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All Journal JIMKesmas (Jurnal Ilmiah Mahasiswa Kesehatan Masyarakat) Indonesian of Health Information Management Journal (INOHIM) Jurnal Ners Science Midwifery Sehat Rakyat: Jurnal Kesehatan Masyarakat Journal of Information Systems for Public Health Journal Health Information Management Indonesian Bengawan :Jurnal Pengabdian Masyarakat Jurnal Kesehatan Tropis Indonesia Medicor : Journal of Health Informatics and Health Policy Indonesian Journal of Science and Education
Novratilova, Sinta
Politeknik Indonusa Surakarta
Biochemistry, Genetics & Molecular Biology Chemistry Computer Science & IT Decision Sciences, Operations Research & Management Dentistry Economics, Econometrics & Finance Education Health Professions Languange, Linguistic, Communication & Media Materials Science & Nanotechnology Medicine & Pharmacology Nursing Physics Public Health Social Sciences Veterinary

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Journal : Science Midwifery

 1 
Analysis of risk factors for incomplete inpatient medical records using the fishbone method Ernawati, Ernawati; Novratilova, Sinta
Science Midwifery Vol 13 No 1 (2025): April: Health Sciences and related fields
Publisher : Institute of Computer Science (IOCS)

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.35335/midwifery.v13i1.1861

Abstract

Incomplete inpatient medical summaries remain a persistent issue that affects administrative processes and the quality of patient data. This study aimed to analyze the completeness and contributing factors of incomplete inpatient medical summaries using the Fishbone Method (Ishikawa Diagram). A qualitative descriptive approach was employed, with data collected through observations, interviews, and document reviews of 99 inpatient medical summaries, selected using Slovin’s formula with a 10% margin of error. The study involved medical record officers and healthcare professionals, selected through purposive sampling. Data analysis followed the qualitative descriptive method, including data reduction, data presentation, conclusion drawing, and triangulation. The findings identified five primary factors contributing to incomplete medical summaries: Man (low compliance among healthcare professionals), Method (suboptimal Standard Operating Procedures), Machine (ineffective hospital information systems), Money (insufficient investment in training), and Material (medical records not yet fully electronic). The study recommends medical staff training, SOP optimization, and the implementation of an electronic medical record system with a required lock feature to ensure complete documentation of inpatient medical summaries.
Analysis of factors causing duplicate medical record numbers in the electronic medical record system at Hermina Opi Jakabaring Hospital Banyuasin Regency Waskito, Hendri; Novratilova, Sinta
Science Midwifery Vol 13 No 2 (2025): June: Health Sciences and related fields
Publisher : Institute of Computer Science (IOCS)

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.35335/midwifery.v13i2.1995

Abstract

Along with the implementation of electronic medical records at Hermina Opi Jakabaring Hospital, various challenges have emerged in its implementation, one of which is the occurrence of duplicate medical record numbers. Duplication of medical record numbers is when a patient has two or more numbers in the medical record system. The purpose of this study was to determine the factors causing duplication of medical record numbers in electronic medical records. This research method is a descriptive qualitative method. Data were collected from 10 health workers through data collection with observation and interviews. Data were analyzed using the Fishbone method which includes five aspects, namely humans (man), equipment (machine), procedures (method), materials (material) budget (money), the results of the study showed that the biggest obstacle in the HR aspect was the lack of understanding and knowledge of officers about SOP, the unavailability of a medical card printing machine, SIMRS which does not yet have a NIK-based verification feature or a patient data duplication detection system, and the unavailability of a budget provided for the procurement of a medical card printing machine. This study provides strategic recommendations in overcoming duplication of medical record numbers so that it can improve the quality of service to patients.
Analysis of the inaccuracy of the prosedure code for outpatient BPJS patients in 2024 at Dr. Harjono S. Hospital, Ponorogo Regency Anggraini, Ivana Salsabila Myrilla; Novratilova, Sinta
Science Midwifery Vol 13 No 3 (2025): August: Health Sciences and related fields
Publisher : Institute of Computer Science (IOCS)

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.35335/midwifery.v13i3.2019

Abstract

The implementation of the Indonesian Case Based Groups (INA-CBG) system is a crucial instrument in the National Health Insurance (JKN) program for the payment of health service claims at advanced referral health facilities (FKRTL). The success of this system depends heavily on the accuracy of the codification of the diagnosis (ICD-10) and the action/procedure (ICD-9-CM) which is a representation of the service output. Code accuracy is not only essential for the collection of claim costs, but also plays an important role in nursing care, improving service quality, and analyzing morbidity-mortality data. A preliminary study at Dr. Harjono S. Ponorogo Hospital in January-February 2025 found 12 outpatient claim files (cardiac and neurological polys) in the June-August 2024 period with inaccuracies in the code of procedure, including 10 files that were not coded and 2 files that were incorrectly coded. Furthermore, initial observations through interviews with internal verifiers indicated the absence of a Standard Operating Procedure (SPO) for coding BPJS patients and the absence of coding evaluations from internal parties and hospital management. Based on these problems, this study aims to analyze the factors that cause the inaccuracy of the procedure code of outpatient BPJS patients at Dr. Harjono S. Hospital, Ponorogo Regency.
Quantitative analysis the completeness of electronic medical summaries for inpatient pediatric at Karya Medika Bantar Gebang Hospital Khodijah, Siti; Novratilova, Sinta
Science Midwifery Vol 13 No 3 (2025): August: Health Sciences and related fields
Publisher : Institute of Computer Science (IOCS)

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.35335/midwifery.v13i3.2058

Abstract

Incomplete documentation of pediatric inpatient electronic medical records at Karya Medika Bantar Gebang Hospital affects the quality of medical recordkeeping. A preliminary study revealed completeness rates of 100% for identification, 70% for important reports, 65% for accurate documentation, and 85% for authentication. This study aimed to analyze the factors contributing to these deficiencies. A qualitative descriptive method was applied, involving one medical record officer, two pediatric ward supervisors, and one triangulation informant. The research covered 764 pediatric inpatient electronic medical records from January to June 2025, with a random sample of 88 records determined using the Slovin formula. The results identified five contributing factors: human (incomplete entries by physicians), machine (unstable internet connection), money (no training budget), method (absence of standard operating procedures), and material (lack of tools for completeness analysis). The highest incompleteness occurred in accurate documentation and important reports. In conclusion, the study emphasizes the need to implement a reward and punishment system, provide backup modems, allocate budgets for staff training, establish SOPs in accordance with regulations, and utilize checklists as an evaluation tool.
Co-Authors ADNAN AVIF Agustyarum Pradiska Budi Agustyarum Pradiska Budi Anggraini, Ivana Salsabila Myrilla Asnasari, Laela AVIF, ADNAN Cecilia Hadri Ernawati Ernawati Fauziah Kurnia Permatasari Hadri, Cecilia Isjati, Muhammad Yusuf Isjati Kalyanita Kurniasari, septiana Vivi Novia nur adi satriyo pradista Nuraeni, Silvi Nurjayanti, Ratih Oktarina, Nenny Permatasari, Fauziah Kurnia Pradista, Nur Adi Satriyo Prayoga, Dina Ayu Raihan Dicky Ardiansyah Ricky, Agustinus Verry Rismawan Wisnu Aji Salsa Billa Karin Setyawati, Sulis Siti Khodijah Sri Suparti SRI WULANDARI Sukmaningsih, Wahyu Ratri Wahyu Ratri Sukmaningsih Wahyu Wijaya Widiyanto Waskito, Hendri Wicaksono, Aliansi Widiyanto , Wahyu Wijaya Widiyanto, Wahyu Wijaya