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All Journal Jurnal Manajemen Pendidikan Jurnal Manajemen Informasi dan Administrasi Kesehatan Journal of Multidisciplinary Academic Jurnal Manajemen Informasi Kesehatan Indonesia (JMIKI) Surya Medika: Jurnal Ilmiah Ilmu Keperawatan dan Ilmu Kesehatan Masyarakat Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Jurnal Ilmiah Wahana Pendidikan Nusantara Hasana Journal Arkus Indonesian Journal of Health Information Management (IJHIM) Jurnal Ilmiah Kesehatan Masyarakat Sehat Rakyat: Jurnal Kesehatan Masyarakat Jurnal Rumpun Ilmu Kesehatan Jurnal Sosial dan Sains Journal of Hospital Management Cerdika: Jurnal Ilmiah Indonesia MEDICORDHIF Jurnal Rekam Medis Journal of Educational Innovation and Public Health Jurnal Medika Nusantara Vitamedica: Jurnal Rumpun Kesehatan Umum Vitalitas Medis : Jurnal Kesehatan Dan Kedokteran Vitamin: Jurnal Ilmu Kesehatan Umum Obat: Jurnal Riset Ilmu Farmasi dan Kesehatan Jurnal Rekam Medic
Widjaja, Lily
Universitas Esa Unggul, Jakarta
Religion Agriculture, Biological Sciences & Forestry Humanities Astronomy Computer Science & IT Dentistry Economics, Econometrics & Finance Education Engineering Environmental Science Health Professions Law, Crime, Criminology & Criminal Justice Library & Information Science Medicine & Pharmacology Nursing Physics Public Health Social Sciences Veterinary Other

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Tinjauan Ketepatan Kode Penyakit Tuberkulosis Paru Berdasarkan ICD-10 pada Pasien Rawat Inap di RSKD Duren Sawit Tahun 2021 Vania Rachma Putri; Puteri Fannya; Deasy Rosmala Dewi; Lily Widjaja
Sehat Rakyat: Jurnal Kesehatan Masyarakat Vol. 2 No. 2 (2023): Mei 2023
Publisher : Yayasan Pendidikan Penelitian Pengabdian Algero

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.54259/sehatrakyat.v2i2.1675

Abstract

Coding accuracy is the process of conforming to the diagnosis code that has been determined by the coding officer based on ICD-10 which greatly affects data reporting and administration. Pulmonary tuberculosis is an infectious disease caused by Mycobacterium tuberculosis which causes disturbances in the respiratory tract. In RSKD Duren Sawit pulmonary tuberculosis is included in the 10 biggest diseases. The purpose of this study was to determine the accuracy of the pulmonary tuberculosis disease code based on ICD-10 in inpatients at RSKD Duren Sawit in 2021. This study used a descriptive method with a quantitative approach that took 80 samples using a saturated sample technique by means of observation and interviews. The results obtained from 80 samples of the accuracy of the pulmonary tuberculosis code of inpatients at RSKD Duren Sawit found that 56 (70%) and 24 (30%) were inaccurate. There are factors that affect the inaccuracy of using the 5M (Man, Money, Material, methode, Machine) element, namely the man element due to the inappropriateness of the coding officer's profession and lack of thoroughness and the element of the coding SOP method which is still being revised. Suggestions should be officers who do coding in accordance with their profession or medical recorders.
GAMBARAN KETEPATAN PENGODEAN PENYEBAB KEMATIAN PADA SERTIFIKAT MEDIS PENYEBAB KEMATIAN KASUS PERINATAL DI RSIA TIARA CIKUPA Octa Rina Sari; Laela Indawati; Noor Yulia; Lily Widjaja
Nusantara Hasana Journal Vol. 3 No. 3 (2023): Nusantara Hasana Journal, August 2023
Publisher : Yayasan Nusantara Hasana Berdikari

