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Factors contributing to inaccurate diagnosis code in obstetric case in hospital Alfina Aisatus Saadah; Risma Nur Sukmawati
Science Midwifery Vol 11 No 1 (2023): April: Midwifery and Health Sciences
Publisher : Institute of Computer Science (IOCS)

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.35335/midwifery.v11i1.1150

Abstract

As the diagnostic code serves as the foundation for determining the cost of health services and formulating policy, its quality must be ensured. In some hospitals, the code is extremely inaccurate. If the patient's diagnosis code is not accurately coded, the level of data validation for the obtained information will be low. This will result in inaccurate reports, including outpatient morbidity reports, top ten disease reports, and Health Insurance (Jamkesmas) claims. This study aimed to examine the inaccuracy of the diagnostic code for obstetric cases in hospital. This study employs a Literature review methodology in which researchers will compile various scientific articles/journals into a scientific work. Based on the findings of the study, the percentage of inaccurate diagnosis codes for obstetric cases was greater than 50% in five journals, 50% in one journal, and less than 50% in three journals. The inaccuracy of the obstetric case diagnosis code is due to Man, Machine, Material, and Method factors. Thereby, it can be concluded that the percentage of inaccuracy of the diagnostic code for obstetric cases is quite high, and that the most common factor causing inaccuracy of the diagnostic code for obstetric cases is the Man factor, namely that the writing of the diagnosis is less clear, complete, and specific. Consequently, it is necessary to monitor and reevaluate medical officers, especially doctors and assistants, and to establish a policy stating that writing diagnoses is the responsibility of doctors and must adhere to ICD rules.
ANALISIS BEBAN KERJA PETUGAS ADMISI RAWAT JALAN DENGAN MENGGUNAKAN METODE WORK LOAD INDICATOR STAFF NEED DI RUMAH SAKIT UMUM DAERAH SIDOARJO Ummu Latifah; Alfina Aisatus Saadah
Jurnal Kesehatan Vol. 1 No. 5 (2023): November
Publisher : CV. ADIBA AISHA AMIRA

Show Abstract | Download Original | Original Source | Check in Google Scholar

Abstract

Workload also takes into account the standard number of employees according to the profession, qualification standards and job evaluation standards. So, the high or low workload does not only depend on the number of workers available, but also depends on the qualifications of the health workers. HR planning can be done by carrying out calculations using the Work Load Indicator Staff Need (WISN) method. Based on interviews conducted by researchers with one of the outpatient admissions officers, information was obtained that the number of outpatient clinic patients in March 2023, 749 patients registering for inpatient admissions, sometimes made the outpatient admissions officers overwhelmed during the patient registration process. The number of outpatient admissions officers is only one person and is not comparable to the number of patient visits from outpatient clinics who will be registered for inpatient care. This causes the workload of officers to become excessive and results in fatigue impact on outpatient admissions officers and outpatient admissions services become less effective and efficient. The aim of this research is to analyze the workload of outpatient admissions officers at Sidoarjo Regional Hospital using the Work Load Indicator Staff Need (WISN) method with quantitative descriptive research methods and observation and interview methods. The results show that the number of outpatient admissions officers is 1 person, the available working time is 120,210 minutes per year, the standard workload is 24,785.56 minutes per year, the slack standard is 0.102 minutes per year, the workforce requirement for outpatient admissions officers is 2 people so it is recommended to add 1 person. outpatient admissions officer and a D3 Medical Records graduate.
ANTI-CANCER PROPERTIES OF PHYTOCHEMICALS DERIVED FROM AZADIRACHTA INDICA: LITERATURE REVIEW Saadah, Alfina Aisatus
TRANSPUBLIKA INTERNATIONAL RESEARCH IN EXACT SCIENCES Vol. 1 No. 4 (2022): OCTOBER
Publisher : Transpublika Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.55047/tires.v1i4.1391

