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TINJAUAN DESAIN FORMULIR REKAM MEDIS RAWAT INAP PELAYANAN BEDAH DI RUMAH SAKIT KHUSUS BEDAH RAWAMANGUN Indah Kristina; Dede Maysaroh
MEDICORDHIF Jurnal Rekam Medis Vol 10 No 1 (2023): MEDICORDHIF Jurnal Rekam Medis
Publisher : APIKES Bhumi Husada Jakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (11.033 KB) | DOI: 10.59300/mjrm.v10i1.90

Abstract

ABSTRACT This research was conducted to identify SOP (standart operasional procedure) governing the design of medical record forms, analyze components reviewed from anatomical, physical and content aspects contained in surgical hospitalization forms, and identify design constraints and use of surgical hospitalization forms. The research method used is a quantitative descriptive analysis method with percentage results to obtain an overview of the design review of surgical hospitalization forms at Rawamangun Special Hospital of Surgery East Jakarta. The data collection method is carried out by direct observation using checks and interviews to respondents using interview guidelines and informed consent interviews. The results of this study showed that the hospital already has a policy related to form design, namely SPO (standard operational procedure) form renewal. Guidelines for filling out medical records files and form design policies in the medical record service guidelines, fulfillment of anatomical, physical and fill aspects on surgical hospitalization forms have not been completed 100% fulfilled, from the average physical aspect of 79.20%, anatomical aspects 47.42% and content aspects 95.7%. For design constraints, the lack of knowledge about the rules of form design according to existing policies in hospitals for usage constraints is not too many obstacles, it's just that the instructions are diformed that are less clear. In conclusion, the hospital already has policies related to the design of medical record forms both SPO and guidelines governing aspects of form design, but there are still unmet aspects of the design of surgical hospitalization forms at Rawamangun Surgical Special Hospital. Existing forms do not meet the rules of the form design policy that has been created by the hospital. Bibliography: 14(2012 – 2021) Keywords: Review, Design, Form, SOP.
TINJAUAN KELENGKAPAN PENGISIAN FORMULIR PERSETUJUAN TINDAKAN KEDOKTERAN SECTIO CAESAREA DI PRIMAYA EVASARI HOSPITAL Indah Kristina; Muhamad Abdul Fatah
MEDICORDHIF Jurnal Rekam Medis Vol 10 No 1 (2023): MEDICORDHIF Jurnal Rekam Medis
Publisher : APIKES Bhumi Husada Jakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (11.033 KB) | DOI: 10.59300/mjrm.v10i1.91

Abstract

ABSTRACT Approval for medical action is the approval given by the patient or his closest family after receiving a complete explanation regarding the medical or dental action to be performed on the patient. recording of approval for medical action as evidence that the patient agrees to the action to be taken and must be filled in completely because it can be used as legal evidence in the event of a claim from the patient. This study was conducted to identify standard operating procedures (SOPs) for completing the approval form for sectio caesarea medical action, identify the completeness of filling out the approval form for planned and emergency sectio caesarea medical actions, identify the factors causing incomplete completion of the consent form for medical action at Primaya Evasari Hospital. The research method used is descriptive method with a sample of 103 medical treatment consent forms. The results of the study, standard operating procedures for filling out approval forms for medical actions are available, completeness of filling out approval forms for medical actions 64% are completely filled out and 36% are incomplete, factors that cause incomplete filling of consent forms for medical actions include not knowing that standard operating procedures are available for filling 20% , did not receive socialization of filling out the 20% form, did not understand how to revise 60%, the impact of incomplete filling in the consent form Medical action is that it cannot make valid evidence in the event of a lawsuit. Keywords: completeness of filling out the consent form for medical action. 
TINJAUAN KETIDAKTEPATAN KODE DIAGNOSIS PENYAKIT DAN TINDAKAN MEDIS KASUS GIGI DAN MULUT RAWAT JALAN DI RUMAH SAKIT X JAKARTA Indah Kristina; Rani Rahmayanti
MEDICORDHIF Jurnal Rekam Medis Vol 10 No 2 (2023): MEDICORDHIF Jurnal Rekam Medis
Publisher : APIKES Bhumi Husada Jakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.59300/mjrm.v10i2.101

Abstract

ABSTRACT This research is to identify the Standard Operating Procedure (SPO) coding, calculate the number of inaccuracies in the disease diagnosis code and medical treatment in outpatient dental and oral cases and the factors causing the code inaccuracy. The research method used is descriptive analysis research method with data collection techniques by observation and interviews. The population of this study amounted to 2141 medical records, especially in the clinical summary in November 2021-April 2022, samples taken as many as 96 clinical summaries. The results of the study: the SOP has been carried out but is in the process of being revised and not yet perfect, the inaccuracy rate of the incorrect disease diagnosis code is 29 (30.20%) and the correct one is 67 (69.80%), while the inaccurate medical code of action is 18 (18.75%) and the correct one is 78 (81.25%), Causing factors: SOP steps are not perfect, the competence of coding officers is still lacking, identification of medical diagnoses and actions is less detailed, and lack of evaluation, especially periodic coding audits. Bibliography : 17 (2006 – 2020) Keywords : Code, Diagnosis, Medical Action, Clinical Summary, Dental, Oral