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All Journal Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Jurnal Kesehatan Tambusai Jurnal Media Informatika Jurnal Pengabdian Masyarakat (ABDIRA) Jurnal EduHealth Jurnal ABDIMAS Budi Darma Jurnal Ilmiah Pengabdian Kepada Masyarakat Aspirasi : Publikasi Hasil Pengabdian dan Kegiatan Masyarakat Jurnal Perilaku Kesehatan Terpadu COVID-19 : Journal of Health, Medical Records and Pharmacy
Theresia Hutasoit
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Factors for Duplication of Medical Record Numbers at UPT Puskesmas Pasar Merah Simanjuntak, Marta; Lubis, Siti Permata Sari; Simanjuntak, Esraida; Hutasoit, Theresia
COVID-19 : Journal of Health, Medical Records and Pharmacy Vol. 1 No. 02 (2024): COVID-19 : Journal of Health, Medical Records and Pharmacy
Publisher : CV. Devitara

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

Abstract

Duplication of medical record numbers is a problem that often occurs in the Integrated Service Unit (UPT) of the Pasar Merah Health Center. This study aims to identify the factors that cause duplication of medical record numbers at UPT Puskesmas Pasar Merah. This research method uses a qualitative approach with in-depth interviews with medical administration officers, patient registration officers, and medical personnel directly involved in managing medical record numbers. In addition, observations were also made to understand the process of managing medical record numbers at UPT Puskesmas Pasar Merah.The results showed that the factors of duplication of medical record numbers involved several aspects, including lack of training of medical administrative officers in database management, recording systems that were not effectively integrated between service units, and the unavailability of medical record number validation when registering new patients. In addition, human error factors such as writing and recording errors are also the cause of duplication of medical record numbers. The recommendations of this study include improving training for medical administrative officers in database management, developing an integrated recording system, implementing direct validation of medical record numbers during patient registration, and strengthening supervision mechanisms to prevent human error in managing medical record numbers. This research is expected to contribute to the improvement of the medical record management system at UPT Puskesmas Pasar Merah, so as to reduce the incidence of duplication of medical record numbers and increase efficiency and accuracy in managing patient data.
FAKTOR – FAKTOR PENENTU KETEPATAN KODE DIAGNOSA CHRONIC KIDNEY DISEASE (CKD) PASIEN RAWAT INAP DI RUMAH SAKIT UMUM IMELDA PEKERJA INDONESIA TAHUN 2023 Hutasoit, Theresia; Sitorus, Mei Sryendang; Erlindai, Erlindai; Christy, Johanna; Syahputri, Melati Adila
Jurnal Kesehatan Tambusai Vol. 5 No. 4 (2024): DESEMBER 2024
Publisher : Universitas Pahlawan Tuanku Tambusai