Abstract

This study aims to assess the anti-cancer properties of phytochemicals derived from Azadirachta indica (neem), given the increasing prevalence of cancer and the need for safer and more effective therapies. Phytochemicals from Azadirachta indica have been reported to have potential as anti-cancer agents, but their mechanism of action is not fully understood. Therefore, this study was conducted to explore the anti-cancer potential of various phytochemicals extracted from Azadirachta indica. This study used literature review method supported by bibliometric analysis tools such as VOSviewer and Publish or Perish. The results showed that phytochemicals from Azadirachta indica have significant cytotoxic effects on cancer cells, as well as being able to induce apoptosis through intrinsic pathways. These results suggest that Azadirachta indica has the potential to be developed as an effective and safe anti-cancer therapeutic agent. Discussion of the results of this study highlights the importance of further development and clinical trials to validate these findings.
Penyuluhan Komunikasi Efektif Petugas Kesehatan Dengan Pengguna Jasa Pelayanan Kesehatan (Pasien Atau Keluarga Pasien) Saadah, Alfina Aisatus; Faida, Eka; Firdaus, Abidatu Zahrotul
Jurnal Abdimas Jatibara Vol 3, No 1 (2024): Jatibara Vol.3 No.1 Agustus 2024
Publisher : STIKES Yayasan RS.Dr.Soetomo

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.29241/jaj.v3i1.1983

Abstract

A hospital is declared successful if it can provide the best service to its patients. Not only due to the completeness of the existing facilities, but also the attitude and service provided by the human resources at the hospital, this will influence the satisfaction aspect of patients who receive treatment at the hospital. Problems in the communication process that often occur between patients and health workers are the use of vocabulary that is too long, difficult to understand, complex, as well as the use of medical terms that patients often do not understand. The aim of this community service is that participants are able to understand effective communication between health workers and health service users (patients or patient families). The type of community service used is by conducting outreach methods. The target data for this community service activity are STIKES students at Dr. Hospital Foundation. Soetomo Surabaya and students majoring in health from other institutions, both private and state. Based on the results of community service, data was obtained that before the counseling was carried out, the level of understanding of participants in the good category was 25%, in the fair category was 47%, and in the poor category was 28%. Meanwhile, after counseling, the level of understanding of participants in the good category was 71%, in the fair category was 23%, and in the poor category was 6%. Data was obtained from pre-test and post-test questions completed by participants. So it can be concluded that after the counseling was carried out,  the level of understanding of the participants changed from being in the adequate category with the largest number to being in the good category. With the enthusiasm of participants in participating in outreach, health facilities and institutions need to provide education and training on effective communication.
Identifikasi Penyebab Misfile Berkas Rekam Medis di Rumah Sakit Surabaya Medical Service Anggraini, Nadira; Yusuf Setiawan, Mohammad; Aisatus Saadah, Alfina
Journal of Multidisciplinary Inquiry in Science, Technology and Educational Research Vol. 1 No. 4 (2024): AGUSTUS-OKTOBER 2024
Publisher : UNIVERSITAS SERAMBI MEKKAH

