Garuda - Garba Rujukan Digital

Gambaran Sistem Pengelolaan Rekam Medis di Ruang Rawat Inap Rumah Sakit Harum Sisma Medika Tahun 2017 Fransisko HK; Diana Barsasella
Jurnal Persada Husada Indonesia Vol 4 No 15 (2017): Jurnal Persada Husada Indonesia
Publisher : STIKes Persada Husada Indonesia

Medical records are a permanent legal document that should contain sufficient information to identify patients, justify diagnosis and treatment and record the results. But because the documentation in the medical records is done by various health care providers such as doctors, nurses, therapists and so on and because it is done as a second activity after providing patient care, the documentation is not always as complete and exact as needed or desirable. The purpose of this research is to know the description of Medical Record Management System in the Inpatient Room of Harum Sisma Medika Hospital in 2017 with a sample of 73 people and data collected using questionnaire. Descriptive research design to see the description of research. From the research, there were 64 (87.7%) respondents stated good about medical record system, 58 (79.5%) stated good about medical record method, 52 (71.2%) stated good about medical record processing, 46 (63.0%) respondents Stated good about medical record analysis, 49 (67.1%) of respondents stated good about record medical record system and 67 (91.8%) respondents stated good about quality management of medical record. Therefore, it is expected that all officers can continuously improve the medical record management system in the Inpatient Room of Harum Sisma Medika Hospital.

Pengaruh Kodifikasi ICD 10 dan ICD 9 CM Terhadap Klaim JKN Rawat Inap di RSUD Dr. Soekardjo Kota Tasikmalaya Tahun 2018 Arief Tarmansyah Iman; Diana Barsasela
Jurnal Persada Husada Indonesia Vol 6 No 22 (2019): Jurnal Persada Husada Indonesia
Publisher : STIKes Persada Husada Indonesia

Data sources to be entered into the INA-CBGs application come from medical records summarized in medical resumes, namely diagnosis data and actions / procedures, and if needed can be seen in the medical record file. Inappropriate codification can have an impact / influence on the amount of the output rate of the INA-CBG system, the study was conducted at Dr. Soekardjo, Tasikmalaya City. The study was conducted for 6 months, namely May - October 2018. The purpose of the study was to analyze the effect of the accuracy of the ICD 10 and 9CM ICD codification on claims (INA-CBGs code and INA-CBGs rates) JKN Hospitalized at Dr. RSUD Soekardjo, Tasikmalaya City in 2018. The sample in this study is a medical resume on the file of claims for inpatient care for Dr. RSUD Hospital. Soekardjo, Tasikmalaya City in the period of May 1, 2018 to May 30, 2018. The population is 1528, while the sample is 94. The results of the study indicate that the incorrect diagnosis code is 24 files (25.53%). Whereas the incorrect 9CM ICD code is 21 files (22.34%). The results recoding of 13 files of ICD (13.83%) underwent changes in the code and tariff of INA-CBGs, while the results of reprocessing using results 9CMrecoding ICD revealed that 17 codes (18.09%) experienced changes in the code and tariff of INA-CBGs. The statistical test using Chi Square shows that the change in ICD 10 code towards changes in the code and tariff of INA-CBGs has a significant effect. The hypothesis is the influence of the accuracy of the ICD 10 code on the INA-CBGs code on JKN Claims accepted. Likewise, the results of the chi square test show that the change in the 9 CM ICD code to changes in the INA-CBGs Code and the INA-CBGs rates significantly influence. Hypothesis There is an influence of the accuracy of the ICD9CM code on the INA-CBGs code and tariff on JKN Claims in Dr. Soekardjo, Tasikmalaya City in 2018 was accepted.

Gambaran Sikap Dan Perilaku Pasien Lansia Dengan Hipertensi di Panti Sosial Tresna Werdha Budi Mulia 03 Ciracas Yulius Riyuh; Diana Barsasella
Jurnal Persada Husada Indonesia Vol 3 No 8 (2016): Jurnal Persada Husada Indonesia
Publisher : STIKes Persada Husada Indonesia

