Article Per Year (5 Year)
p-Index From 2021 - 2026
2.076
P-Index
This Author published in this journals
All Journal J-Kesmas: Jurnal Kesehatan Masyarakat (Indonesian Journal of Public Health) Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Jurnal Kesehatan Tambusai J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Journal of Nursing and Health (JNH) Akper Yakpermas Banyumas PELS (Procedia of Engineering and Life Science) Journal of Innovation Research and Knowledge Indonesian Journal of Electronics, Electromedical Engineering, and Medical Informatics
Zahrasita Nur Indira
Universitas Muhammadiyah Purwokerto
Humanities Computer Science & IT Control & Systems Engineering Decision Sciences, Operations Research & Management Dentistry Economics, Econometrics & Finance Education Electrical & Electronics Engineering Engineering Health Professions Law, Crime, Criminology & Criminal Justice Materials Science & Nanotechnology Medicine & Pharmacology Nursing Public Health Social Sciences

Published : 13 Documents Claim Missing Document
Claim Missing Document
Check
Articles

Found 13 Documents
Search

 1   2 
Analisis Faktor Penyebab Pending Klaim Rawat Inap Akibat Koding Rekam Medis Di Rumah Sakit Umum Daerah (RSUD) Dr. Soedirman Kebumen Aldi Pratama; Harry Fauzi; Zahrasita Nur Indira; Prisai Purnama Adi
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Vol. 8 No. 1 (2023): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Februari
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v8i1.1225

Abstract

Klaim Jaminan Kesehatan Nasional (JKN) adalah pengajuan biaya perawatan pasien peserta BPJS Kesehatan oleh pihak rumah sakit kepada pihak BPJS Kesehatan yang dilakukan secara kolektif dan ditagihkan kepada BPJS Kesehatan setiap bulannya. Setelah itu BPJS Kesehatan akan melakukan persetujuan klaim dan melakukan pembayaran untuk berkas yang layak, namun untuk berkas yang belum layak klaim atau pending (unclaimed) harus dikembalikan ke rumah sakit untuk diperiksa kembali. RSUD Dr. Soedirman Kebumen adalah rumah sakit yang bekerja sama dengan BPJS untuk memberikan pelayanan kepada pasien melalui sistem pembiayaan, dimana pada pelaksanaannya masih ditemukan masalah-masalah terutama terkait pending klaim. Kejadian pemding klaim di RSUD Dr. Soedirman Kebumen disebabkan oleh beberapa hal diantaranya administrasi, medis, koding, berkas tidak layak dan lainnya. Berdasarkan studi pendahuluan ditemukan berkas pending klaim pada bulan September 2022 sebanyak 163 dari 1041 berkas pasien rawat inap yang menggunakan Jaminan Kesehatan Nasional. Dari permasalahan tersebut maka dilakukan analisis faktor penyebab pending klaim akibat koding melalui penelitian kuantitatif dengan pendekatan fenomenologi. Hasil analisis menunjukan pengembalian berkas klaim pasien rawat inap BPJS Kesehatan di RSUD Dr. Soedirman Kebumen terjadi karena faktor perbedaan presepsi kode diagnosis dalam berkas klaim antara pihak koder rumah sakit dengan pihak verifikator BPJS Kesehatan. Selain itu kekurangan data pendukung sebagai penegakan diagnosis juga mempengaruhi keakuratan kode diagnosis yang mengakibatkan pending klaim. Berdasarkan permasalahan tersebut perlu adanya upaya yang harus dilakukan rumah sakit seperti kegiatan evaluasi terkait kinerja petugas sesuai job description yang ada dan peningkatan kualitas SDM khususnya petugas koding dengan mengadakan pelatihan serta sosialisasi mengenai pembaharuan kebijakan mengenai klaim. Pengoptimalan kegiatan dengan dibuatnya SPO terkait klaim agar dapat meminimalisir kejadian pending klaim.
ANALISIS KEBUTUHAN PENGEMBANGAN SISTEM INFORMASI RAWAT JALAN DI RUMAH SAKIT UMUM DAERAH BANYUMAS: ANALISIS KEBUTUHAN PENGEMBANGAN SISTEM INFORMASI RAWAT JALAN DI RUMAH SAKIT UMUM DAERAH BANYUMAS Zahrasita Nur Indira; Aris Puji Widodo; Farid Agushybana
Journal of Nursing and Health Vol. 8 No. 2 (2023): Journal of Nursing and Health
Publisher : Yakpermas Press