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.32672/mister.v1i4.2208

Abstract

Misfile merupakan fenomena dalam melakukan pemberkasan dokumen. Dalam penelitian ini, peneliti meneliti perihal misfile berkas dokumen rekam medis di rumah sakit Surabaya Medical Service. Penelitian ini bertujuan untuk mengidentifikasi penyebab misfile berkas rekam medis di Rumah Sakit Surabaya Medical Service. Metode yang digunakan dalam penelitian ini adalah kualitatif deskriptif. Hasil penelitian menunjukkan bahwa terdapat beberapa penyebab utama misfile, dalam lima aspek utama dalam manajemen yaitu, man, money, material, machine, dan method. Hasil wawancara yang dilakukan oleh peneliti, misfile yang disebabkan oleh man, sebanyak 50% atau 4 responden menjawab sangat setuju untuk mengadakan pelatihan dalam penyusunan berkas rekam medis. Misfile yang disebabkan oleh money, sebanyak 5 responden (50%) menjawab sangat setuju alokasi dana untuk teknologi penyimpanan berkas rekam medis. Misfile yang disebabkan oleh material, sebanyak 6 responden (62%) menjawab sangat setuju apabila kualitas rak penyimpanan dapat mengurangi kesalahan penyimpanan rekam medis. Misfile yang disebabkan oleh machine, sebanyak 6 responden (75%) menjawab penggunaan tracer (outguide) sangat membantu dalam menjaga akurasi penyimpanan berkas rekam medis dan 4 responden (50%) menjawab sangat setuju adanya penggunaan pemindai barcode dalam pencarian kembali berkas rekam medis yang hilang, penggunaan komputerisasi dapat mengurangi kesalahan peletakan dan penyimpanan berkas rekam medis sebanyak 6 responden (62%) menjawab sangat setuju. Misfile yang disebabkan oleh method, sebanyak 4-6 responden (50%-62%) menjawab sangat setuju pentingnya peninjauan dan pembaharuan rutin SOP penyimpanan berkas medis dalam menjaga akurasi data dan penerapan SOP dapat mengurangi kesalahan penyimpanan berkas rekam medis. Temuan ini menggarisbawahi pentingnya manajemen rekam medis yang efektif dan memberikan dasar untuk merancang solusi yang dapat meningkatkan efisiensi dan efektivitas pelayanan rekam medis di rumah sakit. Penelitian ini diharapkan dapat memberikan gambaran objektif mengenai situasi aktual filing rekam medis di Rumah Sakit Surabaya Medical Service dan mendorong perbaikan sistem di masa mendatang.
FAKTOR PENDUKUNG DAN PENGHAMBAT PENGGUNAAN REKAM MEDIS ELEKTRONIK (RME) DI INSTALASI REKAM MEDIS RUMAH SAKIT SITI KHODIJAH MUHAMMADIYAH CABANG SEPANJANG Syafanny, Lutfiah Dwi Amanda; Setiawan, Mohammad Yusuf; Saadah, Alfina Aisatus; Purnami, Nani
Jurnal Infokes Vol 15 No 1 (2025): 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/infokes.v15i1.4003

Abstract

Penggunaan rekam medis elektronik dapat memberikan pelayanan informasi kesehatan yang membantu tenaga dalam melakukan suatu pekerjaan dan meningkatkan penggunaan digitalisasi, penggunaan tersebut terdapat faktor pendukung dan penghambat dalam proses RME berlangsung dengan. Tujuan penelitian ini yaitu untuk mengidentifikasi faktor pendukung dan penghambat penggunaan RME berdasarkan 5 unsur manajemen dan menggunakan metode USG (Urgency, Seriousness, Growth) untuk menentukan prioritas suatu permasalahan. Metode pada penelitian ini menggunakan metode deskriptif pendekatan kualitatif dengan teknik purposive sampling sebanyak 6 informan. Hasil penelitian ini didapatkan faktor pendukung dan penghambat yaitu, pada aspek man adanya pihak IT, kurangnya petugas dan SDM yang belum terbiasa, pada aspek money dana yang sudah dialokasikan, aspek material perkembangan RME lebih baik, beberapa fitur yang belum terfasilitasi dan sistem jaringan kurang stabil, aspek machine dilengkapi dengan hardware yang ter-upgrade, aspek method RME sudah terintegrasi dan belum tersedia SPO, dan masalah pada jaringan yang menjadi hasil prioritas masalah. Kesimpulan dari penelitian ini yaitu terdapat beberapa faktor pendukung pada 5 unsur manajemen, masih terdapat faktor penghambat yang ditemukan pada man, material, method dalam penggunaan RME dan hasil dari metode USG. Saran dari penelitian ini adalah melakukan perhitungan beban kerja, peningkatan kualitas SDM dan sistem jaringan, pembuatan SPO, dan memperbaiki masalah yang menjadi hasil prioritas masalah.
Penguatan Literasi Digital Kesehatan Berbasis Nilai Islam pada Remaja Perempuan Wahyuni, Titin; Aisatus Saadah, Alfina; Wilda Faida, Eka; Fadhillatul Lailia, Salsabilla; Ilmiyah Rosyiari, Ahniyatul
Al-Khidmah Jurnal Pengabdian Masyarakat Vol. 5 No. 2 (2025): MEI-AGUSTUS
Publisher : Institute for Research and Community Service (LPPM) of the Islamic University of Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.56013/jak.v5i2.4147