Hipertensi adalah suatu ganguan pada sistem peredaran darah yang cukup banyak mengganggu kesehatan masyarakat. Penyakit hipertensi ini tahun demi tahun terus mengalami peningkatan, tidak hanya di Indonesia namun juga di dunia. Beberapa faktor yang menyebabkan terjadinya hipertensi antara lain; faktor keturunan,ciri perorangan(umur, jenis kelamin dan ras), dan kebiasaan hidup seperti, komsumsi garamberlebihan, makan berlebih/kegemukan, stres atau ketegangan jiwa serta pengaruh lain (merokok dan minum alkohol. Penelitian ini bertujuan untuk mengetahui gambaran sikap dan perilaku lansia dengan hipertensi di Panti Tresna Werdha Budi Mulia 03 Ciracas. Pada penelitian ini menggunakan pendekatan yang bersifat kualitatif dengan rancangan penelitian yang digunakan adalah studi kasus. Hasil observasi berupa dokumentasi wilayah terjadinya kasus hipertensi. Informan penelitian ini yaitu pasien yang terkena hipertensi, dan petugas Panti Tresna Werdha Budi Mulia 03 Ciracas. Hasil penelitian didapatkan bahwa informan kunci bersikap, menerima, merespon, menghargai dan bertanggung jawab terhadap pengobatan hipertensi. Hasil penelitian juga menemukan bahwa informan kunci bertindak atau berupaya untuk secara teratur menjalani pengobatan.

Analisis Kualitatif Dokumen Rekam Medis Kasus Aborsi Tidak Lengkap dalam Aborsi Spontan dengan Metode Hatta Di RSUD Kabupaten Ciamis Tahun 2016 Dila Kardila; Diana Barsasella
Jurnal Persada Husada Indonesia Vol 5 No 18 (2018): Jurnal Persada Husada Indonesia
Publisher : STIKes Persada Husada Indonesia

Medical records are important notes for a health institution in carrying out service organization. Every hospital must have a medical record work unit in providing health data in the hospital for various prominence (RI Law No. 44 Year 2009 Article 29). Method of study was Qualitative Descriptive with Cross Sectional approach of 60 medical records documents on Incomplete Abortion inpatient cases. Incomplete Abortion Qualitative Administrative Analysis result showed 50 (83,3%) cases of clarity of problems and conditions or diagnosis, 37 (61,7%) consistent input, 49 ( 81,7%) service reasons, 37, (61,7%) informed consent, 31 (51,7%) up-to-dates, 55 (91,7%) readable text based on 3 patients, 43 (71,7%) standard abbreviations, 60 (100%) satire avoidance, 53 (88,3%) gapless fulfilment, 60 (100%) usage of standard ink and 50 (88,3%) obvious notes in the order of service. Incomplete recording of 60 (100%) inormtion on compensation and guarantor of costs. Medical qualitative analysis on Incomplete Abortion cases with highest complete record on age of mothers 60 (100%) with score of 4 to the information “Yes”, information “Not The Case” 60 (75,0%) to Blood Pressure statement, information “No” 60 (76,7%) haemorrhaging observation statement, “No Information” 60 (100%) to smoking and alcoholism, anemic haemorrhaging, torn cervix and perforation statements. Frequency of medical record documents on Incomplete Abortion cases can be said to be complete, based on the high level of completeness of administrative and medical notes. Incomplete records occurred in the operation and anesthesia notes while every patient is given curettage action.

Perbedaan Klaim JKN Berdasarkan Tarif INA CBG’S dengan Tarif Perda Rumah Sakit di RSUD Dr. Soekardjo Kota Tasikmalaya Tahun 2015 Arief Tarmansyah Iman; Diana Barsasella
Jurnal Persada Husada Indonesia Vol 5 No 16 (2018): Jurnal Persada Husada Indonesia
Publisher : STIKes Persada Husada Indonesia

Metode pembayaran prospektif yang dikenal dengan Casemix (case based payment, di Indonesia sudah diterapkan sejak tahun 2008 sebagai metode pembayaran pada program Jaminan Kesehatan Masyarakat (Jamkesmas) pada pasien yang dilayani di rumah sakit. Metode penelitian yang digunakan adalah kuantitatif, jenis penelitian adalah penelitian non intervensi, dengan desain penelitian observasional dengan survei analitik yang digunakan peneliti adalah uji beda mean. Populasi dalam penelitian ini meliputi data klaim JKN dan Tarif RSUD Dr. Soekardjo Kota Tasikmalaya periode 1 Januari - 31 Desember tahun 2015. Hasil penelitian menunjukkan bahwa Ada perbedaan rata-rata Klaim JKN berdasarkan tarif INA CBGs dengan berdasarkan tarif Perda secara keseluruhan (Agregat) di RSUD Dr. Soekardjo Kota Tasikmalaya tahun 2015, ada perbedaan rata-rata Klaim JKN berdasarkan tarif agregat INA CBG’S dengan tarif Perda rumah sakit pada pasien yang mendapat pelayanan SMF Obgyn di RSUD Dr. Soekardjo Kota Tasikmalaya tahun 2015, Ada perbedaan rata-rata Klaim JKN berdasarkan tarif agregat INA CBG’S dengan tarif Perda rumah sakit pada pasien yang mendapat pelayanan SMF Penyakit Anak di RSUD Dr. Soekardjo Kota Tasikmalaya tahun 2015, Ada perbedaan rata-rata Klaim JKN berdasarkan tarif agregat INA CBG’S dengan tarif Perda rumah sakit pada pasien yang mendapat pelayanan SMF Penyakit Bedah di RSUD Dr. Soekardjo Kota Tasikmalaya tahun 2015, Ada perbedaan Klaim JKN berdasarkan tarif agregat INA CBG’S dengan tarif Perda rumah sakit pada pasien yang mendapat pelayanan SMF Penyakit Dalam di RSUD Dr. Soekardjo Kota Tasikmalaya tahun 2015.

