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All Journal Infokes : Jurnal Ilmiah Rekam Medis dan Informasi Kesehatan Proceedings of the International Conference on Nursing and Health Sciences Prosiding Seminar Informasi Kesehatan Nasional Journal of Economics and Public Health
Sari, Sella Yulia
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Humanities Biochemistry, Genetics & Molecular Biology Chemistry Economics, Econometrics & Finance Education Health Professions Languange, Linguistic, Communication & Media Medicine & Pharmacology Nursing Public Health Veterinary

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Accuracy of the Tentative Underlying Cause of Death Code Based on Rule 1 And Rule 2 Widyaningrum, Linda; Yuliadi, Naufal Arifin; Sari, Sella Yulia
Proceedings of the International Conference on Nursing and Health Sciences Vol 5 No 1 (2024): January-June 2024
Publisher : Global Health Science Group

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37287/picnhs.v5i1.2858

Abstract

Tentative Underlying Cause of Death (TUCoD) is the code selected as the result of each step in the process, when applying the instructions for each step. This research is a descriptive study with a cross sectional data approach, data sources obtained from primary data, namely the results of patient medical record documents and the results of interviews with the head of medical records and coding officers using research instruments, observation guidelines, interview guidelines, check-lists, MMDS tables. The samples taken was 82 samples from a total population of 444 general death certificates. The data sources taken are primary sources, namely the results of interviews and observations and secondary sources are taken from the SPO for coding the death index. The results of the accuracy of writing the sequence of events were 85% and the inaccuracy was 15%, this was due to the recording being carried out by the doctor in charge of the patient, determination of the tentative underlying cause of death code which is based on rule 1 at 24% with each rule 1 namely Rule 1.1 at 45% and rule 1.2 at 55%, rule 2 is 7% and General Principle rule is 69. Conclution this researsch procedure uses ICD-10 but does not involve MMDS, 85% of the event sequence writing is accurate, while 15% is inaccurate, the determination of rule 1 is 26% respectively for rule 1, namely rule 1.1 at 43% and rule 1.2 at 57% rule 2 at 6% and rule GP at 68% suggest immediate revision of the SOP for causes of death by involving MMDS in the death coding procedure. It would be better for coding officers to be more careful in coding the diagnosis of the basic cause of death so that there is no diagnosis without a code. diagnosis and improve coordination between medical record officers, doctors and other health workers to increase the completeness of medical records.
Relationship between Characteristics of Inpatients with Typhoid Fever (TF) and Length of Stay (LOS) in the Hospital Nugraheni, Sri Wahyuningsih; Darul, Ilyas Syafiq; Widigdya, Aquamarine Lathifatunniisaa’ Putri; Sari, Sella Yulia
Journal of Economics and Public Health Vol 3 No 2 (2024): Journal of Economics and Public Health: June 2024
Publisher : Global Health Science Group

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37287/jeph.v3i2.4008

Abstract

Patient characteristics are unique characteristics that each patient has. Length Of Stay (LOS) between patients varies depending on the patient's condition. Purpose: This study aimed to determine the relationship between the characteristics of Typhoid Fever inpatients and LOS. Method: This type of research is analytical research. The research sample was 203 medical record documents. Data collection using interviews, observations, and work tables. Data processing by collecting, editing, tabulating, calculating, and presenting data. Results: Univariate analysis found that the highest LOS was in the less than ideal category (<6 days), the highest age characteristics were in young people and adults (15-49 years), the highest gender was male, the highest payment method was in the government insurance category, the highest exit method was in the homecoming category, the highest occupation was in the unemployed/not yet employed category. The results of the bivariate analysis of the chi-square test showed the characteristics of age (p = 0.012), gender (p = 0.473), payment method (p = 0.485), exit method (p = 0.570), and occupation (p = 0.021). Conclusion: There is a relationship between age and occupation characteristics with LOS, and there is no relationship between gender characteristics, payment method and exit method with LOS.
The Correlation between Writing Medical Terminology Accuracy with the Accuracy of Typhoid Fever Diagnosis Codes for Inpatients Rahmawati, Eni Nur; Yatim, Nurulshyha Md; Hasanah, Pangestuti ‘Ainun; Sari, Sella Yulia
Journal of Economics and Public Health Vol 3 No 2 (2024): Journal of Economics and Public Health: June 2024
Publisher : Global Health Science Group

