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Journal : Jurnal Ilmiah Kesehatan Masyarakat

Ketersediaan Rekam Medis di Rumah Sakit Islam Jakarta Sukapura Gina Sonia; Lily Widjaja; Deasy Rosmala Dewi; Puteri Fannya
SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat Vol. 1 No. 2 (2022): April 2022
Publisher : Yayasan Literasi Sains Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (209.548 KB) | DOI: 10.55123/sehatmas.v1i2.110

Abstract

The medical record is an administration system that records all diagnoses and actions followed by the storage of medical records. Medical record retrieval is an important part to support the effectiveness of services in providing medical records for patients who return to the hospital. This research method uses quantitative descriptive and data collection techniques by observation, interviews and literature study. Based on the results of the research, the filing officer of the Islamic Hospital of Jakarta Sukapura often faced problems during retrieval, the results of the study found that 17 (3.4%) medical records were not found and 26 (5.2%) medical records were misplaced. Factors inhibiting the implementation of medical record retrieval include man factors such as the educational background of officers and the habitual factor of officers who do not use tracers when carrying out medical record retrieval that is not in accordance with SPO at the Islamic Hospital of Jakarta Sukapura. The money factor does not affect the implementation of medical record retrieval. The machine factor is the SMART system for medical record data entry that comes off the shelf. The method factor is that the standard operating procedure for retrieval of medical records is not fully appropriate. The material factor is the absence of loan receipts.
Tinjauan Pendokumentasian Yang Baik Pada Rekam Medis Pasien Rawat Inap Di Rumah Sakit Kanker Dharmais Jakarta Bayu Fajar Ilhami; Lily Widjaja; Deasy Rosmala Dewi; Laela Indawati
SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat Vol. 1 No. 2 (2022): April 2022
Publisher : Yayasan Literasi Sains Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (278.313 KB) | DOI: 10.55123/sehatmas.v1i2.167

Abstract

The contents of the Medical Record are not only data on the treatment of sick patients, but also overall health data so that it is more accurately called Health Records. In general, the Health Record is an overview of the patient's health provided by the service provider/doctor to the patient to become the patient's health record. The purpose of this study was to determine the quality of good documentation in inpatients at Dharmais Cancer Hospital. The research design is cross sectional, namely research conducted at a certain time. Data sources: article searches conducted on Google Scholar to use articles that are in accordance with the research.research method Descriptiveis to describe directly the object under study using a quantitative approach. The results of the study obtained the number of completeness of medical records reached 89.13%. The sample obtained 92 medical record files, with the results of the Initial Medical Assessment Form getting a completeness score of 88.77%, CPPT Form 87.68%, Shift Handover 90.58%, and Consultation Sheets 89.49%. Medical Record Documentation still needs to be improved. Dharmais Cancer Hospital, the number of completeness of medical records needs to be increased so that the documentation of medical records is of higher quality.
Tinjauan Kelengkapan Berkas Persyaratan Klaim Pasien Rawat Inap Covid-19 di Rumah Sakit Sumber Waras Bahlani; Lily Widjaja; Deasy Rosmala Dewi; Laela Indawati
SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat Vol. 1 No. 2 (2022): April 2022
Publisher : Yayasan Literasi Sains Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (227.522 KB) | DOI: 10.55123/sehatmas.v1i2.237

