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All Journal Jurnal Ilmu Kesehatan Masyarakat (The Public Health Science Journal) Jurnal Puan Indonesia Tedc Jurnal Ilmu Kesehatan Masyarakat (The Public Health Science Journal)
Intan Pujilestari
Politeknik TEDC
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TINJAUAN KETIDAKLENGKAPAN PENGISIAN AUTENTIFIKASI DOKTER PADA FORMULIR RINGKASAN PASIEN PULANG DI INSTALASI REKAM MEDIS PASIEN RAWAT INAP RUMAH SAKIT UMUM PINDAD BANDUNG Intan Pujilestari; Neni Rohaeni
Jurnal TEDC Vol 13 No 3 (2019): JURNAL TEDC
Publisher : UPPM Politeknik TEDC Bandung

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Abstract

Incomplete medical resume is a problem because medical resumes can provide detailed information about what has happened while the patient was hospitalized so that it has an impact on the quality of medical records and services provided by the hospital. Based on a preliminary study from February 8 to March 8, 2021, the authors found that the number of medical records on the summary form of discharged patients at the inpatient medical record installation were incomplete, such as the signature and full name of the doctor that were not filled out, out of 225 medical record files in the form summary of patients returning home, only 155 forms were completed and 70 forms were incomplete. This study aims to determine the incomplete description of filling in the doctor's authentication on the summary form of discharge patients at the medical record installation of inpatients at the Pindad General Hospital, Bandung.The research method used is descriptive research method. Data collection techniques in research include: observation, interviews, documentation and literature study.Based on research at the Pindad General Hospital, Bandung already has a Standard Operating Procedure, but in its implementation it has not been in accordance with the standards set by the hospital. The results showed that the incomplete completion of authentication on the discharge patient summary form carried out by the author obtained a percentage of the completeness of the discharge patient summary form filling of 73.2% and the incomplete filling of 26.8% from October and November with a total sample of 87 discharge patient summary forms.
TINJAUAN BEBAN KERJA PETUGAS ASSEMBLING ANALISIS REKAM MEDIS RAWAT INAP DENGAN METODE WISN (WORK LOAD INDICATOR STAFF NEEDS) GUNA MENUNJANG EFEKTIFITAS KERJA DI RSUP DR. HASAN SADIKIN BANDUNG Intan Pujilestari; Sabrina Chairunnisa
Jurnal TEDC Vol 16 No 2 (2022): JURNAL TEDC
Publisher : UPPM Politeknik TEDC Bandung

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Berdasarkan studi pendahuluan yang dilaksanakan pada tanggal 13 sampai 14 Januari 2020 di RSUP Dr. Hasan Sadikin Bandung dengan sampel 1 petugas assembling analisis rekam medis rawat inap SMF kesehatan anak. Waktu pengerjaan assembling dapat menyelesaikan 41 berkas rekam medis dengan rata-rata 5,51 menit/1 berkas rekam medis selama 3 jam 46 menit atau 226 menit, dan dibagian analisis rekam medis manual atau berbasis kertas dapat menyelesaikan 41 berkas rekam medis dengan rata-rata 6,09 menit/1 berkas rekam medis selama 4 jam 10 menit atau 250 menit. Tujuan penelitian ini untuk mengetahui dan menambah wawasan tentang menghitung beban kerja petugas assembling analisis rekam medis rawat inap berdasarkan metode WISN di RSUP Dr. Hasan Sadikin Bandung. Metode penelitian yang digunakan adalah metode deskriptif dengan pendekatan analisis kuantitatif. Teknik pengumpulan data yaitu dengan wawancara, observasi, dan studi dokumentasi. Instrumen penelitian yang digunakan alat tulis, stopwatch, kalkulator, dan penoman wawancara. Hasil penelitian kebutuhan SDM petugas assembling analisis rekam medis rawat inap dengan metode WISN adalah 8,65 orang atau dibulatkan 9 orang dan sudah sesuai dengan jumlah dilapangan akan tetapi perlu adanya pemerataan antara petugas assembling dengan analisis. Sedangkan efektifitas kerja petugas assembling analisis rekam medis rawat inap belum efektif karena kurangnya kedisiplinan petugas terhadap jam kerja yang telah ditetapkan. Penulis menyarankan dilakukan peninjauan ulang SOP, diadakannya pendidikan dan pelatihan minimal 1 tahun sekali untuk meningkatkan kualitas, kuantitas dan kedisiplinan dalam bekerja menjadi lebih baik lagi
ANALISIS KETEPATAN PEMBERIAN KODE DIAGNOSA DAN TINDAKAN TERHADAP PEMBAYARAN KLAIM JKN RAWAT INAP DI RSUP DR. HASAN SADIKIN BANDUNG Intan Pujilestari
Jurnal TEDC Vol 14 No 2 (2020): Jurnal TEDC
Publisher : UPPM Politeknik TEDC Bandung

