. This research was conducted to find out the reasons for returning the claim file for BPJS Kesehatan inpatient care at the Jakarta Harbor Hospital in 2022. The method in this study used descriptive research with a quantitative approach. The results of the study were 118 samples (6.7%) of 1,762 files, the highest returned cause was an inaccuracy in the coding of diagnoses/actions of 49 (42%), and the second highest was not fulfilling inpatient administration 18 (15%), other causes - others as much as 51 (43%). 3 factors from 5M are the cause of returning claim files, namely the human factor: casemix officers who are not diligent, lack of coder understanding/knowledge, and lack of accuracy in the filing department so that files are missed/left behind, machine: there is an upgrade to the latest version of the INA-application CBGs and V-Claim are also the Ministry of Health's newest program which requires TB patients to be inputted into the SITB application, Material: incomplete claim requirements files. While the money and method factors are not an obstacle or a cause for returning claim files. It is recommended to evaluate and re-socialize the reasons for returning BPJS Health claims so that the process of submitting BPJS Health claims is carried out properly and is 100% accepted.
Tinjauan Ketepatan Kode Diganosis Tuberkulosis Paru Pasien Rawat Jalan di Rumah Sakit SHL Pandeglang Rahelia Putri; Lily Widjaja; Dina Sonia; Daniel Happy Putra
SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat Vol. 3 No. 2 (2024): April 2024
Publisher : Yayasan Literasi Sains Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.55123/sehatmas.v3i2.3423

Abstract

In coding activities, medical recorders and health information are needed who master how to give disease codes according to ICD-10 and actions according to ICD-9 CM so that the resulting code has accuracy according to the diagnosis or action given. One of the most frequently used coding accuracy is accuracy in coding for Pulmonary Tuberculosis. One of the important things is how to describe the accuracy of the Outpatient Pulmonary Tuberculosis diagnosis code at SHL Pandeglang Hospital. This study was shown to determine the accuracy of the diagnosis code for Outpatient Pulmonary Tuberculosis at SHL Pandeglang Hospital. This research method uses a descriptive method with a quantitative approach. The sample of this study was taken by saturated sampling technique. Data were taken using interviews and observations. The results of the study of 122 medical records obtained accuracy of 93 (76.2%) files and inaccuracy of 29 (23.8%) files. Based on the identification of factors causing the inaccuracy of the diagnosis code, there are 4 factors, namely the man factor: occurs due to the lack of accuracy of the coder in coding, the workload of the coder, and the lack of training for coders with non-RMIK backgrounds. Material factors: the unavailability of the Medical Dictionary (Dictionary of Medical Terminology) and the absence of an abbreviated list of diagnoses (standard). Machine factors: damage to the computer, software hangs, and computers that are too old. Method factor: incomplete SPO diagnosis coding.
Analisis Faktor Keterlambatan Pengembalian Rekam Medis Rawat Inap Di Rumah Sakit (Literature Review) Risma Sisni Fadilla; Puteri Fannya; Noor Yulia; Lily Widjaja
Vitalitas Medis : Jurnal Kesehatan dan Kedokteran Vol. 1 No. 3 (2024): Juli : Vitalitas Medis : Jurnal Kesehatan dan Kedokteran
Publisher : Lembaga Pengembangan Kinerja Dosen

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.62383/vimed.v1i3.556

Abstract

Prompt return of patient medical records is an important step in the health records processing workflow. Speed is the key to meeting quality processing standards. The hospital sets a deadline for returning medical records within 2x24 hours after the patient is discharged. Delays can be caused by various factors, which are classified under the 5M management elements: man, materials, machines, methods, and money. The aim of this research is to identify aspects that are the root of the problem in delays in the process of returning medical records to the hospital. The methodology used is a literature review, with analysis of 17 journal articles from the Google Scholar database. The study results showed that human factors such as staff shortages, incomplete doctor signatures, and inadequate staff educational qualifications were the main causes of delays. Material factors often result in incomplete documents. The machine factor is related to the significant distance between the inpatient department and the medical records department. Meanwhile, the method factor, namely SPO socialization has not been carried out and the implementation of job descriptions has not been maximized.
Hubungan Kualitas Layanan Elektronik dan Kualitas Informasi Aplikasi Halodoc Terhadap Kepuasan pada Pengguna Fadia Eka Septiawati; Puteri Fannya; M. Fuad Iqbal; Lily Widjaja
Vitalitas Medis : Jurnal Kesehatan dan Kedokteran Vol. 1 No. 4 (2024): Oktober : Vitalitas Medis : Jurnal Kesehatan dan Kedokteran
Publisher : Lembaga Pengembangan Kinerja Dosen

