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All Journal JURNAL ILMIAH MAKSITEK JURNAL ILMIAH KOHESI International Journal of Public Health Excellence (IJPHE) Medani : Jurnal Pengabdian Masyarakat
ROSALINA, YUDICA
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ANALISA PENETAPAN KODE DIAGNOSIS UTAMA YANG AKURAT BERDASARKAN SPESIFIKASI PENULISAN PADA RESUME MEDIS RAWAT INAP DI RSU SUNDARI MEDAN ROSALINA, YUDICA
JURNAL ILMIAH MAKSITEK Vol 8 No 2 (2023): JURNAL ILMIAH MAKSITEK
Publisher : LP2MTBM MAKARIOZ

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Abstract

Sundari hospital Medan is a type C hospital, that has been used as guidelines ICD-10 for coding, the hospital had not conducted a study to determine the accuracy of the determination of primary diagnosis code based on specification writing primary diagnosis in the medical record document in the inpatient permata medika hospital 2020th periode. Rom the results of the initial survey using interviews with officers, inaccuracies in the coding of diagnosis were found on the medical resume of inpatients. This study used an observational method with a cross-sectional approach and the type of analytic research, while the population of this study amounted to 2,280 files of inpatient medical records for the 2020th periode so that a sample of 99 that are retrieved by using a random sample of sampling techniques. The results of the observations concluded that the main diagnosis code that was accurate from the specific diagnosis (Thypoid Fever) 54 (85,7%) was the main diagnosis code that was accurate from the non-specific diagnosis (Fever) 9 (14,3%), and the main diagnosis code was not accurate from specific diagnosis (Pneumonia) 14 (42.4%) the main diagnostic code was inaccurate from the non specific diagnosis (Effusion) 19 (57.6%). Conclusion obtained that is, to get the accuration of disease code, do not only influenced by writing diagnosed just specific especial, but influenced also by correctness of officer coding and also other factor which influencing in consequence officer koding better be active in searching information if finding diagnosed especial which is not specific and also need the existence of the make-up of knowledge of officer koding by joining in training of Coding ICD-10.
ANALISA PENETAPAN KODE DIAGNOSIS UTAMA YANG AKURAT BERDASARKAN SPESIFIKASI PENULISAN PADA RESUME MEDIS RAWAT INAP DI RSU SUNDARI MEDAN TRI WULAN I 2020 ROSALINA, YUDICA
JURNAL ILMIAH KOHESI Vol 6 No 4 (2022): JURNAL ILMIAH KOHESI
Publisher : LP2MTBM MAKARIOZ

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Abstract

Sundari hospital Medan is a type C hospital, that has been used as guidelines ICD-10 for coding, the hospital had not conducted a study to determine the accuracy of the determination of primary diagnosis code based on specification writing primary diagnosis in the medical record document in the inpatient permata medika hospital 2020th periode.Rom the results of the initial survey using interviews with officers, inaccuracies in the coding of diagnosis were found on the medical resume of inpatients.This study used an observational method with a cross-sectional approach and the type of analytic research, while the population of this study amounted to 2,280 files of inpatient medical records for the 2020th periode so that a sample of 99 that are retrieved by using a random sample of sampling techniques.The results of the observations concluded that the main diagnosis code that was accurate from the specific diagnosis (Thypoid Fever) 54 (85,7%) was the main diagnosis code that was accurate from the non-specific diagnosis (Fever) 9 (14,3%), and the main diagnosis code was not accurate from specific diagnosis (Pneumonia) 14 (42.4%) the main diagnostic code was inaccurate from the non specific diagnosis (Effusion) 19 (57.6%).Conclusion obtained that is, to get the accuration of disease code, do not only influenced by writing diagnosed just specific especial, but influenced also by correctness of officer coding and also other factor which influencing in consequence officer koding better be active in searching information if finding diagnosed especial which is not specific and also need the existence of the make-up of knowledge of officer koding by joining in training of Coding ICD-10.
UPAYA PETUGAS ASSEMBLING UNTUK MELENGKAPI BERKAS REKAM MEDIS PASIEN RAWAT INAP DENGAN MENGGUNAKAN METODE KUALITATIF DI RUMAH SAKIT UNIVERSITAS SUMATERA UTARA ROSALINA, YUDICA
JURNAL ILMIAH KOHESI Vol 6 No 4 (2022): JURNAL ILMIAH KOHESI
Publisher : LP2MTBM MAKARIOZ

