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HUBUNGAN KEJELASAN DAN KELENGKAPAN PENULISAN DIAGNOSA PENYAKIT BRONCHITIS ACUTE DENGAN KETEPATAN PENGODEAN DIAGNOSA PENYAKIT BERDASARKAN ICD 10 DI BANGSAL RAWAT INAP PENYAKIT DALAM RS MITRA MEDIKA BATANG HARI Maisharoh Maisharoh; Dian Sari; Dea Rosanti
Ensiklopedia of Journal Vol 4, No 3 (2022): Vol 4 No. 3 Edisi 1 April 2022
Publisher : Lembaga Penelitian dan Penerbitan Hasil Penelitian Ensiklopedia

Coding is one of the medical record data processing activities in providing codes with letters or numbers or a combination of letters and numbers that represent data components. Of the 10 medical record files selected at random, 6 (60%) files were found to be coding inaccuracy, while 4 (40%) files were in accordance with ICD-10. The purpose of this study was to determine the accuracy of the diagnosis code for acute bronchitis in inpatients in the internal medicine ward at Mitra Medika Batanghari Hospital. This type of research uses a descriptive method with a quantitative approach. The population is 95 medical record documents for inpatient acute bronchitis. This research was conducted in July 2021. The sampling technique used a saturated sample. Data analysis used bivariate analysis with SPSS program. The results showed that there were 56 (58.9%) medical records that were not accurate in coding the diagnosis of acute bronchitis for inpatients in the internal medicine ward, 42 (44.2%) medical records for the clarity of writing a diagnosis of acute bronchitis for inpatients in the medical ward. in which it is not clear and 35 (36.8%) medical records completeness of writing a diagnosis of acute bronchitis in inpatients in an internal medicine ward that are incomplete, and the results of bivariate analysis show that there is a relationship between clarity and accuracy of diagnostic coding pvalue = 0.001 (p<0 ,05). and there is a relationship between clarity and completeness with the accuracy of diagnostic coding pvalue = 0.005 (p<0.05)Keywords: Accuracy, Coding, Acute Bronchitis.

ANALISIS FISHBONE FAKTOR PENGHAMBAT BELUM TERLAKSANANYA PEMUSNAHAN DOKUMEN REKAM MEDISDI RSI IBNU SINA PADANG Dian Sari; Maisharoh Maisharoh; Yusmita Yusmita
Ensiklopedia of Journal Vol 4, No 1 (2021): Vol 4 No. 1 Edisi 1 Oktober 2021
Publisher : Lembaga Penelitian dan Penerbitan Hasil Penelitian Ensiklopedia

Medical records that have expired and their usefulness can be destroyed, that is, where the medical records are physically destroyed. RSI Ibnu Sina Padang has not carried out the extermination because of the inhibiting factors of the elements of Man, Money, and Material. This study aims to determine the fishbone analysis of the inhibiting factors that have not been carried out in the destruction of medical record documents at RSI Ibnu Sina Padang. The research was conducted in June 2021 qualitatively with a phenomenological approach. The research was conducted by in-depth interviews with 5 informants, namely the head of the supporting field, the head of the medical records room, and 3 storage officers. Data processing using collaizzi method. The results of the study found that the factors that hindered the implementation of extermination were the lack of human resources to carry out retention accompanied by a team that had not been formed, training on extermination that they had never participated in, and inadequate facilities and infrastructure. Based on the conclusion, it was found that the aspects that hindered the extermination at RSI Ibnu Sina Padang were due to man and material factors. It is hoped that the management will immediately form an extermination team so that SOPs can be applied and training for the team will be carried out which will increase knowledge about the implementation of extermination.

ANALISIS PEMANFAATAN e-PUSKESMAS DENGAN METODE PERFOMANCE, INFORMATION, EKONOMI, CONTROL, DAN EFISIENSI, SERVICE (PIECES) DI PUSKESMAS KOTA PADANG Devid Leonard; Dewi Mardiawati; Dian Sari
Ensiklopedia of Journal Vol 1, No 1 (2018): Vol 1 No 1 Edisi 1 Oktober 2018
Publisher : Lembaga Penelitian dan Penerbitan Hasil Penelitian Ensiklopedia