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31004/jkt.v5i4.37033

Abstract

Ketepatan dalam pemberian kode diagnosis merupakan hal yang harus diperhatikan oleh perekam medis khususnya coder. Salah satu kompetensi yang harus dimiliki oleh seorang perekam medis adalah kodefikasi penyakit dan tindakan medis. Ketepatan kode diagnosis pada penyakit CKD sangat dipengaruhi oleh kelengkapan rekam medis. Berdasarkan hasil survei awal yang dilakukan terdapat 37 rekam medis yang lengkap yaitu (60,65%) kode diagnosis pada penyakit CKD sesuai dengan ICD-10 dan terdapat 24 rekam medis yang tidak lengkap yaitu (39,34%).  Bertujuan untuk mengetahui apa saja faktor penentu ketepatan kode diagnosa CKD pada pasien rawat inap. Jenis penelitian ini adalah deksriptif dengan pendekatan kualitatif yaitu mendeksripsikan dan menggambarkan secara rinci permasalahan yang diteliti dengan mempelajari semaksimal mungkin suatu kejadian. Populasinya yaitu petugas koding rawat inap yang berjumlah 5 orang. Jumlah sampel yang digunakan sebanyak 31 rekam medis CKD rawat inap. Cara pengumpulan data dengan menggunakan observasi dan wawancara. Hasil yang diperoleh dari penelitian ini, dari 31 rekam medis CKD rawat inap terdapat 12 rekam medis yang memiliki kode kurang tepat (38,70%) dan 19 rekam medis yang tepat (61,30%). Faktor penentu ketepatan kode seperti Man kurang telitinya petugas dalam kelengkapan pengisian berkas rekam medis, Material ketidaklengkapan pengisian dan tidak ditulisnya diagnosis penyakit, Method masih ditemukannya petugas yang kurang memahami SPO, dan Machine gangguan jaringan komputer. Berdasarkan hasil penelitian, diharapakan untuk diberikannya pelatihan coding terkait tatacara mengkode yang tepat sesuai panduan SPO, ICD-10 dan perlu ditingkatkan komunikasi antar petugas coding dan dokter yang memberi diagnosis serta melengkapi bagian pemeriksaan penunjang agar dapat menghasilkan kode yang tepat.
Analysis of the Influence of Workload-Based Staff Requirements on the Outpatients Coding Section of BPJS with WISN Method Hutasoit, Theresia; Devi Fitriani, Arifah; Begum Suroyo, Razia
Jurnal Perilaku Kesehatan Terpadu Vol. 2 No. 1 (2023): Jurnal Perilaku Kesehatan Terpadu (Jupiter)
Publisher : Hasanuddin Medan

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.61963/jpkt.v1i2.19

Abstract

Professional staffs in the coding section have an important role in doing activities in the hospital. The coding section officer is responsible for documents claimed by BPJS Health and is responsible for the claim. This study aims to determine the estimated number of workers in the outpatients coding section of BPJS needed based on the WISN (Workload Indicator Staff Need) method and to determine the competence and workload of coding officers. This is qualitative research using work time and measurements the WISN (Workload Indicator Staff Need) method. Retrieval of data from this study used observations, interviews and documentation studies. The results of this study were in the form of an estimate of the number of outpatient coding officers for BPJS patients needed to do job descriptions properly so that maximum work results were achieved. The results of the workload calculation using the WISN (Workload Indicator Staff Need) method, the minimum number of workers required was two officers, where currently there were two outpatient coding officers, so it was advisable to add two people, including one doctor as verification and one more person scanning the medical record. These additions should consider the competence of personnel in their fields so that they are able to perform well in accordance with existing standards.
Tahapan Audit Koding Rekam Medis dengan Menggunakan Analisa Kualitatif pada Pasien Rawat Inap di RS Khusus Mata SMEC Tahun 2025 Hutasoit, Theresia; Daeli, Cosmas Samuel; Sitorus, Mei Sryendang; Simanjuntak, Marta; Rotonga, Zulham Andi; Hasibuan, Ali Sabela; Liem, John Barker; Valentina, Valentina; Zulfahmi, Zulfahmi; Sitompul, Osayku Inesa
Jurnal Pengabdian Masyarakat (ABDIRA) Vol 6, No 1 (2026): Abdira, Januari
Publisher : Universitas Pahlawan Tuanku Tambusai

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31004/abdira.v6i1.1278

Abstract

Medical records are crucial documents that document all healthcare services. Accurate coding forms the basis for claims billing, research, and clinical decision-making. However, incomplete and inaccurate recording often presents obstacles, necessitating a coding audit. This Community Service project aimed to identify the stages of a coding audit using qualitative analysis of inpatients. The audit was conducted on four cases. The analysis used six review components: consistency of diagnosis and treatment, clinical recording, treatment justification, informed consent, documentation practices, and potential for compensation. The results of the medical record coding audit indicated that most components were consistent and met standards, including diagnosis, treatment, clinical recording, and completion of informed consent. However, inconsistencies were still found in instructions for discontinuing or replacing medications. There were no incidents that could potentially result in compensation. However, improvements are still needed in the documentation of instructions for discontinuing or replacing medications. The results emphasize the importance of ongoing socialization and monitoring to optimize the quality of medical records.
Hubungan Kelengkapan Resume Medis Rawat Inap BPJS Dengan Persetujuan Klaim BPJS Di RS Advent Medan 2024 Christy, Johanna; Simanjuntak, Marta; Hutasoit, Theresia; Erlindai, Erlindai; Lase, Siji Valentine
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Vol. 11 No. 1 (2026): 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.v11i1.1891

