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ANALISIS PELAKSANAAN PEMUSNAHAN DOKUMEN REKAM MEDIS INAKTIF DI SARANA PELAYANAN KESEHATAN Maisharoh Maisharoh; Dian Sari; Esa Fatira
Jurnal Kesehatan Lentera 'Aisyiyah Vol. 4 No. 1 (2021): Jurnal Kesehatan Lentera 'Aisyiyah
Publisher : BPPM Politeknik 'Aisyiyah Sumatera Barat

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Abstract

Pelaksanaan pemusnahan masih terdapat kendala meliputi banyaknya dokumen rekam medis inaktif yang belum dimusnahkan, minimnya jumlah petugas di instalasi rekam medis terutama dibagian pemusnahan, kurangnya pengetahuan petugas terhadap pelaksanaan pemusnahan yang mengakibatkan tidak berjalannya SOP pelaksanaan pemusnahan secara efisien.Metode penelitian kualitatif dengan pendekatan Literature Review. Kriteria inklusi yang digunakan melihat google scholar dengan keyword pelaksanaan pemusnahan dan dokumen rekam medis inaktif dan menggunakan jurnal dari tahun 2015-2020 untuk mengetahui faktor-faktor yang mempengaruhi pelaksanaan pemusnahan dokumen rekam medis inaktif. Data dianalisa dengan compare (kesamaan), contras (ketidaksamaan), critize (pandangan), synthesize (perbandingan) dan summarize (ringkasan). Hasil dari 6 jurnal berdasarkan 5M (Man, Money, Mhetode, Mhacine, Material) diketahui bahwa terdapat pengetahuan petugas yang kurang baik, anggaran proses pemusnahan tidak ada, masih ada yang belum mempunyai prosedur tetap mengenai pelaksanaan pemusnahan, sarana dan prasarana seperti alat pencacahan belum tersedia, dan bahan yang digunakan dalam pemusnahan yaitu lembaran dokumen rekam medis yang tidak bernilai guna.Berdasarkan hasil penelitian tersebut dapat disimpulkan bahwa pelaksanaan pemusnahan belum berjalan sesuai SOP dan masih kurangnya petugas pemusnahan. Diharapkan kepada peneliti selanjutnya terhadap beberapa artikel terkait perlu penelitian lanjut tentang menganalisis pelaksanaan pemusnahan terutama pelaksanaan SOP, dan kurangnya SDM di bagian instalasi rekam medis yang sangat menjadi fakor banyaknya masalah di bagian pemusnahan
RECONSTRUCTION AI APPLICATION DEVELOPMENT DIAGNOSIS CODEFICATION AND HOSPITAL OBSTETRICS CASE ACTION Maisharoh Maisharoh; Dian Sari; Yulfa Yulia
INTECOMS: Journal of Information Technology and Computer Science Vol. 8 No. 6 (2025): INTECOMS: Journal of Information Technology and Computer Science
Publisher : Institut Penelitian Matematika, Komputer, Keperawatan, Pendidikan dan Ekonomi (IPM2KPE)

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31539/wf7f9k30

Abstract

Introduction The electronic medical record (RME) has become the backbone of the modernization of Health Services. However, at this time there are still many found in the process of diagnosis and medical treatment codefication in obstetric cases in hospitals is done manually, which resulted in delays, inaccuracies in the code, as well as the difficulty of BPJS claims. Artificial Intelligence (AI) is one of the solutions in improving the accuracy, efficiency, and consistency of codefication. Objective: This study aims to accelerate the adoption of RME technology, ensure the security of health data, and support interoperability between health facilities, thus speeding up processes, minimizing errors, and supporting the quality of Health Services. Method :  This study was conducted with the concept of Research and Development (RnD). The stages include problem identification, data collection, application design, design validation, revision, limited trial, re-revision, interpretation of results, and socialization. The study was conducted at Rsia Mutiara Bunda Padang in July 2025 involving 6 respondents (code officers, casemix, and management). Data were collected through FGDs, interviews, and observations. Validation is performed by medical records and IT experts, while application trials are judged on speed and accuracy.  Result : The AI application developed can accelerate the process of diagnosis and action codefication on cases with 100% accuracy and coding time efficiency increased by 40% compared to manual methods. Discussion : Reconstruction the development of this AI application improves the accuracy and speeds up the process of codefication of diagnoses and ac apa kabartions in obstetric cases, minimizes errors, and can support the digital transformation of hospitals. Reconstruction, Application, AI, Codefication, Obstetric.