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52488/jnh.v8i2.234

Abstract

A hospital is a place that provides health services which include observation, diagnostic, therapeutic, and rehabilitation activities for patients. Development of information systems using Prototype. To support the development of the information system, the PIECES framework is used, which is seen in terms of performance, information, economics, control, efficiency, and service. One part of the service at RSUD Banyumas that has used a management information system is an outpatient installation. However, the clinical pathway audit process has not been carried out in the outpatient department, so it cannot measure the quality of services provided by doctors and cannot be done in decision and policy making. This type of research is qualitative. The management of clinical pathway data audits still uses a manual system and does not optimize computerized data processing. Based on the results of the research that has been carried out, the following conclusions were obtained Outpatient information system at RSUD Banyumas so far, there are problems with the process carried out manually related to the management of Clinical Pathway audits. There needs to be an integrated information system to the hospital management to facilitate access to the information needed.
Analisis Diagnosis Tuberkulosis Paru Pasien Rawat Inap Bulan November 2023 di RSUD Banyumas Najwa Azkia Rahma; Zahrasita Nur Indira; Harry Fauzi; Utami Budi Lestari
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 5 No 3 (2024): June
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v5i3.4718

Abstract

According to the World Health Organization (WHO) in the Global Tuberculosis Report 2021, TB is one of the 10 causes of death in the world. The Ministry of Health of the Republic of Indonesia recorded a total of 658,543 TB cases in 2023 as of November 3, 2023. At Banyumas Hospital, TB cases are still relatively high, the factors that affect this pulmonary TB are clinical factors. The research was made to determine the clinical factors of Pulmonary TB disease and supporting examination factors in determining the success of claims at Banyumas Hospital. This type of research method uses quantitative, with analytical descriptive research design, and cross sectional research design. The type of data used is secondary data, namely medical record data for inpatients with pulmonary TB, Data analysis using Univariate which describes the percentage of Pulmonary TB. The total number of TB patients had 43 medical records in November 2023 at Banyumas Hospital, the result of the percentage of male sex factors (62.79%) Female (37.21%), the most OAT-giving factor RHZE (76.74%), the most age factor for the elderly (30.23%). Supporting Factors for positive TCM reading (48.83%) and RO factor Thorax pulmonary TB reading (93.02%). The advice from this study is to monitor TB patients to regularly take OAT so that they never break up for 6 months.
Analisis Kesesuaian Kode Diagnosis Utama Neoplasma Di Rumah Sakit Umum Daerah Dr. Soedirman Kebumen Nurami, Amara Nabiila Sekar; Fauzi, Harry; Nur Indira, Zahrasita; Purnama Adi, Prisai
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Vol. 9 No. 1 (2024): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Februari
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v9i1.1226

Abstract

Neoplasm is a disease associated with abnormal tissue development due to neoplasia, which is the process of abnormal growth and development of body tissues that grow actively with the autonomic (uncontrolled) system. Information for a patient in a hospital will not be complete and useful if it has not been processed, then coding is required. Giving special diagnosis code of neoplasm should consider 3 things to get the right code, namely topography code, morphology, and behavior. However, in its implementation, there are still many errors in the coder's determination of the neoplasm diagnosis code. This has an impact on services to patients such as errors of Action, care and treatment. This study aims to determine the description of the accuracy of topography and morphology codes in neoplasm diagnosis at Dr. Sudirman Kebumen. The type of research used is descriptive quantitative. Based on the research obtained from 178 inpatient medical records in the case of neoplasms, the samples taken were as many as 39 C codes determined that the accuracy amounted to 8 (20.51%) inaccurate category amounted to 31 (79.49%). Inaccuracy in writing the neoplasm code due to the results of PA (anatomical pathology) that has not come out at the time of coding the disease, anatomical pathology Examination Result Sheet that often the results come late because the laboratory examination outside the hospital and the coding officer is less thorough, sometimes there is a doctor's writing that is less clear so that the difficulty of the officer in reading the diagnosis. This led to the inaccuracy of the neoplasm diagnosis code in Dr. Sudirman Kebumen in September 2020.
Analisis Kelengkapan Desain Formulir Pasien Rawat Jalan Di Puskesmas Purwokerto Timur I Cahyani, Lintang Dwi; Hakim, Agya Osadawedya; Indira, Zahrasita Nur; Permatasari, Merdiana Ika
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.v9i2.1649