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37287/jeph.v3i2.4017

Abstract

The accuracy of writing medical terminology can affect the accuracy of coding because if the code written by the doctor is not clear, the coder will have difficulty determining the diagnosis code and this can hamper the data processing process in the hospital. Based on the results of the initial survey, the level of accuracy in writing medical terminology was 40% and coding accuracy was 80%. This study aims to determine the relationship between the accuracy of writing medical terminology and the accuracy of typhoid fever diagnosis codes. Type of analytical research with a cross-sectional approach design. The total population is 312 documents with a sample of 175 medical record documents. Simple random sampling technique. Observation and interview data collection techniques. This research instrument is an observation guide, interview guide, checklist, and ICD-10. The results of the research on the accuracy of writing medical terminology were 78 documents (44.57%) and the inaccuracy of writing was 97 documents (54.43%). Inaccuracies are due to not being by the writing in ICD-10, namely 14 documents (14.43%), not complying with the list of abbreviations at the hospital 33 documents (34.02%), and inaccuracies due to the use of Indonesian, namely 50 documents (51.55%). The accuracy of typhoid fever case codes was 141 documents (80.57%) and code inaccuracies were 34 documents (19.43%). Inaccuracy due to incorrect assignment of the fourth character code. The results of the chi-square test showed that the p-value was 0.000<0.05, which means there is a relationship between the accuracy of writing medical terminology and the accuracy of the typhoid fever diagnosis code in inpatients at PKU Muhammadiyah Hospital, Surakarta. Suggestions for the head of medical records are to create an SOP or standing procedure regarding writing appropriate and consistent medical terminology by ICD-10 and a list of abbreviations, so that there is agreement between doctors and medical records officers.
ANALISIS PEMANFAATAN DATA SENSUS HARIAN RAWAT INAP UNTUK EVALUASI PELAPORAN INDIKATOR RAWAT INAP Rahmawati, Eni Nur; Cahyaningrum, Nopita; Febrianti, Fera; Sari, Sella Yulia
Jurnal Infokes Vol 15 No 1 (2025): 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/infokes.v15i1.4775

Abstract

Sensus Harian Rawat Inap dimanfaatkan untuk pembuatan laporan indikator rawat inap, pengambilan keputusan oleh manajemen rumah sakit, menilai tingkat keberhasilan atau memberikan gambaran tentang keadaan pelayanan di rumah sakit. Indiktor rawat inap merupakan parameter yang digunakan dalam mengetahui kinerja pelayanan rawat inap. Tujuan penelitian untuk mengetahui pemanfaatan data SHRI yang digunakan untuk evaluasi pelaporan indikator rawat inap. Jenis penelitian deskriptif dengan pendekatan retrospektif, metode pengumpulan data dengan observasi dan wawancara. Objek penelitiannya SHRI dan subjeknya petugas analising reporting dan perawat. Hasil penelitian alur dan prosedur pelaksanaan SHRI sudah sesuai SOP, tetapi belum ada SOP cara pengisian SHRI. Analisis data SHRI pada bulan September 2024 terdapat perbedaan data yang belum valid dan lengkap, karena ketidakdisiplinan perawat dalam pengisian SHRI diantaranya jumlah pasien yang tertulis dobel, belum tertulisnya jumlah pasien masuk dan pasien pindahan, tanggal keluar pasien banyak yang kosong sehingga membuat perbedaan data jumlah hari perawatan, lama dirawat dan jumlah pasien keluar hidup dan mati. Data SHRI yang belum valid dan lengkap dapat menyebabkan kesalahan dalam proses perhitungan indikator rawat inap (BOR, LOS, TOI, BTO, GDR, NDR) oleh analising reporting. Input data yang tidak lengkap menyebabkan proses perhitungan indikator rawat inap tidak valid, sehingga output yang dimanfaatkan oleh manajemen rumah sakit untuk evaluasi laporan penggunaan tempat tidur belum tepat dalam pengambilan keputusan kemajuan kualitas pelayanan dan sarana prasarana rumah sakit. Faktor-faktor pelaksanaan SHRI pada material masih menggunakan formulir kertas SHRI, machine belum ada aplikasi SHRI elektronik, methods belum ada SOP cara pengisian SHRI. Saran perlu adanya dukungan manajemen rumah sakit memberikan sosialisasi secara berkala tentang pentingnya kelengkapan pengisian SHRI, merencanakan pembuatan SHRI elektronik dan pembuatan SOP pengisian SHRI agar data lebih lengkap.
ANALISIS KELENGKAPAN KODE DIAGNOSIS CARCINOMA MAMMAE PASIEN RAWAT INAP Rahayuningsih, Lilik Anggar Sri; Utami, Yeni Tri; Rahmawati, Eni Nur; Sari, Sella Yulia
Prosiding Seminar Informasi Kesehatan Nasional 2025: SIKesNas 2025
Publisher : Fakultas Ilmu Kesehatan Universitas Duta Bangsa Surakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.47701/wjvhw226