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.62383/vimed.v1i4.803

Abstract

User satisfaction with the Halodoc application is measured by meeting user needs. The halodoc application is a health application which has many features and uses, one of which is that patients can chat and communicate with specialist doctors who are experienced in their respective fields. This research aims to determine the relationship between the quality of electronic services and the quality of the Halodoc application information on user satisfaction. Researchers also use the DeLone and McLean information system success model by taking several necessary variables. The samples used by researchers were users of the halodoc application or had used the halodoc application. The data collection instrument uses a questionnaire where the questionnaire is distributed digitally. The questionnaire is distributed in December 2023 - January 2024. Hypothesis testing is carried out by examining the relationship between electronic service quality and information quality on user satisfaction using the Chi-Square test, the research results show that service quality electronics and information quality have a relationship with user satisfaction.
Factors for Selection of Medical Records and Health Information Study Programs for New Students at Universitas Esa Unggul, Jakarta, Indonesia Dewi, Sisilia Kartika; Nanda Aula Rumana; Dina Sonia; Lily Widjaja
Arkus Vol. 10 No. 1 (2024): Arkus
Publisher : HM Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37275/arkus.v10i1.406

Abstract

University is one of the educational facilities in order to equip oneself with the knowledge and skills needed to face the future. There are several factors that underlie prospective students in determining the major they want to enter at university. This study aimed to describe the factors for selecting a medical records and health information study program for new students at Universitas Esa Unggul, Jakarta, Indonesia. This research is a descriptive observational study. The inclusion criteria for this research were new students from the Universitas Esa Unggul medical records program class of 2023 who were willing to take part in this research process. The research subjects were carried out using proportional random sampling techniques. A total of 129 students participated in this research. Data collection was carried out using a questionnaire. The study results showed that most of the students were teenagers (58.1%) and women (67.4%) and chose the regular program (76.7%). The highest factors influencing new students' decisions are accreditation (university image) (90.31%) and employment availability (89.73%), while the lowest is the interest factor, namely the dream of becoming a medical recorder (76.16%). In conclusion, the study program image factor (accreditation) is the underlying factor in selecting a medical records and health information study program for new students at Universitas Esa Unggul, Jakarta, Indonesia.
Analisis Kebutuhan Perekam Medis dan Informasi Kesehatan dengan Metode Analisis Beban Kerja Kesehatan di Puskesmas Tambora Muhamad Fazriyansah; Lily Widjaja; Laela Indawati; Muhammad Rezal
Jurnal Manajemen Informasi dan Administrasi Kesehatan Vol. 7 No. 2 (2024): JMIAK
Publisher : Program Studi D3 Rekam Medis dan Informasi Kesehatan

