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All Journal Jurnal Manajemen dan Administrasi Rumah Sakit Indonesia (MARSI) Health Information : Jurnal Penelitian Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan
Hakim, Agya Osadawedya
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Decision Sciences, Operations Research & Management Dentistry Economics, Econometrics & Finance Health Professions Medicine & Pharmacology Nursing Public Health

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Analisis Kelengkapan Desain Formulir Pasien Rawat Jalan Di Puskesmas Purwokerto Timur I Cahyani, Lintang Dwi; Hakim, Agya Osadawedya; Indira, Zahrasita Nur; Permatasari, Merdiana Ika
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Vol. 9 No. 2 (2024): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Agustus
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v9i2.1649

Abstract

Puskesmas is one of the health service institutions provided by the Indonesian government and is the spearhead of the national health system. Efforts in establishing quality health centre service quality, that is, by paying attention to every aspect of it. The anatomical and physical aspects are used here. Please note the number of measurement cards for patients. One of them is processing the patient's medical record form design. Medical record forms are designed and used for maintenance and monitoring. The design of the form aims to improve and complete aspects of the outpatient form design that are currently still in use and to improve the quality of health services at the Purwokerto Timur I Health Center. The objective of this research is to identify the completeness of the outpatient forms available at the Purwokerto Health Center. Timur I. This analysis uses a quantitative method with a cross-sectional descriptive approach. The subject of this study was the outpatient form at the Purwokerto Timur I Health Center. The results obtained from this study were quite good, that is, there was an outpatient form at the Purwokerto Timur I Health Center, but the results of the analysis of this form still need to be improved in completeness. There is a completeness of 76,92% in the form. The aspect of the content that has the best completeness of the form.
Analisis Penyebab Pengembalian Klaim BPJS Pasien Rawat Inap Ditinjau Dari Proses Pengkodean Di RSUD Majenang Zahra, Awlia Varasemitha; Hakim, Agya Osadawedya; Fauzi, Harry; Gunawan, Gunawan
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Vol. 9 No. 2 (2024): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Agustus
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v9i2.1651

Abstract

Pending Claim is a refund because there is no agreement between BPJS Health and FKRTL regarding coding rules and medical determination (claim dispute). The correct diagnosis and action code will determine the smooth process of submitting claims for medical services to BPJS Health and reduce the number of claim returns. This study aims to determine the causes of inpatient claim returns in terms of the coding process at Majenang Hospital. The research method used is a qualitative method with an observational descriptive design. Data was obtained from pending claims from July to September 2023. Data collection methods were observation and interviews. Majenang Hospital research results showed that 371 claims were returned and 187 claims were returned due to coding confirmation. Factors inhibiting the accuracy of a diagnosis or action code are the use of combined codes, errors in determining the main diagnosis, differences in perception, and discrepancies in supporting results with the diagnosis. Efforts that can be made to minimize the number of claim returns include reviewing diagnosis or action codes, communicating between DPJP, the casemix team and BPJS verifiers, coding training and having an SPO.
FAKTOR - FAKTOR YANG MEMPENGARUHI PROSES PENGKODEAN DIAGNOSIS DI RUMAH SAKIT UMUM DAERAH CILACAP Febriana, Dina; Hakim, Agya Osadawedya; Indira, Zahrasita Nur; Anggraeni, Okti
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Vol. 9 No. 2 (2024): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Agustus
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v9i2.1654

