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All Journal Intan Husada : Jurnal Ilmiah Keperawatan Jurnal Kesehatan Pengabdian Masyarakat Jurnal Health Information Management and Medical Record Health Educational Laboratory
Nita Budiyanti
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Dentistry Education Health Professions Library & Information Science Medicine & Pharmacology Neuroscience Nursing Public Health

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TINJAUAN LITERATUR PERBEDAAN ICD-10 DAN ICD-11 : LITERATURE REVIEW THE DIFFERENCES OF ICD-10 AND ICD-11 Nita Budiyanti; Syifa Meilinda; Robiatul Adawiyah; Sandhy Fauzan Ramdansyah
Intan Husada : Jurnal Ilmiah Keperawatan Vol. 11 No. 02 (2023): Vol. 11 No.2 , Juli 2023
Publisher : Politeknik Insan Husada Surakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52236/ih.v11i2.269

Abstract

Pendahuluan. ICD merupakan standar internasional untuk pencatatan kesehatan dan statistik penyakit baik pada tingkat primer, sekunder maupun tersier. Begitu banyak perkembangan penyakit dari waktu ke waktu yang membuat ICD terus menerus mengalami perubahan untuk menyesuaiakan setiap penyakit baru yang muncul dengan kode diagnosis penyakit tersebut. Di Indonesia, saat ini yang digunakan untuk mengkode diagnosis penyakit adalah ICD-10. Pada ICD-10 masih banyak kekurangan baik dari segi penyakit ataupun proses pengkodean yang menurut banyak orang sudah sangat ketinggalan zaman di era elektronik ini. Maka dari itu WHO telah merancang revisi terbaru dari ICD yaitu ICD-11. Perbedaan antara ICD-10 dan ICD-11 terlihat sangat signifikan. Pada struktur dasar antara ICD-10 dan ICD-11 memiliki berbagai perbedaan Tujuan dalam penelitian ini adalah untuk mengetahui perbedaan struktur antara ICD-10 dan ICD-11 Metode : Penelitian ini menggunakan desain penelitian literature review Hasil : Penelitian ini menunjukan adanya perbedaan struktur dasar antara ICD-10 dan ICD-11 Kesimpulan : Berdasarkan literature review ini maka dapat disimpulkan bahwa ICD-10 dan ICD-11 memiliki perbedaan struktur dasar
Perancangan Desain User Interface Formulir Serah Terima Pre & Post Operasi Elektronik dengan Metode UCD Salma Putri Rismayanti; Anton Kristijono; Nita Budiyanti
Journal of Health Information Management and Medical Record Vol. 1 No. 2 (2025): Vol 1. No 2 ( Desember ) 2025
Publisher : Poltekkes Kemenkes Yogyakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.29238/himmr.v2i1.3103

Abstract

Healthcare facilities are required to implement Electronic Medical Records to achieve integrated medical record management. RS TK III 04.06.03 Dr. Soetarto Yogyakarta has implemented EMR, but the pre and post operative handover forms used to transfer data between treatment rooms still use manual forms, which slow down the process of searching for patient data. This study aims to design a user interface for electronic pre and post operative handover forms. This is a qualitative study with a Research and Development (R&D) design that adopts the User Centered Design (UCD) method as the design method. Data collection was conducted through interviews with five health workers who use the pre and post operative handover forms and the completion of a System Usability Scale (SUS) questionnaire to evaluate the design results. This study produced a user interface design that includes a Login Page, Dashboard Page, OK Menu Page, Pre Operative Page, Post Operative Page, Print Page, and PDF of the Pre and Post Operative Handover Form Results. The evaluation results showed an average design acceptance score of 86.5, which falls within the “Acceptable” assessment criteria with a grade scale of ‘B’ and an adjective rating of “Best Imaginable”. The results of this study indicate that the user interface design of the electronic pre and post operative handover form is acceptable and accordance with user needs.
Perancangan Website INCLADIS sebagai alat bantu dalam menunjang akurasi kodefikasi penyakit sesuai ICD 10 dan ICD 11 Nita Budiyanti
Health Educational Laboratory Vol. 1 No. 2
Publisher : Poltekkes Kemenkes Yogyakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.29238/helab.v1i2.2785