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Abstract

Background: Assembling officers must make efforts to maintain the completeness of medical record files. By making these efforts, it is hoped that they can complete incomplete medical record files. at the University of North Sumatra Hospital. The results of interviews with the Head of Medical Records and Documentation Studies for inpatient medical record files revealed that this goal had not yet been achieved because incomplete inpatient medical record files were still found. Research Objective: to determine the efforts that can be made to maintain the completeness of medical record files. Research method: This type of research is descriptive research with a qualitative approach and a cross-sectional research design. The subjects in this research were assembling officers, two doctors, two nurses, and the head of the Medical Records agency. Data collection techniques are observation, interviews and documentation studies. Research Results: the causes of incomplete medical record files are a) Man: nurses prioritize service or treatment of patients; nurses still don't remind doctors of the parts of the medical record that must be filled in by the doctor, the doctor visits once a week; Doctors must immediately treat patients who need help. b) methods; the procedure for filling out medical record files has not been socialized to doctors or nurses. c) machines; There is no date stamp facility. e) Money; There is no incentive system if filling in medical records is still incomplete. Efforts to complete the medical record files for inpatient medical patients.
Analisis Kepuasan Pelayanan Pemberian Vaksinasi Di Era Pandemik Covid-19 Di UPT Puskesmas Medan Tuntungan Rosalina, Yudica
Medani : Jurnal Pengabdian Masyarakat Vol. 1 No. 3 (2022): Desember 2022
Publisher : Lembaga Riset Ilmiah

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.59086/jpm.v1i3.524

Abstract

Ditemukan bahwa adanya pasien yang kurang puas terhadap pelayanan yang di terima contohnya: Keramahan petugas saat pelaksanaan vaksinasi, Alur saat pelaksanaan vaksinasi Covid-19, Edukasi dan Protokol Kesehatan. Sehingga terjadinya kesalah pahaman yang menimbulkan rasa kurang nyaman. Mengenai Kepuasan pelayanan di tempat pemberian vaksinasi di Unit Pelaksana Teknis (UPT) Puskesmas Medan Tuntungan. Jenis penelitian ini menggunakan penelitian Kualitaif dengan Metode yang digunakan dalam penelitian ini adalah metode observasi dan wawancara. Studi kasus yang dilakukan di UPT Puskesmas Medan Tuntungan. Dari penelitian ini adalah beban kerja, pada bahaian NAKES, Dewasa, Pralansia, Lansia dan Pelayanan Publik dan data pendukung lainnya. Data penelitian ini di ambil dengan melakukan observasi dan wawancara sebagai dokumentasi. Berdasarkan hasil distribusi frekuensi seperti terangkum dalam tabel. Dapat diketahui bahwa kepuasan pasien vaksinasi pada pasien Nakes di UPT Puskesmas Medan Tuntungan dari 100 responden sebagian besar 5 (5%) menyatakan sangat puas dan 85 (85%) menyatakan puas. pada pasien dewasa di UPT Puskesmas Medan Tuntungan dari 100 responden sebanyak 12 % menyatakan sangat puas, 88 % menyatakan puas. pada pasien Pralansia di UPT Puskesmas Medan Tuntungan dari 100 responden sebanyak 5% menyatakan sangat puas, 90% menyatakan puas, dan sebanyak 5 % menyatakan cukup puas. pada pasien Lansia di UPT Puskesmas Medan Tuntungan dari 100 responden sebanyak 9% menyatakan sangat puas, 86 % menyatakan puas dan 5 % menyatakan cukup puas. pada pasien Pelayanan Publik di UPT Puskesmas Medan Tuntungan dari 100 responden sebanyak 12% menyatakan sangat puas dan 88 % menyatakan puas.
Perbandingan Kelengkapan Pengisian Rekam Medis Antara Dokter Umum Dan Dokter Spesialis Di Rumah Sakit Vita Insani Siantar Rosalina, Yudica
Medani : Jurnal Pengabdian Masyarakat Vol. 2 No. 3 (2023): Desember 2023
Publisher : Lembaga Riset Ilmiah