Abstract

Hospitals are health institutions that provide medical services to individuals as a whole, including inpatient, outpatient, and emergency care. Hospitals need to improve the quality of their services. This can be done by having a good medical record unit. Medical records are documents that contain information about the patient's identity, examination, treatment, procedures, and other services provided to the patient. An important data processing to store data in medical records is coding. Classifying and providing codes for disease diagnosis is known as coding. Writing codes on medical records must be precise and accurate. The impact of coding errors can affect the quality of medical records. Based on an initial survey related to coding carried out at Cilacap Regional Hospital, a problem was found that officers had difficulty reading the doctor's writing. This study aims to determine what factors influence the diagnosis coding process at Cilacap Regional Hospital. This research is a type of qualitative research with data collection method instruments through observation and interviews. The research subjects amounted to 2 people, namely coder officers and the head of the medical records unit. The results of the study obtained several factors that influence the coding process including; Writing a diagnosis that is difficult to read, incompleteness in medical records can affect the coding process that will be carried out by the coder, and the absence of a medical dictionary as a coding support book in finding unknown terms in coding.
Penyebab Pengembalian Berkas Klaim BPJS Kesehatan Pasien Rawat Inap Ditinjau Dari Syarat-Syarat Pengajuan Klaim di RSUD Majenang Tuzzahra, Raudya; Hakim, Agya Osadawedya; Romodon, Dion; Gunawan, Gunawan
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 6 No 1 (2024): December
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v6i1.5469

Abstract

Issues related to BPJS Health insurance claims often pose challenges for healthcare facilities. The primary reasons for claim rejections typically involve administrative errors, such as incomplete documentation or incorrect diagnostic codes. This study aims to identify the factors contributing to the high rate of inpatient claim rejections at RSUD Majenang. Employing a qualitative approach with a case study design, this research analyzes data collected from in-depth interviews with hospital verification officers and coding officers. The findings reveal that inaccurate diagnostic coding and incomplete supporting documentation are the primary causes of claim rejections. Inaccurate diagnostic coding is attributed to several factors, including errors in diagnosis recording, discrepancies in perceptions between hospital verifiers and BPJS Health, and potential indications of diagnostic code misuse. Additionally, a lack of interdepartmental coordination and inadequate understanding of claim guidelines contribute to the problem. The findings of this study have significant implications for efforts to improve the quality of healthcare services and the efficiency of claim management in hospitals. To streamline BPJS Health claims, it is necessary to enhance the competency of staff, strengthen interdepartmental coordination, improve the quality of medical documentation, and conduct periodic evaluations of claim procedures.
Analisis Faktor Penyebab Ketidaklengkapan Berkas Rekam Medis Rawat Jalan Menggunakan Metode 5M di RS Paru Dr. H.A. Rotinsulu Bandung Serafina, Maritza Dubit; Romodhon, Dion; Hakim, Agya Osadawedya; Aeni, Yomi Nur
Jurnal Manajemen dan Administrasi Rumah Sakit Indonesia (MARSI) Vol 9, No 1 (2025): Jurnal Manajemen dan Administrasi Rumah Sakit Indonesia (MARSI)
Publisher : LPPM Universitas Respati Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52643/marsi.v9i1.5827

Abstract

Analisis ketidaklengkapan pengisian rekam medis  sangat dibutuhkan, untuk memahami sebesar apa angka ketidaklengkapan rekam medis di RS Paru Dr. HA Rotinsulu Bandung pada triwulan 2024. Ditemukan bahwa dari seluruh rekam medis rawat jalan  di bulan Oktober terdapat 2 . 946 berkas, di bulan November terdapat 2 . 838 berkas, dan di bulan Desember ada 2 . 826 berkas.  Ketidaklengkapan tertinggi pada bulan Oktober sebesar 132 (91,86%) pada lembar asesmen medis, ketidaklengkapan tertinggi pada bulan November sebesar 82 (97,06%) pada lembar  nurse note , dan ketidaklengkapan tertinggi pada bulan Desember sebesar 18 (91,71%) pada lembar edukasi .  Metode penelitian yang dimanfaatkan dalam penelitian adalah metode penelitian kualitatif dengan menggunakan pendekatan deskriptif. Teknik pengumpulan data yang digunakan peneliti adalah wawancara. Ketidaklengkapan pengisian berkas rekam medis rawat jalan ini dapat disebabkan oleh faktor 5M yang beragam dari  manusia : kurangnya ketelitian petugas , uang :  dana yang belum optimal , metode : belum ada SOP dan evaluasi berkala , mesin : gangguan akses internet ,  dan  bahan : sudah melakukan rekap itu ulasi data rekam medis dengan benar. Kesimpulan penelitian ini adalah angka kelengkapan pengisian rekam medis belum menggapai  s trandar rekam medis di rumah sakit. Hal ini disebabkan karena penerapan sistem layanan rekam medis belum maksimal.      Kata  kunci : ketidaklengkapan rekam medis, rawat jalan, 5M 
Visualisasi Spasial Kunjungan Pasien Rumah Sakit Menggunakan Sistem Informasi Geografis Rindiyani, Fadillah Dea; Fauzi, Harry; Nadi, Danu Tirta; Hakim, Agya Osadawedya; Aeni, Yomi Nur
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 6 No 3 (2025): June
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v6i3.5866

