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All Journal Jurnal Kreativitas PKM JOURNAL OF SCIENCE AND SOCIAL RESEARCH Jurnal Manajemen Informasi Kesehatan Indonesia (JMIKI) Indonesian of Health Information Management Journal (INOHIM) PREPOTIF : Jurnal Kesehatan Masyarakat Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Infokes : Jurnal Ilmiah Rekam Medis dan Informasi Kesehatan J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Sehat Rakyat: Jurnal Kesehatan Masyarakat PELS (Procedia of Engineering and Life Science) Jurnal Akuntansi, Ekonomi dan Manajemen Bisnis
Husni Abdul Muchlis
Universitas Esa Unggul
Computer Science & IT Control & Systems Engineering Dentistry Economics, Econometrics & Finance Education Electrical & Electronics Engineering Engineering Health Professions Medicine & Pharmacology Nursing Public Health Social Sciences Veterinary

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Hubungan Kualitas Resume Medis dan Ketepatan Koding Kasus Pneumonia dengan Hasil Klaim di RSIJ Sukapura Sansy Dua Lestari Putri Azah; Husni Abdul Muchlis; Hosizah Hosizah; Witri Zuama Qomarania
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 7 No 3 (2026): June
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v7i3.5839

Abstract

Hospitals submit BPJS Health insurance claim documents to obtain reimbursement for healthcare services provided. Observations at RSIJ Sukapura identified 32 pending claim files (70%) caused by incomplete documentation of clinical symptoms in medical discharge summaries. This issue led to the revision of the diagnosis code from J18.9 to J22, resulting in reduced claim values and an increased number of pending claims. This study aimed to examine the relationship between the quality of medical discharge summaries, coding accuracy, and claim outcomes among hospitalized pneumonia patients at RSIJ Sukapura. A quantitative study was conducted using a population of 102 pneumonia cases recorded in May 2024. Using purposive sampling, 89 claim files were selected for analysis. The results showed that 71 files (79.8%) had good-quality medical discharge summaries, 75 files (84.3%) demonstrated accurate coding, and 70 files (78.7%) resulted in eligible claims. Multiple logistic regression analysis revealed a significant relationship between the quality of medical discharge summaries, coding accuracy, and claim outcomes (p < 0.001). Good-quality documentation and accurate coding increased the likelihood of producing eligible claims. Therefore, physician education regarding complete documentation in accordance with BPJS Health requirements is recommended to reduce pending claims.
Pengaruh Kualitas Catatan terhadap Keakuratan Kode Penyebab Kematian di Rumah Sakit Pertamina Jaya Regy Permata Sari; Husni Abdul Muchlis; Hosizah Hosizah; Yati Maryati
Sehat Rakyat: Jurnal Kesehatan Masyarakat Vol. 5 No. 2 (2026): Mei 2026
Publisher : Yayasan Pendidikan Penelitian Pengabdian Algero

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.54259/sehatrakyat.v5i2.7440

Abstract

The accuracy of cause-of-death coding is essential for health statistics and policy-making. Incomplete, inaccurate, and unclear documentation by physicians can lead to coding errors and reduce the validity of mortality data. This study aimed to analyze the effect of documentation quality on the accuracy of cause-of-death coding at Pertamina Jaya Hospital. This quantitative study used a cross-sectional design and was conducted in January 2026. The sample consisted of 56 Medical Certificates of Cause of Death (MCCD) from September–November 2024, selected using quota  sampling. Data were collected through observation and analyzed using univariate and bivariate analyses with logistic regression. The results showed that 14 MCCDs (25%) had accurate cause-of-death coding, while 42 MCCDs (75%) were inaccurate. Poor-quality documentation was found in 30 MCCDs (54%), while good-quality documentation was found in 26 MCCDs (46%). Bivariate analysis demonstrated a significant effect of documentation quality on coding accuracy (p = 0.037). An odds ratio of 4.062 indicated that good-quality documentation had four times greater odds of producing accurate cause-of-death codes, explaining 12.1% of the variance in coding accuracy (R² = 0.121). The study concludes that standard operating procedures and training for physicians and coders are needed to improve accuracy and validity of mortality data.
Peningkatan Kapasitas PMIK Dalam Mengolah dan Menganalisis Data Klaim INA-CBG’s untuk Meningkatkan Akurasi Kodefikasi & Dokumentasi di RSIJ Pondok Kopi Husni Abdul Muchlis; Mieke Nurmalasari; Witri Zuama Qomarania; Anastasia Cyntia Dewi Kurniawati; Muhammad Fuad Iqbal; Yati Maryati
Jurnal Kreativitas Pengabdian Kepada Masyarakat (PKM) Vol 9, No 2 (2026): Volume 9 Nomor 2 (2026)
Publisher : Universitas Malahayati Lampung

