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All Journal Jurnal Kesehatan Komunitas JUBIDA-Jurnal Kebidanan Journal of Sustainable Community Service
Triani, Melfina
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Humanities Economics, Econometrics & Finance Education Health Professions Industrial & Manufacturing Engineering Nursing Public Health Social Sciences

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SOCIALIZATION OF THE ACCURACY REGARDING THE CALCULATION OF RECAPITULATION FOR INPATIENTS BASED ON AGE, DISEASE AND GENDER AT CHARIS MEDIKA HOSPITAL Putri, Riza Suci Ernaman; Putri, Widya; Triani, Melfina
JOURNAL OF SUSTAINABLE COMMUNITY SERVICE Vol. 4 No. 4 (2024): SEPTEMBER
Publisher : Transpublika Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.55047/jscs.v4i4.732

Abstract

A hospital is one of the subsystems of health services that organizes two types of services for the community, namely health services and administrative services. Health services include medical services, medical rehabilitation and care services. Every health service or hospital should be proud if every patient who visits continues to increase, the increase in patients can be seen from the changes in the existing graph of the number of patient visits. The number of patient visits that continues to increase greatly affects the smooth running of each health service, because patients who often visit have high trust in the health service they visit. The number of visits for inpatients for postpartum care based on age, disease, and gender is 115 visits, the number of visits for care patients based on age, disease, and gender is 37 visits. It can be concluded that medical records officers should write down inpatient data completely and clearly in the register book, good communication between medical records officers and doctors treating patients should be good so that the diagnosis written by the doctor in the patient's medical record is easy to read.
ANALISIS KUANTITATIF DAN KUALITATIF PADA DOKUMEN REKAM MEDIS RAWAT INAP PERIODE JANUARI 2025 DI RSUD EMBUNG FATIMAH BATAM Putri, Widya; Ernaman Putri, Riza Suci; Triani, Melfina
JUBIDA- Jurnal Kebidanan Vol. 4 No. 1 (2025)
Publisher : Yayasan Rahmatan Fidunya Wal Akhirah

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.58794/jubida.v4i1.1491

Abstract

Rekam medis yang lengkap dan akurat sangat penting untuk menjamin mutu pelayanan kesehatan dan perlindungan hukum di rumah sakit. Penelitian ini bertujuan untuk menganalisis kelengkapan dokumen rekam medis secara kuantitatif dan kualitatif. Penelitian ini menggunakan pendekatan deskriptif kuantitatif dan kualitatif terhadap 12 dokumen rekam medis rawat inap dengan riwayat operasi dari total 53 dokumen di ruang rawat inap anak RSUD Embung Fatimah Batam. Teknik pengambilan sampel yang digunakan adalah purposive sampling, dengan kriteria dokumen rekam medis rawat inap pasien anak yang menjalani operasi. Instrumen penelitian menggunakan daftar periksa (checklist) yang dikembangkan berdasarkan standar kelengkapan rekam medis. Analisis kuantitatif mencakup empat komponen utama: identifikasi, laporan penting, autentikasi, dan pendokumentasian yang benar. Analisis kualitatif meninjau kekonsistenan isi dan cara pencatatan untuk memastikan kelengkapan dan keakuratan informasi. Hasil analisis kuantitatif menunjukkan kelengkapan 100% pada komponen identifikasi, autentikasi, dan sebagian besar laporan penting, namun terdapat ketidaklengkapan 8% pada laporan anestesi dan asesmen keperawatan anak. Analisis kualitatif menunjukkan kekonsistenan 100% pada hampir semua aspek, kecuali pada praktik pencatatan (92%) karena ketidaktelitian petugas. disarankan agar pengisian berkas rekam medis sebaiknya dilakukan secara real-time untuk meningkatkan akurasi dan efisiensi pencatatan.
Klasifikasi dan Kodefikasi Diagnosis Infeksi, Parasit, Neoplasma, Cedera, Keracunan, dan Penyebab Luar di RSUD Embung Fatimah Ernaman Putri, Riza Suci; Putri, Widya; Triani, Melfina
Jurnal Kesehatan Komunitas Vol 11 No 2 (2025): Jurnal Kesehatan Komunitas
Publisher : LPPM Hang Tuah Pekanbaru

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25311/keskom.Vol11.Iss2.2263

Abstract

Medical records play an important role in supporting quality health services, one of which is through accurate diagnosis classification and coding. This study aims to analyze the classification and coding of diagnoses of infection, parasites, neoplasms, injuries, poisoning, and external causes for the period of January 2025 at Embung Fatimah Hospital. The type of research used is quantitative research with a descriptive observational research design., conducted on January 20 - February 5, 2025. Data collection techniques were carried out through direct observation and documentation studies from the medical records unit. The number of samples analyzed was 40 out of 391 outpatient diagnosis data. The analysis technique used was descriptive analysis to identify and classify diagnoses. Of the 391 data it was found that, code S (injury) was the most common, with 180 cases, followed by code D (neoplasm), with 132 cases. The ten most common diseases include Vulnus Lacerasi (S31.4), Thalassemia (D56), and Superficial Injury of Head (S00). It was recommended that hospitals conduct routine audits of medical documents to ensure the accuracy of diagnoses.
Co-Authors Ernaman Putri, Riza Suci Putri, Riza Suci Ernaman Putri, Widya