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.59003/nhj.v3i3.957

Abstract

The basic cause of death is used as an evaluation of a health service, knowing the general health status, reporting mortality and prevention of deadly diseases and preparing for medical needs in the future. The purpose of this research is to know the description of the accuracy of the coding accuracy of the cause of death on the perinatal case death certificate at RSIA Tiara. The research method used in this research is a descriptive mix method where a mix of quantitative and qualitative is by describing and explaining the accuracy of the UCoD coding on medical certificates causing death in perinatal cases. The population in this study were all medical records of babies who died in 2020, 2021 and 2022, totaling 32 medical records. The sample used in this study was a saturated sample where all populations were sampled, namely 32 medical records. The results of the presentation of the accuracy of the coding on the medical certification cause of death were as much as 69% while those that were not correct were as many as 31%. It is preferable to code all diagnoses in the prenatal case death certificate using the guideline and rules P1,P2,P3,P4 to give the correct code. Factors causing inaccuracy in codification of the underlying cause of death on the death certificate, the doctor's writing on the infant's medical resume in the final diagnosis section using cursive letters creates obstacles for the coding officer in determining the correct code. There is no special SPO for coding prenatal cases. Lack of human resources with a background in medical records.
Tinjauan Ketepatan Penjajaran Rekam Medis Di Rumah Sakit Umum Daerah Kembangan Fauziah Irfany; Lily Widjaja; Laela Indawati; Deasy Rosmala Dewi
Vitamin : Jurnal ilmu Kesehatan Umum Vol. 2 No. 1 (2024): January : Jurnal ilmu Kesehatan Umum
Publisher : Asosiasi Riset Ilmu Kesehatan Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.61132/vitamin.v2i1.188

Abstract

Alignment is the process of aligning medical records in the storage room according to the system used. The medical record storage system at Kembangan Hospital uses centralization, the medical record numbering system uses the Unit Numbering System (UNS) and the alignment system uses Terminal Digit Filing (TDF). The aim of this research is to determine the accuracy of medical record alignment. This research used a descriptive method with a quantitative approach, the population was 293 medical records using a saturated sample. From the results of research on the primary digit 07 storage shelf, it was found that there were inaccuracies in the alignment of 162 medical records (55%). This alignment inaccuracy was divided into three digits, namely 34 medical records (21%) had the 1st digit incorrect, 85 medical records (52%) had the 2nd digit incorrect and 43 medical records (27%) had the 3rd digit incorrect. . It was found that the cause of the alignment error was due to human error, the unavailability of a tracer and the map not using color coding. Medical records that cannot be found can be traced by looking at the patient's history of treatment at Simrs Khanza, then looking for the first digit number that is being searched for. When a medical record is not found, a search for the accuracy of the alignment of the medical record is carried out using the medical record tracking method. If a medical record cannot be found, a new medical record will be used temporarily.
Analysis Of The Quality Of Services and Physical Facilities Of The Hospital On Word Of Mouth With Patient Experience As An Intervening Variable At Mekar Sari Hospital Dani Sagitha; Natsir Nugroho; Lily Widjaja
OBAT: Jurnal Riset Ilmu Farmasi dan Kesehatan Vol. 2 No. 2 (2024): March : OBAT: Jurnal Riset Ilmu Farmasi dan Kesehatan
Publisher : Asosiasi Riset Ilmu Kesehatan Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.61132/obat.v2i2.304