FAKTOR PERAN PERAWAT DALAM PENGISIAN BERKAS REKAM MEDIS DI RUMAH SAKIT HARUM SISMA MEDIKA JAKARTA TIMUR Alpi Cintya; Diana Bersassela
Jurnal Manajemen Informasi Kesehatan Indonesia (JMIKI) Vol 2, No 2 (2014)
Publisher : Asosiasi Perguruan Tinggi Rekam Medis dan Informasi Kesehatan Indonesia- APTIRMIKI

AbstractMedical Recordis necessarythingtonote, many roles ofmedical personnelwhoare veryinfluentialin theMedicalRecordfilefilling. One of the roleis thenurse’s role, becausenurseismedical professionalwhomoreoftencontactwiththe patientthan doctor. Types ofthis research isquantitative, and subject of research are nurses from theentire roomat RumahSakitHarumSismaMedikaJakartaTimur. Theresearch wasconducted inApril-May2012in Jakarta. TotalPopulationsare 100 people and Samples are117respondents. Resultshowedthat there isno significant relationship between independent and dependent variablesbecausethe knowledgeandskillofrespondents are already good. Incompletedata of 42.91% were found during January-March 2012. TheresultsofMedical RecordsQuality were amounted that56% of respondentsweregood and43% of respondents were notgood. Result of Bivariateanalysis that there are significant relationshipbetweenknowledgeandmedical recordqualitywiththe p-value of 0.027. The assessment resultsforrespondent knowledgeof medical record qualitywereobtained50% good knowledge and50% bad knowledge, theresults ofrespondent skills wereobtained68%good skill and 32% bad skill. Based on theresearch results, medical recordsteam andthe headof nursingatRumahSakitHarumSismaMedikaEast Jakartaare expected toprovidemoretrainingto nurses from entire roomincludedhead room and attending nurse.Key words: quality, medical recordAbstrakRekam Medis merupakan hal yang sangat perlu diperhatikan, banyak peran tenaga medis yang sangatberpengaruh dalam pengisian berkas Rekam Medis. Salah satunya adalah peran perawat, karena perawat adalahtenaga medis yang sangat sering bersentuhan dengan pasien selain dokter. Jenis penelitian kuantitaif dengansubjek penelitian adalah para Perawat seluruh ruangan di RS Harum Sisma Medika Jakarta Timur. Prosespenelitian ini telah dilakukan pada bulan April-Mei 2012 di Kota Jakarta. Jumlah Populasi 117 dan Sampel100 responden. Hasil penelitian menunjukkan antara variabel independen dan dependen tidak terjadi hubunganyang bermakna atau signifikan dikarenakan dari segi pengetahuan dan keterampilan responden diketahui sudahbaik. Didapat angka tidak lengkapnya data selama bulan Januari-Maret tahun 2012 sebesar 42,91%, dan denganhasil Mutu Rekam Medis berjumlah 56% responden yang baik dan 43% responden yang kurangbaik. Dan daripenghitungan Bivariat diperoleh adanya hubungan yang bermakna atau siginifikan antara pengetahuan danmutu rekam medis dengan p-value 0,027. Hasil penilaian dari pengetahuan responden terhadap mutu rekammedis diperoleh hasil 50% berpengetahuan baik dan 50% berpengetahuan buruk, sedangkan pada keterampilandiperoleh hasil sebesar 68% responden memiliki keterampilan baik dan 32% memiliki keterampilan buruk.Berdasarkan hasil penelitian, maka pihak rekam medis dan kepala keperawatan di Rumah Sakit Harum SismaMedika Jakarta Timur diharapkan bisa memberikan pelatihan secara lebih kepada petugas perawat diseluruhruangan termasuk kepala ruangan dan perawat jaga.Kata kunci: mutu, rekam medis

ANALISIS SISTEM PENDAFTARA N PASIEN RAWAT JALAN DI PUSKESMAS KECAMATAN DUREN SAWIT JAKARTA TIMUR 2014 Berry Fether; Diana Barsasella
Jurnal Manajemen Informasi Kesehatan Indonesia (JMIKI) Vol 3, No 1 (2015)
Publisher : Asosiasi Perguruan Tinggi Rekam Medis dan Informasi Kesehatan Indonesia- APTIRMIKI