Abstract

Puskesmas is one of the health service institutions provided by the Indonesian government and is the spearhead of the national health system. Efforts in establishing quality health centre service quality, that is, by paying attention to every aspect of it. The anatomical and physical aspects are used here. Please note the number of measurement cards for patients. One of them is processing the patient's medical record form design. Medical record forms are designed and used for maintenance and monitoring. The design of the form aims to improve and complete aspects of the outpatient form design that are currently still in use and to improve the quality of health services at the Purwokerto Timur I Health Center. The objective of this research is to identify the completeness of the outpatient forms available at the Purwokerto Health Center. Timur I. This analysis uses a quantitative method with a cross-sectional descriptive approach. The subject of this study was the outpatient form at the Purwokerto Timur I Health Center. The results obtained from this study were quite good, that is, there was an outpatient form at the Purwokerto Timur I Health Center, but the results of the analysis of this form still need to be improved in completeness. There is a completeness of 76,92% in the form. The aspect of the content that has the best completeness of the form.
Faktor - Faktor Yang Mempengaruhi Proses Pengkodean Diagnosis Di Rumah Sakit Umum Daerah Cilacap Febriana, Dina; Hakim, Agya Osadawedya; Indira, Zahrasita Nur; Anggraeni, Okti
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.v9i2.1654

Abstract

Hospitals are health institutions that provide medical services to individuals as a whole, including inpatient, outpatient, and emergency care. Hospitals need to improve the quality of their services. This can be done by having a good medical record unit. Medical records are documents that contain information about the patient's identity, examination, treatment, procedures, and other services provided to the patient. An important data processing to store data in medical records is coding. Classifying and providing codes for disease diagnosis is known as coding. Writing codes on medical records must be precise and accurate. The impact of coding errors can affect the quality of medical records. Based on an initial survey related to coding carried out at Cilacap Regional Hospital, a problem was found that officers had difficulty reading the doctor's writing. This study aims to determine what factors influence the diagnosis coding process at Cilacap Regional Hospital. This research is a type of qualitative research with data collection method instruments through observation and interviews. The research subjects amounted to 2 people, namely coder officers and the head of the medical records unit. The results of the study obtained several factors that influence the coding process including; Writing a diagnosis that is difficult to read, incompleteness in medical records can affect the coding process that will be carried out by the coder, and the absence of a medical dictionary as a coding support book in finding unknown terms in coding.
Analysis of the Release of Medical Record Information as a Guarantee of Legal Aspects of Patient Data Confidentiality: Analisis Pelepasan Informasi Rekam Medis sebagai Penjamin Aspek Hukum Kerahasiaan Data Pasien Setyaningsih, Fahmi; Meylia, Nadira Zalfa; Mayasari, Winda Nur; Parmesti, Khoirunnisa Riski; Wahyudi, Rusli Diki; Indira, Zahrasita Nur; Siregar, Rahmadhani
Procedia of Engineering and Life Science Vol. 7 (2025): Prosiding Seminar Nasional dan Rakernas PORMIKI X
Publisher : Universitas Muhammadiyah Sidoarjo