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33024/jkpm.v9i2.23624

Abstract

ABSTRAK Keberhasilan klaim JKN-BPJS sangat bergantung pada akurasi dokumentasi klinis dan kodefikasi diagnosis serta prosedur. RSIJ Pondok Kopi masih menghadapi kendala dalam pemanfaatan data klaim untuk evaluasi mutu dan optimalisasi nilai klaim. Kegiatan ini bertujuan meningkatkan kemampuan PMIK dalam mengolah dan menganalisis data klaim INA-CBG’s untuk mendukung akurasi kodefikasi dan dokumentasi. Program dilaksanakan melalui sosialisasi, pelatihan teknis Excel PivotTable, dan pendampingan penyusunan dashboard analisis klaim. Evaluasi menggunakan pre-test dan post-test serta observasi produk analisis. Pelatihan meningkatkan skor pengetahuan tim sebesar 22 poin, terutama pada materi MCC/CC. Tim berhasil menghasilkan dua laporan dashboard internal terkait capture rate MCC/CC dan distribusi LOS (AMLOS/GMLOS). Peningkatan kompetensi PMIK dalam analisis data klaim mampu memperbaiki akurasi kodefikasi dan mendorong pemanfaatan data klaim sebagai alat manajemen mutu dan optimalisasi nilai klaim rumah sakit. Kata Kunci: Data Klaim, Dokumentasi Klinis, INA-CBG’s, Klaim BPJS, Kodefikasi.  ABSTRACT The success of JKN–BPJS claims strongly depends on the accuracy of clinical documentation and clinical coding of diagnoses and procedures. RSIJ Pondok Kopi still faces challenges in utilizing claim data to evaluate service quality and optimize reimbursement values. This community service activity aims to improve the capacity of Health Information Management professionals (PMIK) in processing and analyzing INA-CBG’s claim data to support accurate coding and clinical documentation. The program was carried out through socialization, technical training using Excel PivotTable, and mentoring in developing analytical dashboards. Evaluation was conducted using pre-test and post-test assessments, as well as observation of the analytical products. The training improved staff knowledge by 22 points, with the highest increase in MCC/CC competence. The team successfully produced two internal dashboard reports related to MCC/CC capture rate and LOS distribution (AMLOS/GMLOS). Improving PMIK competency in claim data analysis enhances the accuracy of clinical coding and encourages the use of claim data as a tool for quality management and reimbursement optimization in hospitals. Keywords: Claim Data, Clinical Coding, Clinical Documentation, INA-CBG’s, BPJS Claim.
Analysis of Inpatient Care Utilization Among Type 2 Diabetes Mellitus Patients Nauri Anggita Temesvari; Husni Abdul Muchlis
Jurnal Infokes Vol 16 No 1 (2026): Jurnal Ilmiah Rekam Medis dan Informatika Kesehatan
Publisher : Universitas Duta Bangsa Surakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.47701/zh1qzk63

Abstract

Globally and in Indonesia, diabetes mellitus (DM) is mainly type 2. When outpatient care fails to control blood glucose, hospitalization treatment becomes necessary. This is in line with the implementation of the referral system in the era of the National Health Insurance. This study aims to analyze the utilization of hospitalization among patients diagnosed with Type 2 DM (T2DM). A cross-sectional design was applied using sample data from BPJS Kesehatan Year 2024, representing 2023 visit records. All patients admitted with T2DM were included. Inpatient utilization measured by admission frequency, intervals, length of stay, referral sources, diagnostic consistency, discharge status, and comorbidities among T2DM patients. Descriptive analysis was performed on patient characteristics and hospitalization utilization patterns. In 2023, there were 480 admissions involving 417 patients, mean interval between hospitalizations was 69 days. The length of hospital stay increased with the presence of complications. Most referrals came from hospitals, 66% of primary diagnoses matched the admission diagnosis, and hypertension was the most common comorbidity. Most discharge status was recovered. Recommendations include enhancing continuity of care and the referral back program through system integration to mitigate T2DM readmission risks.
PENGARUH AKURASI KODING TERHADAP HASIL PENGAJUAN KLAIM RAWAT INAP BPJS KESEHATAN DI RS SENTRA MEDIKA CIBINONG Jayanti Lestari; Husni Abdul Muchlis; Hosizah Hosizah; Nauri Anggita Temesvari
JOURNAL OF SCIENCE AND SOCIAL RESEARCH Vol. 8 No. 1 (2025): February 2025
Publisher : Smart Education