Abstract

Penelitian ini bertujuan untuk menganalisis kelengkapan dan keakuratan kode diagnosis kanker payudara (carcinoma mammae) pasien rawat inap di Rumah Sakit, berdasarkan International Statistical Classification of Diseases and Related Health Problems edisi ke-10 (ICD-10) dan International Classification of Diseases for Oncology (ICD-O). Metode yang digunakan adalah deskriptif dengan pendekatan retrospektif terhadap 109 dokumen rekam medis menggunakan teknik total sampling. Data dikumpulkan melalui observasi dan wawancara, kemudian dianalisis secara deskriptif. Hasil penelitian menunjukkan kelengkapan informasi medis topografi mencapai 100%, sedangkan kode morfologi hanya 72%. Namun, tingkat keakuratan menunjukkan 64% kode topografi akurat dan 0% kode morfologi yang akurat. Ketidaklengkapan dan ketidakakuratan disebabkan oleh keterbatasan data pemeriksaan penunjang, kebijakan internal rumah sakit, serta kurangnya pelatihan petugas koding. Kesimpulan dari penelitian ini adalah bahwa sistem pengkodean perlu ditingkatkan melalui pembaruan standar operasional, pelatihan petugas, serta integrasi data penunjang untuk meningkatkan mutu pengelolaan data diagnosis pasien kanker payudara
FAKTOR PENYEBAB PENDING KLAIM BPJS RAWAT INAP DENGAN PENERAPAN REKAM MEDIS ELEKTRONIK DI RSUD DR. MOEWARDI SURAKARTA Utami, Yeni Tri; Akbar, Prima Soultoni; Amelia, Reza; Sari, Sella Yulia
Prosiding Seminar Informasi Kesehatan Nasional 2024: SIKesNas 2024
Publisher : Fakultas Ilmu Kesehatan Universitas Duta Bangsa Surakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.47701/sikenas.vi.3939

