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All Journal J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Iris Journal of Health Information Management (IJHIMa)
Nurul Fitri Khumaira
Apikes Iris
Computer Science & IT Decision Sciences, Operations Research & Management Health Professions Public Health Social Sciences

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Analisis Persiapan Implementasi Rekam Medis Elektronik Di Rumah Sakit Islam Siti Rahmah Padang Dion Permadi; Annisa Wahyuni; Yuli Mardi; Nurul Fitri Khumaira
Iris Journal of Health Information Management Vol 3 No 2 (2023): Iris Journal of Health Information Management
Publisher : AKADEMI PEREKAM DAN INFORMASI KESEHATAN (APIKES) IRIS PADANG

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.61723/ijhima.v3i2.104

Abstract

Siti Rahmah Islamic Hospital, Padang is a type A private hospital located in Padang in preparation for implementing electronic medical records and also improving the quality of human resources and health services. This study aims to determine the preparation for implementing electronic medical records at RSI Siti Rahmah Padang. The research used was qualitative using interviews, the method of taking the subject of informants using purposive sampling with several informants 5 people and data collection using analysis techniques by interviewing informants. The results of the research that has been carried out to prepare for the implementation of electronic medical records at RSI Siti Rahmah Padang have been running from the start of the enactment of the PMK Law 24 of 2022 by increasing human resources through training on electronic medical records and providing facilities and infrastructure to support the successful implementation of medical records. electronic medical from the aspect of technology, and information technology (IT). From this research, it can be concluded that preparations for the implementation of electronic medical records have started with human resources increasing insight into medical record officers and medical staff in other healthcare facilities.
A ANALYSIS OF PREPARATIONS FOR THE IMPLEMENTATION OF ELECTRONIC MEDICAL RECORDS AT RSJ PROF HB SAANIN PADANG USING THE DOQ-IT METHOD Nurul Fitri Khumaira; Annisa Wahyuni; Yuli Mardi
Iris Journal of Health Information Management Vol 3 No 2 (2023): Iris Journal of Health Information Management
Publisher : AKADEMI PEREKAM DAN INFORMASI KESEHATAN (APIKES) IRIS PADANG

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.61723/ijhima.v3i2.109

Abstract

According to PMK No. 24 of 2022, a medical record is a document containing data on patient identity, examination, treatment, actions, and other services that have been provided to the patient. Through this policy, health service facilities are required to run an electronic patient medical history recording system. The transition process is carried out until no later than 31 December 2023. This type of research uses quantitative methods. Quantitative research methods are used to determine the picture of hospital readiness. The method used to analyze hospital readiness is DOQ-IT with indicators of organizational culture readiness, governance and leadership readiness, human resource readiness, and infrastructure readiness. Based on the results of the research that has been carried out, information can be obtained that in the aspects of human resources, organizational work culture, leadership governance, and infrastructure as a whole can be seen from the answers of 18 ready respondents (46.06%) and very ready as many as 20 people (49.87%) then with the respondent's answer not ready as many as 1 person (2.22%) the answer is very unprepared as many as 1 person (0.35%) and for the answer hesitant as many as 1 person (1.44%), it is confirmed from the informant that the preparation for the implementation of electronic medical records is ready to be implemented.
The Hubungan Kelengkapan Rekam Medis Terhadap Akurasi Pengkodean ICD-10 dan ICD-9 Annisa Wahyuni; Nurul Fitri Khumaira; Siska Siska
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 5 No 3 (2024): June
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v5i3.4947

Abstract

The completeness of medical records is an important factor that affects the quality of data and coding accuracy. Based on the initial survey at the 'Aisyiyah General Hospital, found from 20 medical records still 75% completeness of filling in the incoming and outgoing summary sheets, the absence of anamnesis and diagnosis results, and 60% completeness of the doctor's item recording component. The purpose of this study was to find out the relationship between the completeness of medical record documents with the accuracy of the ICD-10 and ICD-9 coding. This study used descriptive and inferential quantitative methods with a population of 638 documents, and the number of samples of 84 files uses simple random techniques. The frequency of filling in the medical record document is incomplete 89.3%, the duration of the ICD-10 code is 26.2% and the ICD-9 CM was 32.2%. The analysis results showed that there was no significant relationship between the completeness of medical record documents and the accuracy of the ICD-10 and ICD-9 coding (P-Value > 0.05). Complete medical records tend to have more accurate coding, while incomplete medical records often cause errors in coding. The importance of maintaining the completeness of medical records to increase coding accuracy has a positive impact on the management of health data, clinical decision-making, and health insurance claims. Efforts to increase the completeness of medical records, such as training in medical staff and effective electronic system implementation, are recommended to ensure better coding quality.
Co-Authors Annisa Wahyuni Annisa Wahyuni Dion Permadi Siska Siska Yuli Mardi Yuli Mardi