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.54314/jssr.v8i1.2798

Abstract

Abstract: Claim files that are returned / pending can result in a decrease in hospital income due to a mismatch in service costs with the number of claims billed. The results of submitting inpatient claims at Sentra Medika Cibinong Hospital in September-November 2023 were 327 (10%) pending files out of 3,250 files billed. The purpose of the study was to determine the effect of coding accuracy on the results of submitting BPJS Health inpatient claims. With a quantitative approach and cross sectional design. The population was all inpatient claim files, a sample of 300 claim files with the Accidental Sampling technique. Data analysis using chi square test and observation data collection. The results showed inaccurate coding files 116 (38.7%) and accurate coding 184 (61.3%) and pending files 49 (16.3%) and not pending 251 (83.7%). While the results of the chi square test obtained a P-value of 0.002 <0.05 OR value of 2.733 It was concluded that there was an influence between coding accuracy on the results of submitting BPJS Health inpatient claims at Sentra Medika Cibinong Hospital. Furthermore, inaccurate coding accuracy files are 2.7 times more likely to be pending than accurate files. Accurate coding files were pending 20 (10.9%) and not pending 164 (89.1%), inaccurate coding files were pending 29 (25%) and not pending 87 (75%). Suggestions for conducting regular evaluations of cases that have the potential to experience pending claims. Keyword: Coding Accuracy, Submission Results, Pending Claims Abstrak: Berkas klaim yang dikembalikan/pending dapat mengakibatkan penurunan pendapatan rumah sakit akibat ketidaksesuaian biaya layanan dengan jumlah klaim yang ditagihkan. Hasil pengajuan klaim rawat inap di RS Sentra Medika Cibinong pada bulan September–November 2023 Sebanyak 327 (10%) berkas pending dari 3.250 berkas yang ditagihkan. Tujuan penelitian untuk mengetahui pengaruh akurasi koding terhadap hasil pengajuan klaim rawat inap BPJS Kesehatan. Dengan pendekatan kuantitatif dan desain cross sectional. Populasi seluruh berkas klaim rawat inap pada bulan Maret 2024, sampel 300 berkas klaim dengan teknik Accidental Sampling. Analisa data menggunakan uji chi square dan pengumpulan data observasi. Hasil penelitian menunjukan berkas koding tidak akurat 116 (38,7%) dan koding akurat 184 (61,3%) serta berkas terpending 49 (16,3%) dan tidak terpending 251 (83,7%). Sedangkan hasil uji chi square diperoleh nilai P-value 0,002 < 0,05 nilai OR 2,733 Maka disimpulkan ada pengaruh antara akurasi koding terhadap hasil pengajuan klaim rawat inap BPJS Kesehatan di RS Sentra Medika Cibinong. Selanjutnya berkas akurasi koding tidak akurat berpeluang 2,7 kali akan terpending dibandingkan berkas yang akurat. Berkas koding akurat yang terpending 20 (10,9%) dan tidak terpending 164 (89,1%), berkas koding tidak akurat yang terpending 29 (25%) dan tidak terpending 87(75%). Saran melakukan evaluasi secara berkala terhadap kasus yang berpotensi mengalami pending klaim. Kata kunci: Akurasi Koding; Hasil Pengajuan; Pending Klaim
HUBUNGAN KEAKURATAN KODE DIAGNOSIS DAN TINDAKAN DENGAN BESARAN TARIF INA-CBGS KASUS DIABETES MELITUS TIPE II DI RSUD ANUTAPURA PALU Yusnaeni Yusnaeni; Husni Abdul Muchlis; Hosizah Hosizah; Witri Uama Qomarania
JOURNAL OF SCIENCE AND SOCIAL RESEARCH Vol. 8 No. 1 (2025): February 2025
Publisher : Smart Education