Implementation of e-puskesmas in Padang City health centers is expected to contribute to health centers in improving the effectiveness and efficiency of health services. The results of observations of e-puskesmas applications are not in accordance with the needs of health center staff (from registration to reporting). To assess the benefits of implementing an e-puskesmas one of the evaluation methods that can be used is an evaluation based on the user's perception using the PIECES method. This research is a qualitative case study approach. This research was conducted at the Padang City health center from February to May 2018. The informants in this study amounted to 10 people taken by purposive sampling technique, data analysis results of Focus Group Discastion (FGD) will be carried outprocess transcription, data reduction, coding, categories, presentation data and data interpretation. Aspects of Performance input of patient data and response time is faster, in the aspect of information there are still obstacles, namely the resulting report is still limited to LB1 reports, still constrained for data briging with P-care BPJS, on theaspect the economic use of e-puskesmas still does not provide benefits which is large in terms of reporting because there are still data input activities and reporting that must be done manually. In terms ofaspects control, the implementation of e-puskesmas still faces constraints in terms of data security because all officers can access the e-puskesmas with the same user and password. For theaspects of efficiency the e-puskesmas users are still constrained by the workload of recording and reporting that is still done manually to the City Health Office, theaspect service needs to be the development of the modules in the e-puskesmas such as the LB2 to LB 4 reporting menu module. It is necessary to develop a menu / module on the e-Puskesmas system, the need for a data security system by providing login access according to the user level and the need for communication with BPJS related to briging data.

PEMERIKSAAN DAN PENYULUHAN KESEHATAN DI PANTAI AIR MANIS PADANG Maisharoh Maisharoh; Dian Sari; Rahmadhani Rahmadhani; Afika Rahma; Fianika Fianika
Jurnal Salingka Abdimas Vol 2, No 2 (2022)
Publisher : Jurnal Salingka Abdimas

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (332.341 KB)

Health is a dynamic balanced state influenced by genetic, environmental, and daily lifestyle factors such as eating, drinking, working, resting, to managing emotional life. Health check is an examination that focuses on primary and secondary prevention efforts, namely detecting various health factors as a whole that can cause certain diseases in the future. A number of public health problems stem from the healthy behavior of the community and the influence of the socio-cultural system that becomes the values and beliefs of the local community. The purpose of community service activities is to make people understand the importance of health checks. The method used is the lecture and discussion method. The counseling activity was carried out in the Padang Air Sweet Beach area in September 2022. The activity was attended by lecturers, lecturer staff, as well as students and the community who were in the Padang Air Sweet Beach working area. The results of the examination activities showed that the community knew what factors were influencing various kinds of diseases that were often experienced by the community, including diabetes mellitus, gout and cholesterol and the impact that these diseases would have. The conclusion of this activity is that the public can know about the importance of carrying out regular and periodic health checks so as to increase optimal health.

UPAYA PENINGKATAN PENGETAHUAN DAN KESADARAN PASIEN TERHADAP PENTINGNYA DOKUMEN BPJS KESEHATAN Dian Sari; Maisharoh Maisharoh; Rahmad Hidayat; Salsabila Salsabila; Ismailinda Ismailinda; Putri Ananda
Jurnal Salingka Abdimas Vol 1, No 2 (2021)
Publisher : Jurnal Salingka Abdimas

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BPJS Kesehatan adalah Badan Usaha Milik Negara (BUMN) yang menyelenggarakan jaminan sosial kesehatan bagi seluruh rakyat Indonesia. Masyarakat sebagai peserta Jaminan Kesehatan Nasional yang diselenggarakan oleh BPJS Kesehatan dan stakeholder terkait perlu mengetahui prosedur dan kebijakan pelayanan dalam memperoleh pelayanan kesehatan sesuai dengan haknya. Metode yang digunakan adalah metode ceramah dan diskusi. Kegiatan penyuluhan dilakukan di Rumah Sakit Ibu dan Anak (RSIA) Mutiara Bunda pada bulan Agustus 2021. Kegiatan dihadiri oleh staf rekam medis RSIA Mutiara Bunda serta pasien yang sedang berobat di RSIA Mutiara Bunda. Hasil dari kegiatan penyuluhan didapatkan pasien telah mengetahui alur dari pasien BPJS dan persepsi mereka yang salah selama ini tentang penolakan pasien di rumah sakit, dan dampak yang akan mereka terima jika dokumen BPJS tidak lengkap. Pasien telah mengetahui sistem rujukan berjenjang yang memiliki 3 tingkatan yaitu pasien harus melalui faskes tingkat pertama karena pelayanan kesehatan dasar yang didapat dari faskes pertama, pasien dapat di rujuk ke faskes tingkat kedua yaitu pelayanan kesehatan spesialistik oleh dokter sub spesialis di faskes tingkat kedua, pelayanan yang terakhir di faskes tingkat ketiga yaitu pelayanan kesehatan sub spesialistik oleh dokter sub spesialis di faskes tingkat lanjutan. Kesimpulan dari kegiatan ini adalah pasien dapat mengetahui tentang BPJS serta alur dalam pelayanan BPJS sehingga terwujudnya kesadaran pasien terhadap pentingnya dokumen BPJS yang haarus mereka lengkapi.

