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All Journal Iris Journal of Health Information Management (IJHIMa)
Sayati Mandia
Akademi Perekam dan Informasi Kesehatan (APIIKES) Iris
Computer Science & IT Decision Sciences, Operations Research & Management Health Professions Public Health Social Sciences

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ANALISIS PENGODEAN DIAGNOSA UTAMA BERDASARKAN ICD 10 DI RUMAH SAKIT UMUM DAERAH (RSUD) dr. RASIDIN PADANG Afdhal Dinil Haq; Sayati Mandia; Dewi Oktavia
Iris Journal of Health Information Management Vol 1 No 1 (2021): 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.v1i1.12

Abstract

Coding is one of the competencies of medical records which has a very important role in supporting the improvement of the quality of health services. Coding of an accurate, complete and consistent diagnosis will produce quality data. Quality of coded data is important for Health Information Management personnel because it is not only related to the quality of health services but also related to claiming costs and hospital development in the future. this was done at the Regional General Hospital dr. Rasidin Padang in January 2019. This study aims to determine the most major diagnoses based on ICD 10 at dr. Rasidin Padang in 2019. This study used a retrospective descriptive method with a quantitative approach. The research design used in this study was a descriptive cross-sectional study. The population used by all patient medical record files in January 2019 was 295 medical record files. The results of this study showed that the top five main diagnoses in January 2019 were, 18 patients with dengue haemorrhagic fever (DHF), 17 patients with Bronchopneumpnia, 14 patients with Diabetes Mellitus, 11 patients with Hyperemesis Gravidarum and 10 patients with Benign Neoplasm.
STUDI DESKRIPTIF KETIDAKLENGKAPAN DOKUMEN REKAM MEDIS RAWAT INAP PADA KASUS DEMAM Sayati Mandia
Iris Journal of Health Information Management Vol 1 No 1 (2021): 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.v1i1.8

Abstract

Dengue fever has become a global public health problem. Epidemiological measurements of the DHF burden such as incidence and prevalence are important for policy making and monitoring progress in disease control. The WHO reports that the global incidence of dengue has increased 30-fold in the past 50 years and it is estimated that between 50 and 100 million new infections occur each year, resulting in about 20,000 deaths. Medical records are filled in by doctors, nurses / midwives and medical record personnel. However, in filling out medical records, incompleteness is often found and causes inaccurate information. The research design used a retrospective analysis approach. The variables in this study are incompleteness; authentication and documentation on the patient discharge summary form. The population in this study were inpatient medical records for Dengue Hemorrhagic Fever cases at the Hospital "X" Padang City from January to December 2019 as many as 45 medical record documents (discharge summary form) for inpatients. The results showed that there was the most incomplete data in the item code ICD 10 53% followed by 57% patient address
Co-Authors Afdhal Dinil Haq Dewi Oktavia