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.54314/jssr.v8i1.2827

Abstract

Abstract: The accuracy of the diagnosis and action codes is related to the amount of INA-CBG costs that will be claimed. Initial observation results showed that of the 31 claim files there were 17 (54.8%) with inaccurate codes. This study aims to determine the relationship between the accuracy of diagnosis codes and actions with the INA-CBGs rates for type II DM cases at Anutapura Regional Hospital, Palu, in January – August. This type of research is quantitative research with a cross sectional research design. The population size was 387 and the sample size was 79 claim files using a simple random sampling technique. Data collection was carried out through document review of inpatient claim files and INA-CBGs rates. Data analysis using the Chi-Square test. The research results from 79 claim files contained 25 (31.6%) inaccurate diagnosis with inaccurate INA-CBGs rates. The results of the Chi-Square test by looking at the Fisher's exact test value show that there is a relationship between the accuracy of the diagnosis code and the action and the INA CBG's rates for type II DM cases at Anutapura Regional Hospital with a p-value of 0.04 < 0.05 and an OR value = 3.811 This means that the accuracy of the diagnosis and action codes has a 3.811 chance of producing the correct INA-CBGS rate. It is hoped that coders will be more careful in assigning accurate codes according to ICD-10 and ICD-9 rules in order to produce the correct INA-CBGs rates. Keyword: Accuracy Of Diagnosis and Action Codes, ICD-10 and ICD-9 Coding, INA-CBGs Rates Abstrak: Keakuratan kode diagnosis dan tindakan berhubungan dengan besaran tarif biaya INA-CBGs yang akan diklaim. Hasil observasi awal menunjukkan dari 31 berkas klaim terdapat 17 (54.8%) dengan kode yang tidak akurat. Penelitian ini bertujuan untuk mengetahui hubungan keakuratan kode dengan besaran tarif INA-CBGs kasus DM tipe II di RSUD Anutapura Palu pada bulan Januari – Agustus. Jenis penelitian ini adalah penelitian kuantitatif dengan rancangan cross sectional. Besar populasi sebanyak 387 dan besar sampel sebanyak 79 berkas klaim dengan teknik simple random sampling. Pengumpulan data dilakukan melalui telaah dokumen terhadap berkas klaim rawat inap dan besaran tarif INA-CBGs. Analisis data dengan uji Chi-Square. Hasil penelitian dari 79 berkas klaim terdapat 25 (31.6%) kode diagnosis dan tindakan yang tidak akurat dengan tarif INA-CBGs yang tidak tepat. Hasil uji Chi-Square dengan melihat nilai fisher’s exact test menunjukkan ada hubungan antara keakuratan kode diagnosis dan tindakan dengan besaran tarif INA CBG’s kasus DM tipe II di RSUD Anutapura dengan nilai p-value sebesar 0,04 < 0,05 dan nilai OR=3,811 artinya keakuratan kode diagnosis dan tindakan mempunyai peluang 3,811 kali menghasilkan tarif INA-CBGS yang tepat. Diharapkan petugas koder lebih teliti dalam menetapkan kode yang akurat sesuai aturan ICD-10 dan ICD-9 agar dapat menghasilkan tarif INA-CBGs yang tepat. Kata kunci: Keakuratan Kode Diagnosis dan Tindakan, Pengkodean ICD-10 dan ICD-9, Tarif INA-CBGs
PENGARUH KUALITAS DOKUMENTASI KLINIS TERHADAP KETEPATAN WAKTU KODEFIKASI KLINIS PASIEN JKN DI INSTALASI CASEMIX RSU KABUPATEN TANGERANG Hesti Yuniarti; Husni Abdul Muchlis; Hosizah; Mieke Nurmalasari
JOURNAL OF SCIENCE AND SOCIAL RESEARCH Vol. 9 No. 2 (2026): April 2026
Publisher : Smart Education

