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All Journal Panrita Abdi - Jurnal Pengabdian pada Masyarakat Jurnal Pengabdian UntukMu NegeRI Jurnal Kesehatan Komunitas Jurnal Rekam Medis dan Informasi Kesehatan JURNAL PHOTON Ensiklopedia of Journal Menara Ilmu Jurnal Manajemen Informasi Kesehatan Indonesia (JMIKI) Indonesian of Health Information Management Journal (INOHIM) Community Engagement and Emergence Journal (CEEJ) ARSY : Jurnal Aplikasi Riset kepada Masyarakat Jurnal Rekam Medis (Medical Record Journal) Jurnal Olahraga dan Kesehatan (Orkes)

Henny Maria Ulfa

Universitas Hang Tuah Pekanbaru

Author-ID : 752010

Religion Agriculture, Biological Sciences & Forestry Arts Humanities Chemistry Computer Science & IT Economics, Econometrics & Finance Education Environmental Science Health Professions Law, Crime, Criminology & Criminal Justice Medicine & Pharmacology Nursing Physics Public Health Social Sciences Other

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Analisa Kelengkapan Informed Consent Tindakan Operasi di Rumah Sakit Sansani Pekanbaru Henny Maria Ulfa
Indonesian of Health Information Management Journal (INOHIM) Vol 6, No 1 (2018): INOHIM
Publisher : Lembaga Penerbitan Universitas Esa Unggul

AbstractInformed consent is the consent given patients told a doctor after being received an explanation. Researchers find there are still many incomplete Informed consent form. The purpose of this research is to know the analysis of the completeness of informed consent of surgery at Sansani Hospital Pekanbaru. Research methods Mixed Methods, design research Sequential Explanatory, The population all medical record of patient of surgery in 2017 were 2892, sample 97 medical record. The technique of Sampling Quota sampling, informants amounted 3 people observation, interview techniques are quantitative, qualitative analysis. The results of accuracy completeness of the informed consent has not reached 100%. Completeness of the Informed Consent Policy there has been no while the SOP and already, there's been a human resources analysis completeness with the DIII record medical degrees, the cause factor is still less awareness of the responsible officer in charge, no patient's family as witnesses, medical record officer effort is made by restoring the medical record to the room treatments. Recommends that there should be a policy and need to have monitoring, evaluation for completeness of charging medical record overall including Informed Consent so that reaches 100%.Keywords: Completeness informed consent the act of operation, medical record, the hospitalAbstrakInformed consent adalah persetujuan yang diberikan pasien kepada dokter setelah diberi penjelasan. Peneliti menemukan masih banyak formulir informed consent yang tidak lengkap. Tujuan penelitian mengetahui Analisa Kelengkapan Informed Consent Tindakan Operasi di Rumah Sakit Sansani Pekanbaru. Metode penelitian kombinasi (Mixed Methods), desain penelitian Sequential Explanatory. Populasi seluruh rekam medis pasien tindakan operasi tahun 2017 berjumlah 2892 dan jumlah sampel 97 rekam medis. Teknik pengambilan sampel Quota Sampling, informan berjumlah 3 orang dengan observasi dan wawancara. Tehnik analisis kuantitatif dan kualitatif. Hasil penelitian kelengkapan ketepatan pengisian informed consent belum mencapai 100%, Kebijakan kelengkapan Informed Consent belum ada, SOP sudah ada, sudah ada Sumber daya manusia melakukan analisa kelengkapan berlatar belakang DIII rekam medis, faktor penyebabnya kurang kesadaran petugas bertanggung jawab dalam pengisian, tidak ada keluarga pasien menjadi saksi, upaya dilakukan petugas rekam medis mengembalikan rekam medis ke ruang rawatan. Saran harus ada kebijakan, monitoring dan evaluasi untuk kelengkapan pengisian rekam medis secara keseluruhan termasuk Informed Consent sehingga mencapai 100%.Kata Kunci: Kelengkapan Informed Consent Tindakan Operasi, rekam medis, Rumah Sakit

Analisis Ketepatan Kode Diagnosa Penyakit Antara Rumah Sakit Dan BPJS Menggunakan ICD-10 Untuk Penagihan Klaim di Rumah Sakit Kelas C Sekota Pekanbaru Tahun 2016 Henny Maria Ulfa; Haryani Octaria; Tri Purnama Sari
Indonesian of Health Information Management Journal (INOHIM) Vol 5, No 2 (2017): INOHIM
Publisher : Lembaga Penerbitan Universitas Esa Unggul

AbstractThe implementation of the diagnostic coding should be completed and corrected in accordance with ICD-10 directives. The information obtained from the Class C Hospital in Pekanbaru City was occurred a mistake in determining the main diagnosis and secondary diagnosis which affects to the difference in encoding disease between hospitals and BPJS, then the diagnose code will be returned from the verifier to the hospital coder staff, that impact on the delay in the process of claiming BPJS. This reseach employs qualitative metodh within total informan are seven people. The result of this research found that the quality coding, the element of quality coding (reliability, validity, completnes and timely), the coding policies and procedures, the standards and coding ethics (clear and consistent) are good. We recommend for hospital to conduct a training and education for the coder’s staff continuously, and for BPJS to provide the information on current regulations and involve the hospital in making its regulation.Keyword: code accuracy, bpjs, billing claims AbstrakProses rumah sakit terhadap pengkodean harus dimonitor untuk beberapa elemen kualitas pengkodean yaitu Konsisten bila dikode petugas berbeda kode tetap sama (reliability), Kode tepat sesuai diagnosis dan tindakan (validity), Mencakup semua diagnosis dan tindakan yang ada di rekam medis (completenens). Di Rumah Sakit Kelas C Se-kota Pekanbaru terdapat perbedaan kode antara rumah sakit dan ferivikasi BPJS salah satunya untuk tindakan apendiksitis dan apendiksitis yang disertai dengan pelengkatan maka akan dikode dengan apendektomy.Informen penelitian berjumlah 7 orang yang terdiri dari direktur rumah sakit, kepala rekam medis,koding, dan ferivikator BPJS. Hasil yang diperoleh bahwa Kualitas pengkodean, Elemen kualitas pengkodean baik itu reliability, validity, completnes dan tepat waktu, dan Kebijakan dan prosedur pengkodean untuk rumah sakit sudah bagus, Standar dan etika pengkodean yang meliputi jelas dan konsisten, saran adanya pelatihan dan pendidikan untuk petugas koder selain itu BPJS dapat memberikan informasi mengenai peraturan-peraturan terbaru dan mengikut sertakan keterlibatan dari pihak rumah sakit dalam pembuatan peraturan.Kata kunci: ketepatan kode, bpjs, penagihan klaim

Co-Authors Abdurrahman Hamid Afifah Melsya Azli na Azlina Defry Adryansyah Putra Denai Wahyuni Deoni titriani indah sari Deoni Elmia Kursani Febrianti Febrianti Firman Edigan Gumayesty, Yeyen Kartika Septia Nanda M. Rizki Raafi Mohd. Rinaldi Amartha Mutia Sabrina Nur'Aina Basir Nurul Suci Rahayu Octaria, Haryani Raviola Raviola Risa Amalia Tasya Citra Mulia Tona Doli Silitonga Tona Doli Silitonga Tri Purnama Sari Twenty Gustia Wulan Sari Yessi Harnani YULISMAN

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Journal : Indonesian of Health Information Management Journal (INOHIM)