IMPLEMENTASI QUIZIZZ DALAM UPAYA PENINGKATAN MOTIVASI BELAJAR MAHASISWA Dian Sari; Maisharoh Maisharoh; Hendra Nusa Putra; Zurrahmah Zurrahmah; Wina Dwi Apriani; Windi Liantama
Jurnal Salingka Abdimas Vol 2, No 1 (2022)
Publisher : Jurnal Salingka Abdimas

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Penurunan minat dalam proses tatap muka dapat berdampak pada hasil belajar. Revolusi industri 4.0 membawa pengaruh besar terhadap perubahan disemua sektor kehidupan, semula berbasis tatap muka dikelas, berubah dengan berkolaborasi dengan memanfaatkan jaringan internet (Online Learning). Untuk mengurangi dampak negatif penggunaan teknologi, hal ini dapat menunjang proses pembelajaran dengan memanfaatkan kecanggihan teknologi. Suatu aplikasi pembelajaran yaitu QUIZIZZ membantu dosen dan mahasiswa agar proses pembelajaran dapat berlangsung dan pengamalan belajar yang menyenangkan dapat dirasakan saat pembelajaran dan hal tersebut dapat juga dilakukan secara jarak jauh. Kegiatan dilakukan pada tanggal 18 sampai 20 April 2022 kepada mahasiswa tingkat 2 prodi RMIK STIKES Dharma Landbouw Padang. Kegiatan ini dilakukan oleh 3 orang dosen dan 3 orang mahasiswa. Metode yang digunakan dalam kegiatan pengabdian masyarakat ini adalah dengan cara praktek yang dilakukan langsung oleh mahasiswa dan diawasi secara langsung oleh tim pelaksana pengabdian masyarakat. Pada saat pelaksanaan, mahasiswa sangat antusias dalam melakukan quiz secara online. Melalui aplikasi ini, mahasiswa dapat terpacu untuk menjawab dengan benar dikarenakan perengkingan langsung dapat terlihat oleh semua mahasiswa. Hal tersebut dapat meningkatkan minat belajar mahasiswa agar mendapatkan perengkingan yang mereka inginkan.

EVALUASI PENGGUNAAN E-PUSKESMAS MENGGUNAKAN METODE HUMAN, ORGANIZATION, TECHNOLOGY DAN NET-BENEFIT DI PUSKESMAS LUBUK BUAYA PADANG Dian Sari; Maisharoh Maisharoh
Ensiklopedia of Journal Vol 5, No 1 (2022): Vol. 5 No. 1 Edisi 1 Oktober 2022
Publisher : Lembaga Penelitian dan Penerbitan Hasil Penelitian Ensiklopedia

E-Puskesmas is a health service application that is used in all services, especially in the registration and reporting section at the Puskesmas. The use of e-Puskesmas at the Lubuk Buaya Padang Health Center still has problems that interfere with registration and reporting. The purpose of this study was to determine the evaluation of the use of e-Puskesmas using the HOT-Fit method at the Lubuk Buaya Health Center. This type of research is qualitative using a phenomenological approach. This research was conducted at the Lubuk Buaya Padang Health Center from May to June 2022 with four informants conducted by means of interviews and observations. Data is processed by triangulation method and analyzed using collaizi. The results obtained from the human, the obstacles are the implementation of training, network problems, reporting that is still manually. Aspect organizational has obstacles, including the organizational structure has not been updated and the SOP on e-Puskesmas has not been socialized. Aspect technology is the problem with the system error in the e-Puskesmas application so that it interferes with the patient registration process. Based on the results of research, the use of e-Puskesmas seen from several aspects of registration and reporting is still not optimal, therefore in the use of e-Puskesmas it is necessary to pay attention and overcome the things that become obstacles in its use such as networks, socialization of e-Puskesmas SOP and applications e-Puskesmas need to be improved to minimize service process problems.

HUBUNGAN KELENGKAPAN DAN KEJELASAN PENULISAN DIAGNOSA TINDAKAN DENGAN KETEPATAN KODE TINDAKAN MEDIS DI RUMAH SAKIT X Maisharoh Maisharoh; Dian Sari
Ensiklopedia of Journal Vol 5, No 3 (2023): Vol. 5 No. 3 Edisi 2 April 2023
Publisher : Lembaga Penelitian dan Penerbitan Hasil Penelitian Ensiklopedia