Abstract

Koding klinis sebagai salah satu rangkaian dalam kegiatan pengolahan data rekam medis dan informasi kesehatan merupakan kegiatan pemberian kode dengan menggunakan huruf atau angka atau kombinasi hurud dalam angka yang mewakiliki komponen data. Koding klinis meliputi penetapan kode diagnosis dan kode tindakan berdasarkan data diagnosis utama dan diagnosis sekunder sesuai ICD-10 dan ICD-9-CM. Koding klinis memudahkan dalam penyajian informasi dalam menunjang fungsi perancanaan, manajemen dan riset di bidang kesehatan. Penelitian ini bertujuan untuk membantu PMIK khususnya coder untuk menentukan kode diagnosis yang tepat dan akurat. Metode yang digunakan yaitu ADDIE (Analysis, Design, Development & Implementation dan Evaluation), dimulai dari studi pendahuluan, perancangan dan pengujian website untuk menghasilkan website INCLADIS. Website ini dirancang untuk membantu menentukan kode ICD-10 dan ICD-11 yang tepat sesuai kata kunci pencarian diagnosa penyakit. Website yang dirancang akan meningkatkan akurasi kode dan tercapainya kemudahan pencarian kode. Website yang dirancang dinilai lebih efisien untuk diterapkan, karena dengan web segala pencarian kode penyakit dapat lebih cepat ditemukan dan akses yang lebih mudah.
Optimalisasi Mutu Pelayanan Rekam Medis melalui Edukasi, Pelatihan, Pendampingan, dan Implementasi Sistem Informasi Manajemen Klinik bagi Petugas PMB Jurusan Kebidanan Poltekkes Kemenkes Yogyakarta : Optimizing Medical Record Service Quality through Education, Training, Mentoring, and Implementation of a Clinic Management Information System for Staff at the Independent Midwifery Practice (PMB), Department of Midwifery, Poltekkes Kemenkes Yogyakarta Arif Nugroho Triutomo; Nita Budiyanti; Hari Wibowo; Syarah Mazaya Fitriana
Jurnal Kesehatan Pengabdian Masyarakat (JKPM) Vol. 6 No. 2 (2025): 2
Publisher : Poltekkes Kemenkes Yogyakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.29238/jkpm.v6i2.3444

Abstract

Quality medical record services are an important component in supporting the efficiency and quality of healthcare delivery. A preliminary assessment at the Independent Midwifery Practice (PMB), Department of Midwifery, Poltekkes Kemenkes Yogyakarta, identified several problems, including the continued use of manual medical record documentation, suboptimal utilization of computers, relatively long registration service times, and limited storage capacity for medical record documents. This community service program aimed to improve staff knowledge and competency regarding Electronic Medical Records (EMR) through education, training, mentoring, and implementation of a Clinic Management Information System (SiKlik), while improving the quality of registration services. The program was conducted from March to October 2024 using a blended approach and involved 12 staff members at the Independent Midwifery Practice (PMB), Department of Midwifery, Poltekkes Kemenkes Yogyakarta. The activities included EMR education, demonstration and hands-on practice in using SiKlik, mentoring during system implementation in the registration process, and evaluation using pretest and posttest assessments. Service quality was evaluated through a satisfaction survey involving 30 patients who had received services before and after EMR implementation. The results showed that the mean staff knowledge score increased by 24 points, from 65 at pretest to 89 at posttest. All participants (100%) were able to operate the basic functions of SiKlik, and system utilization in daily services reached 100%. The implementation of SiKlik also improved registration service efficiency, with the mean service time decreasing from 35 minutes to 15 minutes. All patients (100%) reported that the service was faster, and overall patient satisfaction reached 100%. The education, training, mentoring, and implementation of SiKlik demonstrated positive outcomes in improving staff competency, service efficiency, and patient satisfaction. The implementation of a Clinic Management Information System can support the transition from manual to electronic medical records and contribute to improving the quality of services at the Independent Midwifery Practice (PMB), Department of Midwifery, Poltekkes Kemenkes Yogyakarta.
Co-Authors Anton Kristijono Arif Nugroho Triutomo Hari Wibowo Robiatul Adawiyah Salma Putri Rismayanti Sandhy Fauzan Ramdansyah Syarah Mazaya Fitriana Syifa Meilinda