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.21070/pels.v7i0.2092

Abstract

Medical records are certainly very close to maintaining the security and confidentiality of patient data in the means of releasing information by ensuring the legal aspects of the security and confidentiality of patient data. Maintaining the security and confidentiality of patient data during the process of releasing medical record file information is very important in order to facilitate access to information on lawsuits by health services and health practitioners, as well as authorized third parties. This study aims to provide an overview of the release of medical record information in the legal aspect of confidentiality. The things that were studied were the procedures for releasing medical record information, the requirements for releasing medical information, the parties involved in releasing medical information, information on the use of releasing medical information and looking at the security aspects of the process of releasing medical record information, as well as facilities and infrastructure in the information release room. The data collection methods used in this study were interviews and observations. The results of the research on the process of releasing medical information show that two patients are in accordance and two patients are not in accordance with the SOP (Standard Operating Procedure) that applies at JIH Purwokerto Hospital, the human resources involved in the process of releasing information are Medical Recorder and Health Information (PMIK) officers and non PMIK, and inadequate facilities and infrastructure available in the information release room.
Analysis Of Pending Claims For Inpatients Social Security Organizing Body (Bpjs) Health Hospital Mitra Siaga Tegal: Analisis Pending Klaim Pasien Rawat Inap Badan Penyelenggara Jaminan Sosial (Bpjs) Kesehatan Rumah Sakit Mitra Siaga Tegal Indira, Zahrasita Nur; Yustafia, Atiqah Filda; Wijayanti, Wahyu Nur; Bella, Cindy Rozza; Mulyani, Agustina Dwi; Wibowo, Dimas Ari
Procedia of Engineering and Life Science Vol. 7 (2025): Prosiding Seminar Nasional dan Rakernas PORMIKI X
Publisher : Universitas Muhammadiyah Sidoarjo

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.21070/pels.v7i0.2237

Abstract

The Hospital understands and realizes the importance of the claim process as a reimbursement for insurance patients who have been treated. pending claims, namely the return of claims where there is no agreement between BpJS Health and FKRTL regarding coding and medical rules (dispute claims), but settlements are carried out in accordance with statutory provisions. Mitra Siaga Tegal Hospital in September 2022 obtained data that there were 94 pending BPJS claim files for inpatients out of 1427 files that had been submitted for claims to BPJS. This is due to coding errors, incorrect data entry, incomplete supporting examinations such as the absence of therapy and laboratory results. The method used in this research is qualitative with in-depth interviews with the Assistant Manager of Insurance Control and the officer in charge of Inpatient Claims at Mitra Siaga Tegal Hospital. The purpose of this study was to find out the causes of pending claims for hospitalization in September 2022 at Tegal Mitra Siaga Hospital. The results of the study show that pending cases of inpatient BPJS claims at Mitra Siaga Hospital in Tegal can occur due to several factors, which consist of administrative, medical, and coder aspects. The most common factor causing pending hospitalization claims was the coder aspect in 76 cases
ANALISIS KESIAPAN PENERAPAN REKAM MEDIS ELEKTRONIK (RME) DI RUMAH SAKIT MITRA SIAGA TARUB TEGAL Zahrasita Nur Indira; Aep Saepulloh
Journal of Innovation Research and Knowledge Vol. 4 No. 9: Februari 2025
Publisher : Bajang Institute

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.53625/jirk.v4i9.9871

Abstract

Electronic Medical Records have many benefits in health services. At this time, Mitra Siaga Tarub Tegal Hospital will implement services with electronic medical records as a whole, both outpatient, inpatient, emergency and other supports to increase efficiency and improve service quality and ensure patient safety. Therefore, an assessment must be carried out on the readiness of RME implementation. In this case, it can identify which are priorities and help shape operational functions in supporting the optimization of RME implementation. The purpose of this study is to analyze the readiness of the implementation of RME at Mitra Siaga Tarub Tegal Hospital. Using a case study method with a qualitative approach. This research was conducted at Mitra Siaga Tarub Tegal Hospital. This research will start from December 2024 to January 2025. Using the purposive sampling method in the selection of the informants involved. This study obtained results that show that it is quite ready in the organizational culture. Knowledge of the implementation of RME has been disseminated to the entire hospitalia community and there are still obstacles related to services that are still using manuals because they have not been integrated. Mitra Siaga Tarub Tegal Hospital has a very clear goal in implementing RME. The informant is confident that he can succeed in changing the manual medical record system to electronic one implemented in hospitals. The readiness of human resources (HR), infrastructure and infrastructure facilities are ready, this can be seen from the positive response of the hospitalia community in the use of RME. The implementation of RME is going well although there are still some obstacles. The readiness of RME implementation needs to be improved as the development of RME progresses, both from organizational culture, governance and leadership readiness, in terms of human resource readiness and infrastructure readiness
ANALISIS KEBUTUHAN TENAGA KERJA UNIT FILING REKAM MEDIS MENGGUNAKAN WISN DI RSUD DR. SOEDIRMAN KEBUMEN Budiyanti, Shifa Amanda; Indira, Zahrasita Nur; Romodon, Dion; Praptanti, Agustina Fitri
Jurnal Kesehatan Tambusai Vol. 6 No. 1 (2025): MARET 2025
Publisher : Universitas Pahlawan Tuanku Tambusai