Abstract

Every hospital organizes a health insurance program, the implementation of the national health insurance program is operated by the Health Office, before the hospital collects payments to the Health Office, a complete inpatient claim requirement file is required, if the inpatient claim requirement file is incomplete it will hamper the process. the health office's claim to the hospital, causing a pending claim. The purpose of this study was to get an overview of the completeness of the claim file requirements for Covid-19 inpatients at Sumber Waras Hospital. The research was conducted using a quantitative descriptive method. The sample in this study was taken from the claim requirements file for Covid-19 inpatients at the Sumber Waras Hospital. Sampling using systematic random sampling. Data was collected using a checklist and interview guidelines submitted to Casmiex officers at Sumber Waras Hospital. Based on the results of a study of 87 files for claim requirements for Covid-19 inpatients, 75.90% were obtained. The factors causing the incompleteness of the Covid-19 inpatient claim file requirements are the Covid-19 inpatient claim requirement file provided by the service officer in hardcopy, the service officer does not provide all the files that exist at the patient's discharge date in that month, the occurrence of errors in inputting patient data and medical support officers do not directly enter the results of laboratory tests. Therefore, it is necessary to disseminate information to service personnel so that they can complete the claim requirements for inpatients in a timely manner.
Literature Review : Kelengkapan Kode Topography dan Morphology pada Kasus Neoplasma Dian Nur Muslimah; Deasy Rosmala Dewi; Laela Indawati; Lily Widjaja
SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat Vol. 2 No. 1 (2023): Januari 2023
Publisher : Yayasan Literasi Sains Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.55123/sehatmas.v2i1.1000

Abstract

In the Medical Record for determining the cancer diagnosis code (Neoplasm), there are 2 codes, namely the topographic code and the morphology code. These two codes are very important because the topographic code is a code that shows the location of the tumor, while the morphology code is a code that shows the nature of the tumor. If the two codes are not included, it will not determine the level of malignancy of the tumor. The aim of the study was to identify the completeness of the topographic and morphological codes in neoplasm cases. Literature study conducted on 7 journals uploaded online in the span of 2011-2021. Search journals in this study using the keywords "completeness", "Topography and Morphology code" obtained through Google Scholar. The results of the literature review show that the completeness of topographic and morphological codes in neoplasm cases has not yet reached 100%. The highest completeness of topographic codes is 98% at Aisyiyah Hospital Malang in 2018. While the lowest percentage is 0% at MRCCC Siloam Semanggi Hospital in 2020 and Karanganyar District Hospital in 2011. The highest completeness of morphology codes is 82.4% at Santa Elisabeth Hospital Medan while The lowest percentage was 0% at MRCCC Siloam Semanggi Hospital in 2020, Bhayangkara Hospital, Aisyiyah Hospital, Dr Moewardi Hospital, and Karanganyar District Hospital. The incompleteness is due to 2 factors Man: Coder inaccuracy in coding, officers have not implemented coding procedures in neoplasm cases. Method: there is no SOP for coding neoplasms, there is no PA result sheet, and the doctor's writing is not clear and complete. In assigning codes to neoplasm cases, officers should code according to the SOP, so that the resulting code is complete and accurate.
Analisis Kualitatif Kelengkapan dan Kekonsistensian Diagnosis di Rumah Sakit Patria IKKT Suciyanti Suciyanti; Lily Widjaja; Puteri Fannya; Dina Sonia
SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat Vol. 2 No. 2 (2023): April 2023
Publisher : Yayasan Literasi Sains Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar

Abstract

Qualitative analysis is a review of filling in medical records related to the consistency of the contents of medical records. A good medical record must contain complete medical records. This type of research is descriptive with a qualitative approach with observation and interview data collection techniques. This qualitative analysis has 6 components. The purpose of this study was to find out a qualitative analysis of the completeness and consistency of diagnosis in dengue fever patients for the period September-October 2022. This research was conducted using a systematic random sampling method. From 85 medical records, the results of a qualitative analysis on the completeness of the consistency of the diagnosis obtained the percentage of consistency of 63.53%. While the results of the 6 subcomponents include: Completeness of diagnosis at admission: 58.82% incomplete, Consistency of diagnosis at admission: 58.82%, Completeness of diagnosis while being treated: 64.71%, Consistency of diagnosis while being treated amounted to: 64.71%, Completeness of diagnosis when going home amounted to: 67.06%, Consistency of diagnosis when going home amounted to: 67.06%. Of the 6 sub-components the highest proportion of consistency was consistency of completeness and consistency of diagnosis at the time of going home = 67.06%. While the lowest completeness & consistency of diagnosis at admission = 58.82%. The conclusion is that the qualitative analysis of the completeness and consistency of the diagnosis is not 100% in accordance with the Hospital MSS.
Analisis Kualitatif Konsistensi Pencatatan Rekam Medis Rawat Inap Kasus Penyakit Dalam di Rumah Sakit Pelabuhan Jakarta Putri Nurindahsari; Dina Sonia; Lily Widjaja; Daniel Happy Putra
SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat Vol. 2 No. 4 (2023): Oktober 2023
Publisher : Yayasan Literasi Sains Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.55123/sehatmas.v2i4.2352

