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All Journal Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Jurnal Kesehatan Tambusai PELS (Procedia of Engineering and Life Science)
Indira, Zahrasita Nur
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Computer Science & IT Control & Systems Engineering Dentistry Electrical & Electronics Engineering Engineering 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.
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.
Analysis of the Release of Medical Record Information as a Guarantee of Legal Aspects of Patient Data Confidentiality: Analisis Pelepasan Informasi Rekam Medis sebagai Penjamin Aspek Hukum Kerahasiaan Data Pasien Setyaningsih, Fahmi; Meylia, Nadira Zalfa; Mayasari, Winda Nur; Parmesti, Khoirunnisa Riski; Wahyudi, Rusli Diki; Indira, Zahrasita Nur; Siregar, Rahmadhani
Procedia of Engineering and Life Science Vol. 7 (2025): Prosiding Seminar Nasional dan Rakernas PORMIKI X
Publisher : Universitas Muhammadiyah Sidoarjo

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.21070/pels.v7i0.2092

Abstract

Medical records are certainly very close to maintaining the security and confidentiality of patient data in the means of releasing information by ensuring the legal aspects of the security and confidentiality of patient data. Maintaining the security and confidentiality of patient data during the process of releasing medical record file information is very important in order to facilitate access to information on lawsuits by health services and health practitioners, as well as authorized third parties. This study aims to provide an overview of the release of medical record information in the legal aspect of confidentiality. The things that were studied were the procedures for releasing medical record information, the requirements for releasing medical information, the parties involved in releasing medical information, information on the use of releasing medical information and looking at the security aspects of the process of releasing medical record information, as well as facilities and infrastructure in the information release room. The data collection methods used in this study were interviews and observations. The results of the research on the process of releasing medical information show that two patients are in accordance and two patients are not in accordance with the SOP (Standard Operating Procedure) that applies at JIH Purwokerto Hospital, the human resources involved in the process of releasing information are Medical Recorder and Health Information (PMIK) officers and non PMIK, and inadequate facilities and infrastructure available in the information release room.
Analysis Of Pending Claims For Inpatients Social Security Organizing Body (Bpjs) Health Hospital Mitra Siaga Tegal: Analisis Pending Klaim Pasien Rawat Inap Badan Penyelenggara Jaminan Sosial (Bpjs) Kesehatan Rumah Sakit Mitra Siaga Tegal Indira, Zahrasita Nur; Yustafia, Atiqah Filda; Wijayanti, Wahyu Nur; Bella, Cindy Rozza; Mulyani, Agustina Dwi; Wibowo, Dimas Ari
Procedia of Engineering and Life Science Vol. 7 (2025): Prosiding Seminar Nasional dan Rakernas PORMIKI X
Publisher : Universitas Muhammadiyah Sidoarjo

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.21070/pels.v7i0.2237

Abstract

The Hospital understands and realizes the importance of the claim process as a reimbursement for insurance patients who have been treated. pending claims, namely the return of claims where there is no agreement between BpJS Health and FKRTL regarding coding and medical rules (dispute claims), but settlements are carried out in accordance with statutory provisions. Mitra Siaga Tegal Hospital in September 2022 obtained data that there were 94 pending BPJS claim files for inpatients out of 1427 files that had been submitted for claims to BPJS. This is due to coding errors, incorrect data entry, incomplete supporting examinations such as the absence of therapy and laboratory results. The method used in this research is qualitative with in-depth interviews with the Assistant Manager of Insurance Control and the officer in charge of Inpatient Claims at Mitra Siaga Tegal Hospital. The purpose of this study was to find out the causes of pending claims for hospitalization in September 2022 at Tegal Mitra Siaga Hospital. The results of the study show that pending cases of inpatient BPJS claims at Mitra Siaga Hospital in Tegal can occur due to several factors, which consist of administrative, medical, and coder aspects. The most common factor causing pending hospitalization claims was the coder aspect in 76 cases
ANALISIS KEBUTUHAN TENAGA KERJA UNIT FILING REKAM MEDIS MENGGUNAKAN WISN DI RSUD DR. SOEDIRMAN KEBUMEN Budiyanti, Shifa Amanda; Indira, Zahrasita Nur; Romodon, Dion; Praptanti, Agustina Fitri
Jurnal Kesehatan Tambusai Vol. 6 No. 1 (2025): MARET 2025
Publisher : Universitas Pahlawan Tuanku Tambusai