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Abstract

Based on the result study conducted by authors in the sub-installation of coding part of inpatient in RSUP Dr. Hasan Sadikin Bandung 7 January until 10 January year 2020 was conducted sampling as many as 61 files taken from the correction file BPJS which is returned back by the Verificator in September 2020. Authors found the number of precision encoding diagnosis of 22 sample correction files with presentation (36%), and the inaccuracy number of the encoding of diagnosis of 39 correction files with presentation (64%). The method used in this research is a quantitative method with a descriptive approach. The population in the study was a correction file of JKN Inpatient claims in October 2019 as many as 95 files with quota sampling techniques. The data collection techniques used are observation techniques, interview techniques, and literature studies. The results showed that there was precision of codification and action was 63 claims of file correction or with a total percentage of 66.31% and the amount of codification inaccuracy and action was as many as 32 claims of file correction or with a total percentage of 30.68%. The author advises the SOP (standard operational procedure) to be immediately signed by the President Director in order to be a legal, as well as a regular and periodical socialization of the practitioner on how important the writing of complete, precise and accurate medical records and to coordinate or supply to all stakeholders such as doctors, coder, billing personnel, workshops on the rules of claim.
ANALISIS KELENGKAPAN LEMBAR RINGKASAN MASUK DAN KELUAR PASIEN RAWAT INAP COVID-19 GUNA MENUNJANG MUTU REKAM MEDIS DI RUMAH SAKIT BHAYANGKARA TK-II SARTIKA ASIH BANDUNG Intan Pujilestari; Rizqy Dimas Monica; Fury Try Lestary
Jurnal TEDC Vol 16 No 3 (2022): JURNAL TEDC
Publisher : UPPM Politeknik TEDC Bandung

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Abstract

Formulir ringkasan masuk dan keluar merupakan formulir rekam medis yang digunakan untuk mencatatat ringkasan perjalanan penyakit sejak pasien masuk saampai keluar Rumah Sakit. Berdasarkan hasil studi pendahuluan di RS. Bhayangkara TK-II Sarika Asih Bandung ditemukan kelengkapan pengisian ringkasan masuk dan keluar sebesar 63,33% dari 30 ringkasan masuk dan keluar yang diambil secara acak. Tujuan penelitian ini untuk mengetahui gambaran kelengkapan pengisian lembar ringfkasan masuk dan keluar rawat inap Covid-19 guna menunjang mutu berkas rekam medis di RS. Bhayangkara TK-II Sartika asih Bandung. Metode yang digunakan adalah metode deskriptif dengan pendekatan kuantitatif. Dalam penelitian ini menggunakan Teknik sampling simple random sampling. Populasi yang diambil sebanyak 320 berkas dan Sampel diambil sebanyak 178 berkas rekam medis. Teknik pengumpulan data yang digunakan adalah observasi, wawancara dan studi kepustakaan. Hasil penelitian ini menunjukkan adanya standar prosedur operasional pengisian ringkasan masuk dan keluar namun dalam pelaksanaanya belum optimal dikarenakan masih ditemukan pengisian yang belum lengkap. ketidak lengkapan pencatatannya sebesar 75,8% dengan item tertinggi ketidaklengkapan pada Kode ICD diagnosa tambahan sebesar 67,42%. sehingga hasil tersebut dapat dikatakan bahwa lembar ringkasan masuk dan keluar Covid-19 belum baik yang dilihat dari aspek kelengkapan. Disarankan melakukan evaluasi dan tinjauan ulang terhadap Standar Prosedur Operasional, serta diadakan sosialisasi dan evaluasi terhadap dokter, perawat dan tenaga terkait lainnya.
Co-Authors Dini Rohmayani Fury Try Lestary Neni Rohaeni Rizqy Dimas Monica Sabrina Chairunnisa Toha Muhaimin