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33560/.v3i1.69

AbstractHealth services are every efforts organised by individuals or groups simultaneously in an organisation tomaintan and increase health, prevent and cure diseases and restore the health of individuals, families, groupsand/or the community (Lovely and Loobam 1973, in Waluyo, 2008). Health management for the community onthe basic level In Indonesia is through the public health centres. If the service provided is good then visitorswill feel satisfied but when services fails to provide satisfaction leading to a decrease of visitors resulting ina negative image of the public health centre. Registration booth as one of the service point of early servicinggiven by public health centre officers to visitors also influences the level of service system given to thevisitors. If the health system registration is good, the public health centre manajement will also be good andvisitors will feel satisfied of the services rendered. The aim of this research is to find out about the outpatientregistration service system. This is a qualitative research obtained through in-depth interviews, observationand documentations on 4 informants. Results of the research showed patients’ registration service still notoptimal caused by the various interlinking factors. However the service scope is good marked by an increaseof patients. This research suggest a need to improve services related to various factors among others likedmanpower, facilities and procedures.Keywords : Outpatient Registration Services SystemAbstrakPelayanan kesehatan adalah setiap upaya yang diselenggarakan sendiri atau secara bersama-sama dalamsuatu organisasi untuk memelihara dan meningkatkan kesehatan, mencegah dan menyembuhkan penyakitserta memulihkan kesehatan perorangan, keluarga kelompok dan ataupun masyarakat (Lovely dan Loobam1973, dalam Waluyo, 2008). Penyelenggaraan kesehatan untuk masyaraakat ditingkat dasar di Indonesiaadalah melalui Puskesmas. Jika pelayanan yang diberikan dengan baik maka pengunjung akan merasa puasdan ketika pelayanan kurang memuaskan sehingga akan mengurangi minat pengunjung kepuskesmas akanmenjadi citra negative bagi puskesmas tersebut. Loket pendaftaran merupakan salah satu tempat pelayanankepada pengunjung sebagai sumber awal pelayanan yang diberikan oleh petugas Puskesmas. Pelayanan loketjuga berpegaruh pada tingkat sistem pelayanan yang diberikan kepada pengunjung. Jika sistem pelayananpendaftaran baik, maka manajemen puskesmas baik dan pengunjung Puskesmas akan merasa puas terhadappelayanan yang diberikan Puskesmas. Tujuan penelitian ini untuk mengetahui sistem pelayanan pendaftaranpasien rawat jalan. Penelitian ini adalah penelitian kualitatif yang didapatkan dengan metode wawancaramendalam, observasi dan pendokumentasian dengan jumlah informan sebanyak 4 orang. Hasil dari penelitianmendapatkan bahwa pelayanan pendaftaran pasien masih belum optimal yang disebabkan oleh berbagiai faktoryang saling terkait namun cakupan pelayanan sudah baik ditandai dengan jumlah pasien yang meningkat.Hasil penelitian ini menyarankan bahwa perlu ada peningkatan pelayanan yang terkait dengan berbagi faktordiantaranya yaitu SDM, sarana dan prosedur.Kata kunci : Sistem Pelayanan Pendaftaran Pasien Rawat Jalan

Akurasi Pengkodean Injury dan External Causes Berdasarkan ICD-10 dan ICD-9 CM di Rumah Sakit X Sukawan, Ari; Putra, Dony Setiawan Hendyca; Barsasella, Diana; Rahmawati, Fitria Dewi
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 6 No 1 (2024): December
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v6i1.5572

Accurate disease diagnosis coding is essential as it affects morbidity reporting, errors in determining medical procedures, billing issues, and invalidity as legal evidence. One example is injury coding, where ICD-10 guidelines require the 4th and 5th digits to indicate the location and activity associated with the injury. A preliminary study at X Hospital revealed that 80% of medical records had inaccurate injury coding, and external cause codes were absent. The issue is suspected to stem from the lack of coder training on injury and external cause coding. This study aims to assess the accuracy of injury and external cause coding based on ICD-10 and ICD-9 CM. It uses a descriptive approach with a sample of 65 medical records out of a total population of 77 from the fourth quarter of 2023, selected using simple random sampling. Data were collected through observation by reviewing medical records and completing observation sheets, then analyzed univariately. The results showed 66.2% of injury codes were inaccurate, 100% of external cause codes were inaccurate, and 83.08% of procedure codes were accurate. Most inaccuracies were due to the omission of the fifth digit for fractures and the absence of external cause coding.

Title

Found 18 Documents
Search

Abstract

Abstract

Abstract

Abstract

Abstract

Abstract

Abstract

Abstract

Title Search

Found 18 Documents Search

Abstract

Abstract

Abstract

Abstract

Abstract

Abstract

Abstract

Abstract

Title

Found 18 Documents
Search