Abstract

Berdasarkan hasil survei di RSUD dr. Moewardi jumlah klaim BPJS rawat inap yang mengalami pending sebanyak 4878 berkas (16,29%). Penelitian ini bertujuan untuk mengetahui faktor penyebab pending klaim BPJS rawat inap pada penerapan rekam medis elektronik di RSUD dr. Moewardi Surakarta. Metode penelitian menggunakan deskriptif dengan pendekatan retrospektif. Populasi dan Sampel yang digunakan adalah seluruh berkas klaim BPJS rawat inap yang mengalami pending tahun 2023. Metode pengumpulan data dengan observasi dan wawancara. Pelaksanaan klaim BPJS rawat inap telah dilaksanakan sesuai dengan Standar Operasional Prosedur. Faktor penyebab pending klaim diklasifikasikan menjadi 4 faktor yaitu berkas tidak lengkap sebanyak 2995 berkas (61,39 %), ketidaklengkapan berkas penunjang pasien sebanyak 1031 berkas (21,13 %), ketidaktepatan pengodean sebanyak 457 berkas (9,36 %), dan reseleksi diagnosis dan kode yang tidak sesuai dengan kriteria BPJS sebanyak 395 berkas (8,09 %). Dampak dari kasus pending klaim yaitu terjadinya cash flow rumah sakit yang terganggu dan penambahan beban kerja petugas. Upaya dalam mengatasi pending klaim dengan merevisi atau konfirmasi penyebab pending klaim kemudian menelaah kembali dan apabila diperlukan melakukan konfirmasi dengan unit terkait. Sebaiknya RSUD dr. Moewardi melakukan peningkatan koordinasi dengan unit-unit yang terkait mengenai syarat kelengkapan pengajuan klaim sehingga dapat meminimalisir terjadinya pending klaim pada bulan-bulan berikutnya.
HUBUNGAN KEAKURATAN KODE DIAGNOSIS TYPHOID FEVER DENGAN PERSETUJUAN KLAIM BPJS Widyaningrum, Linda; Abi, Muhamad; Fauziah, Nimas Fadhilah; Sari, Sella Yulia
Prosiding Seminar Informasi Kesehatan Nasional 2024: SIKesNas 2024
Publisher : Fakultas Ilmu Kesehatan Universitas Duta Bangsa Surakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.47701/sikenas.vi.3940

Abstract

Kode diagnosis pasien memegang peran penting sebagai acuan penentuan dari besar biaya atau tarif pelayanan kesehatan. Keakuratan kode diagnosis merupakan hal yang penting yang harus diperhatikan oleh tenaga rekam medis termasuk pada kasus Typhoid Fever. Tujuan penelitian untuk mengetahui Keakuratan Kode Diagnosis Typhoid Fever dengan Persetujuan Klaim Badan Penyelenggara Jaminan Sosial di Rumah Sakit Nirmala Suri Sukoharjo. Penelitian ini merupakan penelitian analitik dengan menguji hubungan antara keakuratan kode diagnosis Typhoid Fever dengan persetujuan klaim BPJS. Metode pengumpulan data yang digunakan yaitu observasi dan wawancara. Data diolah dengan analisis uji Fisher’s Exact Test. Hasil penelitian menunjukkan keakuratan kode diagnosis Typhoid Fever yang akurat sebanyak 106 dokumen (90,6%), tidak akurat sebanyak 11 dokumen (9,4%). Persetujuan klaim BPJS diperoleh hasil yang disetujui sebanyak 106 berkas klaim (90,6%) dan yang tidak disetujui sebanyak 11 berkas klaim (9,4%). Dari hasil perhitungan dengan menggunakan SPSS versi 25.0 didapatkan nilai p < 0,05, yaitu p = 0,000 dengan demikian dapat disimpulkan bahwa H0 ditolak. Artinya ada hubungan antara keakuratan kode diagnosis Typhoid Fever dengan persetujuan klaim BPJS di Rumah Sakit Nirmala Suri Sukoharjo. Pengkode sebaiknya dalam melakukan pengodean memperhatikan lembar-lembar penunjang medis.
Co-Authors Abi, Muhamad Akbar, Prima Soultoni Amelia, Reza Darul, Ilyas Syafiq Fauziah, Nimas Fadhilah Febrianti, Fera Hasanah, Pangestuti ‘Ainun Lilik Anggar Sri Rahayuningsih Linda Widyaningrum, Linda Nopita Cahyaningrum Nugraheni, Sri Wahyuningsih Nur Rahmawati, Eni Utami, Yeni Tri Widigdya, Aquamarine Lathifatunniisaa’ Putri Yatim, Nurulshyha Md Yuliadi, Naufal Arifin