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.59086/jpm.v2i3.525

Abstract

Karakteristik rekam medis agar dapat digunakan secara optimal, yaitu antara lain lengkap, tepat waktu, tidak kadaluarsa, dapat dipercaya, relevan dan objektif. Namun banyak dijumpai rekam medis yang kurang memenuhi karateristik tersebut terutama pada masalah kelengkapan dan ketepatan waktu. Pada survai awal pada praktik swasta dokter umum dan dokter spesialis terdapat perbedaan kelengkapan dokumen rekam medis. Tujuan penelitian ini untuk mengetahui kelengkapan pengisian rekam medis antara dokter umum dan dokter spesialis di Rumah Sakit Vita Insani Siantar baik dari segi dokumen, jumlah dokter, dan jenis kasus. Metode Penelitian yang digunakan survei analitik dengan rancangan cross sectional. Sampel penelitian adalah dokumen rekam medis dokter umum dan spesialis pada di Rumah Sakit Vita Insani Siantar. Sampel dokumen rekam medis dokter umum sebanyak 100 dokumen dan sampel dokumen rekam medis dokter umum spesialis sebanyak 100 dokumen. Hasil analisa deskriptif menunjukan perbedaan kelengkapan pengisian rekam medis. kelengkapan rekam medis dokter spesialis lebih tinggi daripada dokter umum. Dari 200 rekam medis yang menjadi sampel penelitian, didapatkan hasil kelengkapan rekam medis oleh dokter umum sebesar 58,5% dan kelengkapan rekam medis oleh dokter spesialis sebesar 75%. Kelengkapan dokumen rekam medis dokter spesialis lebih tinggi dibanding rekam medis dokter umum
Radiographic Examination Techniques of Ossa Antebrachii In Fracture Cases With Alternative Positions at Radiology Installation of North Sumatra University’s Hospital Rosalina, Yudica
International Journal of Public Health Excellence (IJPHE) Vol. 2 No. 2 (2023): January-May
Publisher : PT Inovasi Pratama Internasional

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.55299/ijphe.v2i2.440

Abstract

The antebrachial radiography examination procedure typically uses two projections, namely AP and lateral. However, at the USU General Hospital's radiology installation, radiographic examinations of the antebrachium with clinical fractures are conducted using PA and lateral projections. This study aims to determine the procedure for clinical antebrachial radiographic examination of fractures and the rationale for using PA and lateral projections. This research is qualitative, employing a case study approach. Data collection was conducted through observation, active participation, documentation, and structured interviews with radiographers, referring physicians, and radiologists. The results of the study indicate that antebrachial radiographic examinations of clinical fractures at the USU General Hospital Radiology Installation use PA and lateral projections with the elbow in a straight position. The diagnostic information produced from these examinations meets the criteria as it effectively shows both the elbow and wrist joints.
Radiographic Examination Techniques of Ossa Antebrachii In Fracture Cases With Alternative Positions at Radiology Installation of North Sumatra University’s Hospital Rosalina, Yudica
International Journal of Public Health Excellence (IJPHE) Vol. 2 No. 2 (2023): January-May
Publisher : PT Inovasi Pratama Internasional

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.55299/ijphe.v2i2.440

Abstract

The antebrachial radiography examination procedure typically uses two projections, namely AP and lateral. However, at the USU General Hospital's radiology installation, radiographic examinations of the antebrachium with clinical fractures are conducted using PA and lateral projections. This study aims to determine the procedure for clinical antebrachial radiographic examination of fractures and the rationale for using PA and lateral projections. This research is qualitative, employing a case study approach. Data collection was conducted through observation, active participation, documentation, and structured interviews with radiographers, referring physicians, and radiologists. The results of the study indicate that antebrachial radiographic examinations of clinical fractures at the USU General Hospital Radiology Installation use PA and lateral projections with the elbow in a straight position. The diagnostic information produced from these examinations meets the criteria as it effectively shows both the elbow and wrist joints.
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