Article Per Year (5 Year)
p-Index From 2021 - 2026
0.444
P-Index
This Author published in this journals
All Journal Infokes : Jurnal Ilmiah Rekam Medis dan Informasi Kesehatan Jurnal Adijaya Multidisiplin
Ida Aninda
Unknown Affiliation
Religion Humanities Computer Science & IT Economics, Econometrics & Finance Education Electrical & Electronics Engineering Engineering Environmental Science Health Professions Industrial & Manufacturing Engineering Languange, Linguistic, Communication & Media Mathematics Medicine & Pharmacology Nursing Public Health Social Sciences Veterinary Other

Published : 2 Documents Claim Missing Document
Claim Missing Document
Check
Articles

Found 2 Documents
Search

 1 
Implementasi Rekam Medis Elektronik Belum Menjamin Ketepatan Kode Diagnosis Kasus Gagal Ginjal Praptana; Piping Asgiani; Dewi Retno Pamungkas; Reza Iqbal Suhada; Ida Aninda
Jurnal Adijaya Multidisplin Vol 3 No 01 (2025): Jurnal Adijaya Multidisiplin (JAM)
Publisher : PT Naureen Digital Education

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

Abstract

Gagal ginjal merupakan penyakit kronis dengan angka kematian tinggi dan pembiayaan besar oleh BPJS Kesehatan. Salah satu kendala utama dalam klaim BPJS adalah ketidaktepatan kode diagnosis. Implementasi rekam medis elektronik (RME) diharapkan dapat meningkatkan akurasi kode diagnosis dengan memperbaiki keterbacaan dan kelengkapan informasi medis. Penelitian kuantitatif dengan desain studi kasus ini membandingkan ketepatan kode diagnosis sebelum dan setelah implementasi RME di RSU Mitra Paramedika. Sampel terdiri dari 400 kasus gagal ginjal, masing-masing 200 kasus sebelum dan sesudah implementasi. Ketepatan kode diagnosis sebelum implementasi RME sebesar 89% dan setelah implementasi meningkat menjadi 90%, dengan selisih hanya 1%. Ketidaktepatan kode masih terjadi akibat inkonsistensi penulisan dan pemilihan kode diagnosis. Implementasi RME belum menunjukkan perbedaan signifikan dalam meningkatkan ketepatan kode diagnosis. Diperlukan penelitian lebih lanjut untuk mengidentifikasi penyebab utama ketidaktepatan guna meningkatkan kualitas dokumentasi rekam medis.
Nurses’ Role in Completing Anamnesis Supporting Coding of External Cause Injury Diagnoses Andi karisma Nurdiyansyah; Deby Zulkarnain Rahadian Syah; Ida Aninda; Ragil Lintang Juliana; Gebi Yulanda; Piping Asgiani; Nik Azliza Nik Ariffin
Jurnal Infokes Vol 16 No 1 (2026): Jurnal Ilmiah Rekam Medis dan Informatika Kesehatan
Publisher : Universitas Duta Bangsa Surakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.47701/hy0has42

Abstract

The accuracy of ICD-10 external cause injury coding depends heavily on the completeness of anamnesis documentation, particularly information on event chronology, place of occurrence, and patient activity. Nurses, as primary healthcare professionals responsible for anamnesis documentation in the Emergency Department (ED), play a key role in supporting accurate diagnostic coding. However, incomplete documentation of external cause injury information remains a common challenge in hospital settings. This study aimed to analyze the role of nurses in ensuring the completeness of external cause injury anamnesis to support accurate diagnostic coding at Mitra Paramedika Hospital, Yogyakarta. A qualitative descriptive study with a case study approach was conducted involving 12 healthcare workers, consisting of 10 emergency nurses and 2 medical record coders. Data were collected through pre-tests, focused group discussions (FGDs), post-tests, medical record observations, and in-depth interviews. Descriptive analysis was used to assess changes in knowledge and documentation practices before and after the intervention. The results indicated that prior to the FGD, several nurses had limited understanding of the importance of documenting place of occurrence and patient activity for external cause coding. Following the FGD, all participants demonstrated adequate knowledge in the post-test. Additionally, the use of electronic medical records improved documentation readability and completeness, facilitating more accurate coding. This study concludes that nurses play a critical role in external cause injury documentation, and that educational interventions and electronic medical record implementation effectively enhance documentation quality and coding accuracy.
Co-Authors Deby Zulkarnain Rahadian Syah Dewi Retno Pamungkas Gebi Yulanda Nik Azliza Nik Ariffin Nurdiyansyah, Andi Karisma Piping Asgiani Praptana Ragil Lintang Juliana Reza Iqbal Suhada