The correctness of the code is the conformity of the code of action diagnosis determined by the coding officer with the patient's medical record in accordance with ICD-9. Based on the results of observations, coders in coding still found inaccuracies in coding medical records, one of which was inaccuracy in coding medical procedures. This study aims to find out the relationship between the clarity and completeness of action writing and the accuracy of the coding of medical procedures at hospital x. The research was carried out from July to August 2022 quantitatively with a cross sectional approach. The research was conducted by observing medical records. Computerized data processing with univariate and bivariate data analysis. The results of the study found, from 86 medical records, it was clear that 82.6% of diagnoses were legible, 17.4% of diagnoses were illegible. Completeness of writing diagnostics 70.9% complete, 29.1% incomplete. Action coding accuracy 68.6% correct action coding, 31.4% incorrect. Pvalue = 0.000, which means (P ≤ 0.05). It was concluded that the clarity and completeness of writing can affect coding, where unclear writing such as using abbreviations and cursive makes it difficult for officers to read the diagnosis, so officers must first clarify to responsible party before generating the diagnostic code. In the future, it is hoped that the responsible medical staff will write down the diagnosis of the action clearly and completely, and the coder will do the coding carefully.Keywords: Clarity, Completeness, Code Accuracy, ICD-9 CM with great care.

SOSIALISASI KEBIJAKAN REKAM MEDIS ELEKTRONIK DAN PENERAPAN APLIKASI BERBASIS DATABASE ACCESS KODEFIKASI PENYAKIT MENTAL DAN PERILAKU SEBAGAI UPAYA PENERAPAN RME DI LAYANAN KESEHATAN Dian Sari; Maisharoh Maisharoh; Rahmadhani Rahmadhani; Syadita Cholifa; Fani Oktafianti
Jurnal Salingka Abdimas Vol 3, No 1 (2023)
Publisher : Universitas Muhammadiyah Sumatera Barat

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31869/jsam.v3i1.4465

Perkembangan teknologi berdampak juga pada dunia kesehatan salah satunya yaitu penerapan RME (Rekam Medis Elktronik). Dunia pendidikan dimana kampus terkhusus prodi rekam medis dan informasi kesehatan diharapkan menerapkan pembelajaran untuk hal tersebut.. Tujuan dari kegiatan pengabdian kepada masyarakat adalah agar tersosialisasinya ke mahasiswa kebijakan Rekam Medis Elektronik (RME) serta mengaplikasikan penerapan aplikasi berbasis database access kodefikasi penyakit mental dan perilaku sebagai upaya penerapan RME di layanan kesehatan. Metode yang digunakan adalah metode ceramah,diskusi dan praktek. Kegiatan penyampaian materi dan latihan penerapan aplikasi dilakukan di STIKES Dharma Landbouw Padang pada bulan April 2022. Kegiatan dihadiri oleh dosen,mahasiswa pendamping dan mahasiswa tingkat 1 dan 2. Hasil dari kegiatan sosialisasi kebijakan RME dan praktek penerapan aplikasi berbasis database access kodefikasi penyakit mental dan perilaku adalah mahasiswa mengetahui tentang PMK No. 24 Tahun 2022 serta mampu menggunakan aplikasi berbasis database access kodefikasi penyakit mental dan perilaku sebagai upaya penerapan RME di layanan kesehatan.Kata Kunci: Rekam Medis Elektonik, Koding, Aplikasi, Database

ANALISIS PENGELOLAAN DOKUMEN REKAM MEDIS DI BAGIAN FILING RUMAH SAKIT Dr. REKSODIWIRYO PADANG Dian Sari
Jurnal Kesehatan Lentera 'Aisyiyah Vol. 2 No. 2 (2019): Jurnal Kesehatan Lentera 'Aisyiyah
Publisher : BPPM Politeknik 'Aisyiyah Sumatera Barat

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Sistem penyimpanan berkas rekam medis sangat penting untuk dilakukan dalam suatu institusi pelayanan kesehatan. Survey awal di Rumah Sakit Dr. Reksodiwiryo Padang tentang berkas yang disimpan tidak sesuai dengan urutan dan juga tidak sesuai dengan nomor penyimpanan serta adanya penomoran ganda pada berkas pasien. Penelitian ini bertujuan untuk menganalisis pengelolaan dokumen rekam medis di bagian filling Rumah Sakit Dr. Reksodiwiryo Padang. Penelitian dilakukan Rumah Sakit Dr. Reksodiwiryo Padang Tahun 2019. Jenis penelitian Jenis penelitian menggunakan pendekatan kualitatif dengan pendekatan fenomenologi dengan informan sebanyak 5 orang. Proses analisis data dilakukan secara simultan dengan proses pengumpulan data menggunakan model Collaizzi. Hasil penelitian menunjukkan Masih kurangnya SDM baik dalam segi kuantitas maupun kualifikasi pendidikan dan juga penyelenggaraan pelatihan yang dilakukan khususnya pelatihan di bagian filing. Sarana prasarana pada bagian penyimpanan masih belum memadai. Hasil penelitian ini dapat dijadikan referensi dalam meningkatkan kualitas bagian filling Rumah Sakit Dr. Reksodiwiryo Padang sehingga kejadian penomoran ganda dan status yang tidak ditemukan dapat diminimalkan bahkan tidak terjadi

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