Abstract

Qualitative analysis is an activity that examines the filling of medical records for inconsistent and incomplete contents, which indicates that the medical records are inaccurate and incomplete. The purpose of this study was to find out a qualitative analysis of the reliability of recording medical records of inpatient cases of internal medicine for the year 2022. This type of research uses a descriptive method with a quantitative approach and data collection by observation and interviews. Of the 99 medical records, the results obtained were 96% consistent and 4% inconsistent. And the results of the 4 subcomponents include: At the time of admission, namely the consistency of the initial assessment of nurses and inpatient doctors, the results were 98% consistent. On the subcomponent during hospitalization, namely the consistency of progress notes between doctors and nurses, obtaining results of 99% consistency, Consistency of Doctor's Instructions with delivery notes the drug gets 93% consistent results, when going home, namely the consistency of the doctor's return summary and the nurse gets 94% consistency results. Of the 4 sub-components that have the highest consistency, the consistency between the doctor's and nurse's developmental records obtains 99% consistent results. While the lowest was the consistency of the Doctor's Instructions with a record of drug administration obtaining 93% consistent results. The conclusion is that the qualitative analysis of medical record recording is not 100% consistent. It is recommended that the Jakarta Harbor Hospital make standard operating procedures and implement related qualitative analysis of medical records.
Tinjauan Penyebab Pengembalian Berkas Klaim Biaya Pelayanan Pasien Rawat Inap BPJS Kesehatan di Rumah Sakit Pelabuhan Jakarta Tahun 2022 Siti Rahmawati Handayani; Lily Widjaja; Daniel Happy Putra; Dina Sonia
SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat Vol. 2 No. 4 (2023): Oktober 2023
Publisher : Yayasan Literasi Sains Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.55123/sehatmas.v2i4.2617

Abstract

In the process of submitting a BPJS Health Claim, some requirements must be completed by the Health Facility. Of these requirements, the BPJS Health party will know that the claim submission can be paid or returned/delayed. This research was conducted to find out the reasons for returning the claim file for BPJS Kesehatan inpatient care at the Jakarta Harbor Hospital in 2022. The method in this study used descriptive research with a quantitative approach. The results of the study were 118 samples (6.7%) of 1,762 files, the highest returned cause was an inaccuracy in the coding of diagnoses/actions of 49 (42%), and the second highest was not fulfilling inpatient administration 18 (15%), other causes - others as much as 51 (43%). 3 factors from 5M are the cause of returning claim files, namely the human factor: casemix officers who are not diligent, lack of coder understanding/knowledge, and lack of accuracy in the filing department so that files are missed/left behind, machine: there is an upgrade to the latest version of the INA-application CBGs and V-Claim are also the Ministry of Health's newest program which requires TB patients to be inputted into the SITB application, Material: incomplete claim requirements files. While the money and method factors are not an obstacle or a cause for returning claim files. It is recommended to evaluate and re-socialize the reasons for returning BPJS Health claims so that the process of submitting BPJS Health claims is carried out properly and is 100% accepted.
Tinjauan Ketepatan Kode Diganosis Tuberkulosis Paru Pasien Rawat Jalan di Rumah Sakit SHL Pandeglang Rahelia Putri; Lily Widjaja; Dina Sonia; Daniel Happy Putra
SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat Vol. 3 No. 2 (2024): April 2024
Publisher : Yayasan Literasi Sains Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.55123/sehatmas.v3i2.3423