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31004/jkt.v6i1.41763

Abstract

WISN adalah teknik penghitungan kebutuhan sumber daya manusia berdasarkan beban kerjanya. Beban kerja adalah tanggung jawab terhadap pekerjaan yang wajib dirampungkan oleh tenaga kerja profesional setiap tahun di tempat kerjanya. Semakin banyak pasien, maka beban kerja petugas filing semakin tinggi karena rekam medis elektronik belum sepenuhnya dapat dijalankan. Penelitian ini bertujuan untuk mengetahui tenaga kerja yang dibutuhkan unit filing berdasarkan besarnya beban kerja petugas dengan teknik WISN. Penelitian ini merupakan penelitian kualitatif dengan pendekatan deskriptif, populasi pada penelitian ini adalah 7 petugas di unit filing dan sampelnya adalah 3 petugas unit filing RSUD dr. Soedirman Kebumen serta sampel diambil menggunakan purposive sampling. Data dikumpulkan melalui observasi dan wawancara, kemudian hasilnya disajikan dalam bentuk tabel untuk menghitung beban kerja petugas, sehingga diperoleh jumlah tenaga kerja unit filing yang dibutuhkan sesuai teknik WISN. Berdasarkan hasil perhitungan WISN menunjukkan bahwa waktu kerja yang tersedia sebesar 75.000 menit/tahun, rata-rata standar beban kerja sebesar 489.379,1. Standar kelonggaran sebesar 0,45 dan total kebutuhan tenaga filing sebanyak 6,636 atau 7 orang. Jumlah tenaga kerja di unit filing RSUD dr. Soedirman Kebumen adalah 7 petugas. Terdapat permasalahan seperti rekam medis yang tercecer, ruang filing tidak buka 24 jam, dan rak penyimpanan yang penuh. Keseluruhan tenaga kerja unit filing rekam medis sebanding dengan beban kerjanya, sehingga tidak perlu penambahan atau pengurangan petugas, tetapi membutuhkan evaluasi kembali dan melakukan peningkatan cara penyelenggaraan kegiatan di unit filing.
Co-Authors Aep Saepulloh Afgani, Abu Sofyan Al Aldi Pratama Anggraeni, Okti Aris Puji Widodo Aris Puji Widodo Budiyanti, Shifa Amanda Cahyani, Lintang Dwi Cindy Rozza Bella Damayanti, Rifka Oktavia Dion Romodon Farid Agushybana Farid Farid Agushybana Febriana, Dina Hakim, Agya Osadawedya Harry Fauzi Harry Fauzi, Harry Marini, Budiana Mayasari, Winda Nur Meylia, Nadira Zalfa Mulyani, Agustina Dwi Nadi, Danu Tirta Najwa Azkia Rahma Nurami, Amara Nabiila Sekar Parmesti, Khoirunnisa Riski Permatasari, Merdiana Ika Praptanti, Agustina Fitri Prisai Purnama Adi Purnama Adi, Prisai Setyaningsih, Fahmi Siregar, Rahmadhani Taharah, Dena Utami Budi Lestari Wahyudi, Rusli Diki Wibowo, Dimas Ari Wijayanti, Wahyu Nur Yustafia, Atiqah Filda