Abstract

Patient visit data at Bandung Paru Hospital is still managed conventionally, without integration with Geographic Information System (GIS) technology. This study aimed to develop and utilize GIS to visualize patient visits, supporting spatial data-based decision-making. A descriptive method was used, with the research population consisting of all patient visits to paru Hospital in 2024. The sample included outpatient and emergency patients selected through purposive sampling. Secondary data were taken from outpatient and emergency visit records, processed, and displayed in thematic maps using color gradients from green to red to indicate visit intensity, from low to high. The results showed that GIS can provide a spatial overview of patient visit distribution, helped identify visit patterns, and supported strategic planning such as improving facilities and services. Paru Hospital is encouraged to adopt GIS for spatial-based visualization of patient visit data, as it allows the data to be presented in interactive maps, offering clearer insights into the geographic distribution of patients.
Analisis Penyebab dan Kendala Pengajuan Klaim BPJS Kesehatan Pasien Rawat Inap di RSUD Majenang Tahun 2023 Putri, Chaesya Isnaeni; Yektiningtyastuti, Yektiningtyastuti; Hakim, Agya Osadawedya; Gunawan, Gunawan
Health Information : Jurnal Penelitian Vol 17 No 1 (2025): Januari-April
Publisher : Poltekkes Kemenkes Kendari

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.36990/hijp.v17i1.1677

Abstract

Ringkasan : Latar belakang: Pengajuan klaim BPJS Kesehatan mengalami pengembalian tinggi di RSUD Majenang dengan 1.328 berkas dikembalikan tahun 2023, menimbulkan dampak negatif pada operasional dan keuangan rumah sakit. Tujuan: Menganalisis penyebab dan kendala pengajuan klaim BPJS Kesehatan rawat inap untuk meningkatkan efisiensi dan efektivitas proses klaim. Metode: Desain deskriptif kuantitatif-kualitatif menggunakan data primer (wawancara terstruktur verifikator internal, kepala rekam medis, koder) dan sekunder (laporan pengembalian klaim 2023). Populasi 1.328 berkas, sampel 308 berkas systematic random sampling, analisis 5M (Man, Material, Method, Machine, Money). Hasil: Pengembalian klaim didominasi aspek medis (59,09%) karena ketiadaan tatalaksana dan penunjang, aspek koding (31,17%) karena konfirmasi kode diagnosis, dan administrasi (9,74%) karena konfirmasi readmisi dan episode SEP. Kendala meliputi ketelitian petugas, persepsi DPJP, kelengkapan berkas, ketiadaan SPO khusus, dan keterbatasan teknologi bridging system. Simpulan: Faktor manajemen 5M berkontribusi signifikan terhadap pengembalian klaim, dengan aspek medis sebagai penyebab utama dan perlu perbaikan sistematis. Saran: Evaluasi berkala, penyusunan SPO sistematis, penguatan koordinasi antar unit, optimalisasi teknologi informasi bridging system, dan peningkatan kompetensi SDM melalui pelatihan rutin.
Co-Authors Aeni, Yomi Nur Anggraeni, Okti Cahyani, Lintang Dwi Dion Romodon Febriana, Dina Gunawan Gunawan Harry Fauzi, Harry Indira, Zahrasita Nur Nadi, Danu Tirta Permatasari, Merdiana Ika Putri, Chaesya Isnaeni Rindiyani, Fadillah Dea Romodhon, Dion Serafina, Maritza Dubit Tuzzahra, Raudya Yektiningtyastuti Yektiningtyastuti Zahra, Awlia Varasemitha