Abstract

In coding activities, medical recorders and health information are needed who master how to give disease codes according to ICD-10 and actions according to ICD-9 CM so that the resulting code has accuracy according to the diagnosis or action given. One of the most frequently used coding accuracy is accuracy in coding for Pulmonary Tuberculosis. One of the important things is how to describe the accuracy of the Outpatient Pulmonary Tuberculosis diagnosis code at SHL Pandeglang Hospital. This study was shown to determine the accuracy of the diagnosis code for Outpatient Pulmonary Tuberculosis at SHL Pandeglang Hospital. This research method uses a descriptive method with a quantitative approach. The sample of this study was taken by saturated sampling technique. Data were taken using interviews and observations. The results of the study of 122 medical records obtained accuracy of 93 (76.2%) files and inaccuracy of 29 (23.8%) files. Based on the identification of factors causing the inaccuracy of the diagnosis code, there are 4 factors, namely the man factor: occurs due to the lack of accuracy of the coder in coding, the workload of the coder, and the lack of training for coders with non-RMIK backgrounds. Material factors: the unavailability of the Medical Dictionary (Dictionary of Medical Terminology) and the absence of an abbreviated list of diagnoses (standard). Machine factors: damage to the computer, software hangs, and computers that are too old. Method factor: incomplete SPO diagnosis coding.
Co-Authors Adinda Pratiwi Alex Sander Alfi Shiddiq Syafrian Aliyani Aliyani Angelina Angelina Anggraini, Adelia Annisa Nur Salsabila Arip Budiana Bahlani Bangga Agung Satrya Bangun, Evi Vania Bayu Fajar Ilhami Bella Safitri Choirunisa Choirunisa Dani Sagitha Daniel Happy Putra Deasy Rosmala Dewi Deasy Rosmala Dewi Dewi, Deasy Rosmala Dewi, Sisilia Kartika Dian Nur Muslimah Dina Sonia Dina Sonia Dwijayanti, Risma Mei Eka Widya Rita P. Fadia Eka Septiawati Fannya, Puteri Fauziah Irfany Ferina Ferina Ferina, Ferina Gabriella Eviana Bangun Gina Sonia Gita, Elsa Chandra Harahap, Maulidiah Rizki Hosizah Hosizah Ilham Abdurohman Indawati, Laela Intan Rusdiana Dewi Khoirunnisa Sabiladina Laela Indawati Laela Indawati Laela Indawati Laela Indiawati Lautsan, Christina M. Fuad Iqbal Mega Puspita Azidah Muhamad Fazriyansah Muhammad Rezal Muniroh - Muniroh Muniroh Muniroh Muniroh Muniroh Muniroh Muniroh Muniroh Muniroh, Muniroh Natsir Nugroho Noor Yulia Noor Yulia Nurmalasari, Dinda Nurmalasari, Mieke Octa Rina Sari Pratiwi, Adinda Puspita, Kori Puteri Fannya Puteri Fannya Putri Nurindahsari Putri, Alifatul Aulia Sagita Rahayu, Ririn Rahelia Putri Ratna Indrawati Regina Yulianti T. S Rezal, Muhammad Risma Sisni Fadilla Rosmala Dewi , Deasy Rosmala Dewi, Deasy Saarah Salsabila Putri Yadita Salsabila, Annisa Nur Sarah Khonsa Satrya, Bangga Agung Siti Rahmawati Handayani siti Widya Astuti, siti Sonia, Dina Suciyanti Suciyanti Suriyantoro, Suriyantoro Surlialy, Dewi Umi Khoirun Nisak Vania Rachma Putri Viatiningsih, Wiwik Wiranata, Tyansa Eka Sampoerna Wiwik Viatiningsih Yenni Syafitri Yulia, Noor