Abstract

Minister of Health Regulation Number 269/MENKES/PER/III/2008, states that a discharge summary (resume) is carried out by a doctor or dentist on a patient. BPJS claims are submissions of costs incurred by BPJS participant patients from the hospital to BPJS Kesehatan, carried out every month and billed to BPJS Kesehatan. The purpose of this study was to determine the relationship between the completeness of the inpatient medical resume and the approval of BPJS claims at Medan Adventist Hospital. This study uses a quantitative descriptive research method with a cross-sectional research design where data collection was carried out through interviews and checklists carried out in June 2024. be concluded that most BPJS claim applications were not approved Based on the results of the study, the completeness of medical resumes in 50 incomplete and unapproved files amounted to 31 files with a percentage of 38% while those that were complete and approved amounted to 19 files with a percentage of 62%. From the results of the study, it can due to the large number of incomplete medical resumes. Suggestions for healthcare workers are required to understand and implement Standard Operating Procedures (SOPs) for completing medical resumes in accordance with applicable regulations, both hospital regulations and regulations contained in legislation. Improve healthcare workers' discipline in completing medical resumes by recording any missing components of the medical resume, then conducting a joint evaluation within a certain timeframe, especially for those directly involved in recording medical resumes and the BPJS claims section.
Analisis Kesiapan Implementasi Rekam Medis Elektronik Menggunakan Pendekatan DOQ-IT Di Klinik Pratama Wulandari Tahun 2025 Daeli, Cosmas Samuel; Sitorus, Mei Sryendang; Hutasoit, Theresia; Sitompul, Osayku Inesa
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Vol. 11 No. 1 (2026): 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.v11i1.2185

Abstract

The implementation of Electronic Medical Records (EMR) is a mandatory requirement for all healthcare facilities in Indonesia to improve service quality, accelerate patient information access, and support data interoperability through a national platform. The purpose of this study was to analyze the readiness for the implementation of EMR using the DOQ-IT approach by assessing the influence of human resources, organizational work culture, governance and leadership, and IT infrastructure in healthcare services. This research used a descriptive quantitative method with total sampling of 16 respondents from various healthcare professions at Wulandari Primary Clinic. Data were collected using the DOQ-IT questionnaire consisting of multiple-choice questions. The analysis results showed that the overall assessment score was 74.44, which falls into Category II (fairly ready). This indicates that while there are strong capabilities in certain readiness components, weaknesses remain in others. Based on the four readiness aspects, only IT Infrastructure had the lowest classification score (2.50). The most prepared aspect was Human Resources (2.86), followed by Organizational Culture (2.67), and Governance and Leadership (2.58). Recomendation that need to be considered: Improve IT infrastructure, conduct regular training for staff, strengthen the role of leaders, conduct regular evaluations so that RME runs effectively
Co-Authors Begum Suroyo, Razia Callis Dewi Pancarani Christy, Johanna Cosmas Samuel Daeli Erlindai Erlindai Erlindai, Erlindai Esraida Simanjuntak Fitri Yani Fitriani, Arifah Devi Gusla Nengsih, Yeyi Harefa, Calvin Natana Eli Hulu, Mery Windhy Kristina Lase , Kristalina Lase, Siji Valentine Liem, John Barker Lubis, Siti Permata Sari Mei Sryendang Sitorus Mei Sryendang Sitorus Putri Metha Amelya Lumbantoruan Rotonga, Zulham Andi Sabela Hasibuan, Ali Sarlina , Eti Sihite , Geovani Arta Sihite, Geovani Arta Simanjuntak, Esraida Simanjuntak, Marta Sitompul, Osayku Inesa Sitorus, Mei Sryendang Syahputri, Melati Adila Tanjung, Hizraini Valentina Valentina, Valentina Zulfahmi Zulfahmi