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.32585/jmiak.v7i2.5751

Abstract

Observasi awal di Puskesmas Tambora ditemukan dari 15 petugas, hanya satu yang berpendidikan rekam medis, menyebabkan beban kerja berat dan pengelolaan rekam medis tidak optimal. Penelitian ini bertujuan untuk memberikan gambaran hasil analisis kebutuhan perekam medis dan informasi kesehatan di Puskesmas Tambora dengan metode deskriptif kuantitatif yang menggunakan sampel jenuh dari total 15 petugas di unit rekam medis. Dari hasil penelitian yang dilakukan oleh peneliti didapatkan informasi bahwa Puskesmas Tambora memiliki SOP terkait perencanaan kebutuhan SDMK berdasarkan Permenkes No. 33 Tahun 2015. Hasil perhitungan kebutuhan perekam medis dan informasi kesehatan dengan metode analisis beban kerja kesehatan menunjukkan Puskesmas Tambora membutuhkan 16 petugas rekam medis, namun saat ini hanya ada 15 petugas, sehingga kekurangan 1 orang. Saran untuk penelitian ini yaitu dilakukannya penyesuaian jumlah perekam medis dan informasi kesehatan sesuai beban kerja dengan cara 4 orang pelaksana pendaftaran 24 jam lulusan SMA diberikan beasiswa untuk sekolah pendidikan DIII-RMIK di perguruan tinggi yang menyelenggarakan kelas karyawan dan merekrut 1 orang lulusan DIII-RMIK untuk memenuhi kekurangan 5 orang perekam medis dan informasi kesehatan (Manajemen pengelolaan rekam medis). Selain itu, 1 orang pelaksana pendaftaran BPJS lulusan SMA yang berlebih dapat dipindahkan ke bagian pendaftaran pasien yang kekurangan 1 orang petugas lulusan SMA.
Co-Authors -, Muniroh Adelia Anggraini Adi Widodo Adil Hidayat Adinda Pratiwi Alex Sander Alfi Shiddiq Syafrian Aliyani Aliyani Amirah Syafiqah Zahra Anas Fajry Rhomadon Angelina Angelina Anggraini, Adelia Annisa Nur Salsabila Arip Budiana Azhar Muttaqin Azhar Muttaqin Azidah, Mega Puspita Bahlani Bangga Agung Satrya Bangun, Evi Vania Bangun, Gabriella Eviana Bayu Fajar Ilhami Bella Safitri Choirunisa Choirunisa Dani Sagitha Daniel Happy Putra Della Rati Saputri della Dewi, Deasy Rosmala Dewi, Sisilia Kartika Dian Nur Muslimah Dina Sonia Dwi Chandrarika Putri Aulia Dwijayanti, Risma Mei Eka Widya Rita P. Endika Rachmad Fadia Eka Septiawati Fannya, Puteri Fauzan Habibilah Fauziah Irfany Ferina Ferina Ferina, Ferina Firmansye Ika Panggulu Fredrika Welhelmina Gabriella Eviana Bangun Gina Sonia Gita, Elsa Chandra Harahap, Maulidiah Rizki Hosizah Hosizah Ilham Abdurohman Indawati, Laela Intan Rusdiana Dewi Jeillia Jihan Swaradwibhagia Khoirunnisa Sabiladina Kusumapradja, Rokiah Laela Indiawati Lautsan, Christina M. Fuad Iqbal Maulidiah Rizki Harahap Mega Puspita Azidah Muhamad Fazriyansah Muniroh - Muniroh Muniroh Muniroh Muniroh Muniroh Muniroh Muniroh Muniroh Muniroh Muniroh Muniroh Muniroh Muniroh, Muniroh Nanda Aula Rumana Natsir Nugroho Nindia Septa Tiana Nurmalasari, Dinda Nurmalasari, Mieke Octa Rina Sari Pratiwi, Adinda Puspita, Kori Putri Fannya Putri Nurindahsari Putri, Alifatul Aulia Sagita Rahayu, Ririn Rahelia Putri Rani Puspita Ningrum RATNA INDRAWATI Regina Yulianti T. S Rezal, Muhammad Rifda Ulfa Andini Ririn Rahayu Risma Sisni Fadilla Saarah Salsabila Putri Yadita Sabiladina, Khoirunnisa Salsabila, Annisa Nur Sarah Khonsa Setiawan, Mohammad Yusuf Siti Rahmawati Handayani siti Widya Astuti, siti Sofi Romando Putri Suciyanti Suciyanti Suriyantoro, Suriyantoro Surlialy, Dewi Tantri Wilananda Tri Harti Maya Utami Uli Shalatiya uli Umi Khoirun Nisak Vania Rachma Putri Viatiningsih, Wiwik Wiranata, Tyansa Eka Sampoerna Yasinta Rosalia Menna Yenni Syafitri Yulia, Noor