Abstract

The digital transformation within the healthcare sector necessitates an elevation in digital health literacy, particularly among boarding school adolescents who are susceptible to the perils of inaccurate health information. This community service initiative sought to enhance the digital health literacy of students at Al-Rifa’e Islamic Senior High School through an educational framework that amalgamates technology, health content, and Islamic values. The methodologies employed encompassed participatory lectures, contextual discussions, and a questionnaire-based evaluation composed of five fundamental indicators. Results indicated that 88% of participants attained a high level of literacy, 8% demonstrated moderate proficiency, and 4% exhibited low literacy. A remarkable 96.15% were adept at identifying non-credible sources of health information, while 92.31% were capable of determining appropriate responses when confronted with dubious health content. Nevertheless, 19.23% of participants still encountered difficulties in discerning health-related hoaxes, highlighting a significant challenge within the learning continuum. The findings suggest that, despite elevated levels of digital literacy, the competencies associated with evaluation and decision-making remain inadequately developed. The incorporation of Islamic values, such as the principles of tabligh (conveying truth) and tabayyun (verification), proved instrumental in reinforcing students’ comprehension of digital information ethics. This program exemplifies that contextual digital health education, interwoven with religious and cultural values, can effectively cultivate a generation of youth who are both physically healthy and digitally discerning.
Pendampingan Perhitungan Efisiensi Penggunaan Tempat Tidur Berdasarkan Metode Grafik Barber Johnson Faida, Eka Wilda; Saadah, Alfina Aisatus; Intania, Agnestasya; Syahputra, Al Fadin Riady; Veryanti, Fanesa; Amalia, Rizka; Ohoiwutun, Tracy Cathleen
Jurnal Pengabdian Masyarakat Indonesia Vol 5 No 3 (2025): JPMI - Juni 2025
Publisher : CV Infinite Corporation

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52436/1.jpmi.3536

Abstract

Mutu pelayanan rumah sakit dapat ditentukan dari tertib administrasi, salah satunya adalah pengelolaan dan pelaporan rekam medis. RS DKT belum memenuhi data pelaporan rekam medis yang diolah dengan baik, padahal ini dapat menjadi sumber informasi yang dibutuhkan oleh rumah sakit. Salah satunya berupa nilai statistik penggunaan tempat tidur yang dapat diperolah dari data rekam medis berupa sensus harian. Pengabdian masyarakat ini dilakukan dengan metode perhitungan berdasarkan rumus dan grafik barber johnson. Tahapan yang dilakukan adalah dengan mengambil data sekunder yang mencakup angka penggunaan tempat tidur, hari perawatan, pasien keluar (hidup dan mati), lama dirawat. Hasil yang diperoleh adalah BOR sebesar 48,4%; BTO 5,16; ALOS 2,30 dan TOI 2,72. Daerah yang efisien berada pada titik TOI dengan standar 1-3, sedangkan daerah yang tidak efisien berada pada titik BOR, ALOS, BTO. Sehingga diperlukan upaya untuk mencapai nilai yang dapat memenuhi standar agar tidak menimbulkan kerugian bagi pihak RS pada aspek BOR, ALOS, dan BTO. Hal ini sangat berarti sebagai pengambilan keputusan tingkat efisiensi mutu pelayanan rawat inap
Evaluation Of The Implementation Of Electronic Medical Records Using The Hot-fit Method In A Public Health Center In East Surabaya Saadah, Alfina Aisatus; Wahyuni, Titin; Faida, Eka Wilda; Sutha, Diah Wijayanti; Masyfufah, Lilis
International Journal of Health and Information System Vol. 3 No. 1 (2025): May
Publisher : Indonesian Journal Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.47134/ijhis.v3i1.64