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.54314/yf2jxx52

Abstract

Abstract: Timeliness of coding is crucial and requires attention, as failure to do so will delay the coding process and even impact financing claims. Initial observations indicate that 38.88% of coding is inaccurate. This study aims to analyze the effect of clinical documentation quality on the timeliness of clinical coding in the Casemix Installation of Tangerang Regency General Hospital. The study was conducted from August to October 2025 using a quantitative approach with a cross-sectional case study. A sample of 96 medical records was obtained using a random sampling technique. Data collection was carried out by reviewing medical records. The analysis technique used binary logistic regression. The results of the study showed that there was a 52.08% inaccuracy in the timeliness of coding and only 12.5% ??met the 7 criteria of clinical documentation quality. The Nagelkerke R Square value of 0.346 was obtained, which means that the quality of clinical documentation (Independent Variable) contributed 34.6% in explaining the timeliness of clinical coding (Dependent Variable), while 65.4% was explained by other factors outside the research model such as hospital information systems, doctor workloads and other internal policies. The Wald test showed a significant influence between the quality of clinical documentation on the timeliness of clinical coding with a p-value of 0.000 (p = <0.05). It is necessary to update the SIMRS coding system and optimal socialization in filling in the completeness and timeliness of clinical documentation.   Keywords: Medical Record Data. Timeliness of Coding, Quality of Clinical Documentation Abstrak: Ketepatan waktu kodefikasi merupakan hal penting dan perlu mendapatkan perhatian, jika tidak akan menyebabkan keterlambatan proses pengkodean salah satunya diakibatkan oleh kualitas dokumentasi, bahkan berdampak pada klaim pembiayaan. Hasil observasi awal menunjukkan terdapat 38,88% ketidaktepatan waktu kodefikasi. Penelitian ini bertujuan untuk menganalisis pengaruh kualitas dokumentasi klinis terhadap ketepatan waktu kodefikasi klinis di Instalasi Casemix RSU Kabupaten Tangerang. Penelitian dilakukan pada bulan Agustus - Oktober 2025 menggunakan pendekatan kuantitatif dengan kasus potong lintang (Cross- Sectional). Didapatkan Sampel sebanyak 96 rekam medis dengan teknik random sampling. Pengumpulan data dilakukan dengan cara telaah rekam medis. Teknik analisis menggunakan regresi logistik biner. Hasil Penelitian menunjukkan terdapat ketidaktepatan waktu kodefikasi sebesar 52,08% dan hanya terdapat 12,5% yang memenuhi kriteria 7 kriteria kualitas dokumentasi klinis, Diperoleh nilai Nagelkerke R Square sebesar 0,346, dapat diartikan kualitas dokumentasi klinis (Variabel Independen) memiliki konstribusi sebesar 34,6% dalam menjelaskan ketepatan waktu kodefikasi klinis (Variabel Dependen), sedangkan 65,4% dijelaskan oleh faktor lain diluar model penelitian seperti sistem informasi rumah sakit, beban kerja dokter dan kebijakan internal lainnya. Uji wald menunjukkan adanya pengaruh signifikan antara kualitas dokumentasi klinis terhadap ketepatan waktu kodefikasi klinis dengan nilai p-value 0,000 (p = < 0,05). Perlu dilakukan update sistem SIMRS kodefikasi dan sosialisasi optimal dalam pengisian kelengkapan dan ketepatan waktu dokumentasi klinis.   Kata Kunci: Data Rekam Medis, Ketepatan Waktu Kodefikasi, Kualitas Dokumentasi Klinis
Membedah Fenomena Dropping Pasien Jiwa: Analisis Niat Keluarga Berdasarkan Theory Of Planned Behavior Di RS Soeharto Heerdjan Dita Manisha Amrina Putri; Husni Abdul Muchlis; Hosizah Markam; Tria Saras Pertiwi
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Vol. 11 No. 2 (2026): 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.v11i2.2243

Abstract

The low family intention to pick up post-treatment mental patients at Soeharto Heerdjan Hospital is characterized by the increasing number of patient dropping cases, indicating that the discharge process does not only depend on medical aspects but also on family psychosocial factors. This study aims to analyze the influence of attitudes, subjective norms, and perceived behavioral control on family intention to pick up mental patients using a quantitative cross-sectional approach with multiple linear regression. The study population of 430 families of inpatient mental patients was sampled by 81 respondents through accidental/convenience sampling techniques, with primary data from a Likert scale questionnaire 1-4. The results showed the family intention index (56.25), attitude (50.29), subjective norms (51.82), and perceived behavioral control (44.42) in the moderate category; all three variables simultaneously had a significant effect on family intention (p<0.05) with an adjusted R² of 0.730, explaining 73% of the variation in intention. The main obstacles included social support, cost, and time constraints. Suggestions from this study include increasing early education, family counseling, and hospital logistical support to optimize family readiness and intentions in the process of returning mental patients.
Co-Authors Ambarwati Ayuningtyas, Meta Dita Manisha Amrina Putri Hesti Yuniarti Hosizah Hosizah Hosizah Iqbal, Muhammad Fuad Jayanti Lestari Kurniawati, Anastasia Cyntia Dewi Lestari, Betri Widya Lestari, Jayanti Menna, Yasinta Rosalia Muzdalifah, Ifah Nanda Dina Cahya Nauri Anggita Temesvari Nurmalasari, Mieke Oktavianti, Putri Purba, Andrea Krisler Qomarania, Witri Uama Regy Permata Sari Sansy Dua Lestari Putri Azah Temesvari, Nauri Anggita Tria Saras Pertiwi Wahyu Sulistiadi Witri Uama Qomarania Witri Zuama Qomarania Yati Maryati Yati Maryati Yulia, Noor Yusnaeni Yusnaeni Yusnaeni Yusnaeni, Yusnaeni