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31004/jkt.v6i1.41763

Abstract

WISN adalah teknik penghitungan kebutuhan sumber daya manusia berdasarkan beban kerjanya. Beban kerja adalah tanggung jawab terhadap pekerjaan yang wajib dirampungkan oleh tenaga kerja profesional setiap tahun di tempat kerjanya. Semakin banyak pasien, maka beban kerja petugas filing semakin tinggi karena rekam medis elektronik belum sepenuhnya dapat dijalankan. Penelitian ini bertujuan untuk mengetahui tenaga kerja yang dibutuhkan unit filing berdasarkan besarnya beban kerja petugas dengan teknik WISN. Penelitian ini merupakan penelitian kualitatif dengan pendekatan deskriptif, populasi pada penelitian ini adalah 7 petugas di unit filing dan sampelnya adalah 3 petugas unit filing RSUD dr. Soedirman Kebumen serta sampel diambil menggunakan purposive sampling. Data dikumpulkan melalui observasi dan wawancara, kemudian hasilnya disajikan dalam bentuk tabel untuk menghitung beban kerja petugas, sehingga diperoleh jumlah tenaga kerja unit filing yang dibutuhkan sesuai teknik WISN. Berdasarkan hasil perhitungan WISN menunjukkan bahwa waktu kerja yang tersedia sebesar 75.000 menit/tahun, rata-rata standar beban kerja sebesar 489.379,1. Standar kelonggaran sebesar 0,45 dan total kebutuhan tenaga filing sebanyak 6,636 atau 7 orang. Jumlah tenaga kerja di unit filing RSUD dr. Soedirman Kebumen adalah 7 petugas. Terdapat permasalahan seperti rekam medis yang tercecer, ruang filing tidak buka 24 jam, dan rak penyimpanan yang penuh. Keseluruhan tenaga kerja unit filing rekam medis sebanding dengan beban kerjanya, sehingga tidak perlu penambahan atau pengurangan petugas, tetapi membutuhkan evaluasi kembali dan melakukan peningkatan cara penyelenggaraan kegiatan di unit filing.
ANALISIS KELENGKAPAN FORMULIR RINGKASAN MASUK DAN KELUAR RAWAT INAP NON BEDAH DI RUMAH SAKIT X Indira, Zahrasita Nur; Taharah, Dena; Damayanti, Rifka Oktavia
Jurnal Kesehatan Tambusai Vol. 6 No. 1 (2025): MARET 2025
Publisher : Universitas Pahlawan Tuanku Tambusai

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31004/jkt.v6i1.42579

Abstract

Rekam mediscyang tidak lengkap akan berpengaruh padaakeakuratan dari aspek legal dan isi rekam medis, salah satunya pada bagian formulir ringkasan masuk dan keluar rawat inap. Pelayanan rawat inap merupakan pelayanan kepada pasien yang masuk ke rumah sakit dan menggunakan tempat tidur untuk’keperluan observasi, diagnosis, terapi yang diberikan, rehabilitasi medik dan penunjang medik lainnya. Formulir ringkasan masuk dan keluar merupakan bagian yang diabadikan dan memiliki nilai guna serta tidak dimusnahkan. Tujuan penelitian ini untuk mengetahui presentase dan nilai kelengkapan rekam medis rawat inap pada formulir ringkasan masuk dan keluar di rumah sakit umum. Metode penelitian ini menggunakan analisis kuantitatif deskriptif dengan pengumpulan data pasien pada setiap bulannya di bagian pendaftaran rawat inap. Penelitian ini dilaksanakan di salah satu rumah sakit umum yang berada di wilayah Kabupaten Banyumas pada tahun 2024. Hasil penelitian ini didapatkan ketidaklengkapan pada bagian diagnosa sementara, keluarga terdekat dan penanggung jawab pembayaran, riwayat rawat inap, pelayanan (prioritas pelayanan dan jenis pelayanan) dan pada identitas sosial. Simpulan dari penelitian ini adalah formulir hampir sepenuhnya berisikan aspek penting seperti identitas pasien, laporan penting dan autentifikasi, sehingga wajib diisi secara lengkap, tetapi dalam hal ini masih terdapat formulir yang  tidak lengkap seperti pada laporan penting, yang mana kelengkapan diperlukan untuk meningkatkan mutu rekam medis dan digunakan untuk kepentingan administrasi lainnya.
Co-Authors Anggraeni, Okti Bella, Cindy Rozza Budiyanti, Shifa Amanda Cahyani, Lintang Dwi Damayanti, Rifka Oktavia Dion Romodon Febriana, Dina Hakim, Agya Osadawedya Mayasari, Winda Nur Meylia, Nadira Zalfa Mulyani, Agustina Dwi Parmesti, Khoirunnisa Riski Permatasari, Merdiana Ika Praptanti, Agustina Fitri Setyaningsih, Fahmi Siregar, Rahmadhani Taharah, Dena Wahyudi, Rusli Diki Wibowo, Dimas Ari Wijayanti, Wahyu Nur Yustafia, Atiqah Filda