Abstract

The rapid development of information technology that has spread to various sectors of life including health can result in the development of a computer-based medical record system. Computer-based medical records or better known as EMR (Electronic Medical Record) have been used in various hospitals in the world as a complement or replacement for paper-based health records so that they can facilitate the process of managing, accessing, and distributing data or information. Based on the results of brief interviews with health workers working in health centers, it turns out that medical records for obstetric cases are still hybrid. The purpose of this study was to implement the application of Electronic Medical Records using the Hot-Fit method in East Surabaya Health Centers Indonesia. The research method used is descriptive research using a questionnaire sheet as a research instrument. The results of the study obtained data that the application of Electronic Medical Records in East Surabaya Health Centers from system quality, information quality, service quality, system use, organizational structure, facility conditions, and net benefits were categorized as good while for user satisfaction it was suggested to be satisfied and support was suggested to be supportive. So it can be concluded that the application of EMR was given well. Suggestions for the Health Center are the need to improve the system and network, the need to complete the information in the EMR in detail, the need to provide training to health workers in the use of EMR, and the need for socialization by superiors regarding the policy on the use of EMR.
Perancangan Standar Prosedur Operasional Pelepasan Informasi Rekam Medis di RSU Gotong Royong Surabaya Masyfufah, Lilis; Pangestu, Raden Bagus Mochammad Tahta; Saadah, Alfina Aisatus; Erica, Resty Nadia Bella
Indonesian of Health Information Management Journal (INOHIM) Vol 13, No 1 (2025): INOHIM
Publisher : Lembaga Penerbitan Universitas Esa Unggul

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.47007/inohim.v13i1.581

Abstract

AbstractThe development of Standard Operating Procedures (SOP) for each staff activity is essential to ensure patient safety, improve service quality, and prevent malpractice claims. SOPs serve as control tools for both clinical and administrative services provided to patients. Gotong Royong General Hospital has not yet established an SOP for the release of medical information, resulting in unstandardized procedures, particularly regarding processing time and fees charged to patients. This study aimed to design an SOP for the release of medical information at the hospital. A descriptive qualitative approach was applied, using questionnaires for data collection, followed by confirmation with the respondents. The study was conducted in the Medical Records Unit of Gotong Royong General Hospital during April–May 2024. The object of this study was the SOP draft, while the subjects were medical records staff involved in releasing patient information. Data obtained from the questionnaires were analyzed and presented narratively. The results showed that the proposed SOP included time limits for processing requests, official payment through receipts recorded in the hospital information system, the use of a stamped authorization letter, and a clear flow of information release for patients. The hospital is advised to consider implementing the SOP, as it has been adjusted to suit the operational context. Socialization efforts are also needed to inform patients through official media such as banners.Keywords: SOP, medical information, medical records, service quality, socialization AbstrakPenyusunan Standar Prosedur Operasional (SPO) bagi setiap tindakan petugas merupakan langkah penting dalam menjaga keselamatan pasien, meningkatkan mutu pelayanan, serta menghindari risiko malpraktik. SPO berfungsi sebagai alat kendali terhadap layanan yang diberikan, baik layanan kesehatan maupun administrasi. Rumah Sakit Umum Gotong Royong belum memiliki SPO pelepasan informasi medis, sehingga pelaksanaannya belum terstandar, khususnya terkait waktu penyelesaian dan biaya yang dibebankan kepada pasien. Penelitian ini bertujuan untuk merancang SPO pelepasan informasi medis di rumah sakit tersebut. Penelitian menggunakan pendekatan deskriptif kualitatif, dengan pengumpulan data melalui penyebaran kuesioner dan proses konfirmasi hasil kepada responden. Penelitian dilakukan di Unit Rekam Medis Rumah Sakit Umum Gotong Royong pada April–Mei 2024. Objek penelitian adalah rancangan SPO, sedangkan subjeknya adalah petugas rekam medis yang terlibat dalam pelepasan informasi medis pasien. Data hasil kuesioner dikaji dan disajikan dalam bentuk narasi. Hasil penelitian menunjukkan bahwa rancangan SPO yang disusun telah mencakup batasan waktu proses pelepasan informasi, sistem pembayaran resmi melalui nota tercatat di SIMRS, penggunaan surat kuasa bermaterai, serta alur pelepasan informasi yang jelas bagi pasien. Rumah Sakit Umum Gotong Royong disarankan untuk mempertimbangkan implementasi SPO tersebut, karena telah disesuaikan dengan kondisi di lapangan. SPO ini juga perlu disosialisasikan kepada pasien melalui media resmi seperti banner.Kata kunci: SPO, informasi medis, rekam medis, pelayanan, sosialisasi