Abstract

This research is aimed at analyzing the influence of service quality and physical facilities on WoM (Word of Mouth) with Patient Experience as an intervening variable at Mekar Sari Hospital. The research method used in this research is a correlational quantitative research type with a cross-sectional research design approach by looking at the influence of service quality and physical facilities on WoM with satisfaction as an intervening variable.The sampling technique used purposive sampling, namely a sampling technique using the criteria of internal medicine inpatients at Mekar Sari Hospital. The research sample involved 110 respondents. Path analysis is used as a WoM model analysis tool with patient experience as an intervening variable.The results of this study found a joint positive influence of service quality and physical facilities on WoM with patient experience as an intervening variable. The quality of service and physical facilities have a positive influence on both patient experience and WoM.
HUBUNGAN KEMAMPUAN AKADEMIK MAHASISWA REKAM MEDIS DENGAN HASIL BELAJAR PADA MAHASISWA TINGKAT AKHIR Wiranata, Tyansa Eka Sampoerna; Rumana, Nanda Aula; Widjaja, Lily; Putra, Daniel Happy
Jurnal Manajemen Pendidikan Vol. 9 No. 2 (2024): Regular Issue
Publisher : STKIP Pesisir Selatan

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.34125/jmp.v9i2.598

Abstract

This research aims to determine the relationship between student academic abilities and learning outcomes in final year students of the Medical Records and Health Information Study Program at one of the universities in Jakarta. The research method used is quantitative analysis using the independent T-test where researchers describe the relationship between students' academic abilities and learning outcomes. Based on the research results, it was found that the average age of students was 22 years with the majority of students being female, namely 77.8%. The description of academic ability is 88.9% good and 11.1% not good. The average learning outcome description is 3.51 with the largest learning outcome being 3.97 and the smallest being 2.66. Based on the research results, it was found that there was a significant relationship between learning outcomes and academic abilities (p-value <0.002). Where respondents whose academic abilities are good have a higher learning outcome score of 3.54 compared to respondents whose academic abilities are not good, namely 3.25. So, it can be seen that there is a quite significant correlation between academic ability and learning outcomes.
Tingkat Kepuasan Pasien BPJS Di Tempat Pendaftaran Pasien Rawat Jalan Di Rumah Sakit Hermina Bitung Kabupaten Tanggerang Angelina Angelina; Lily Widjaja; Nanda Aula Rumana; Puteri Fannya
Journal of Educational Innovation and Public Health Vol. 2 No. 1 (2024): Januari : Journal of Educational Innovation and Public Health
Publisher : Pusat Riset dan Inovasi Nasional

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.55606/innovation.v2i1.2043

Abstract

Patient satisfaction is a factor that can be used as a reference in determining the success of a service program. Patient satisfaction will arise when it is supported by good quality service. There are five dimensional aspects known as service quality (SERVQUAL), reliability, responsiveness, assurance, empathy, and tangible. These five dimensions influence patient satisfaction. This research aims to provide an overview of the level of satisfaction of outpatient BPJS patients at Hermina Bitung Hospital, Tanggerang Regency in 2023. This research uses a descriptive method with a quantitative approach with the data that has been collected being processed using SPSS (statistical packagen for the social sciences) then the results analyzed by measuring the average percentage for each patient criterion and a sample size of 76 respondents, from this research it can be concluded that patient satisfaction through the reliability dimension is 56.58%, the responsiveness dimension is 55.26%, the assurance dimension was 53.95%, the empathy dimension was 56.58%, while the direct evidence (tangible) was 51.32%. Thus, the researchers concluded that the number of BPJS patients in outpatient registration services was 52.63%. This result still does not reach the minimum service standard set by the Indonesian Ministry of Health in 2008, which is ≥90%.
Tinjauan Pelaksanaan Penyusutan Rekam Medis Di Rumah Sakit Umum Daerah Kembangan Intan Rusdiana Dewi; Lily Widjaja; Laela Indawati; Noor Yulia
Jurnal Rumpun Ilmu Kesehatan Vol. 3 No. 3 (2023): November: Jurnal Rumpun Ilmu Kesehatan
Publisher : Pusat Riset dan Inovasi Nasional

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.55606/jrik.v3i3.2680

Abstract

Shrinkage is the reduction of medical records on storage shelves by moving inactive medical records to a different room from the active shelf seen from the last patient visit. The purpose of this study was to determine the implementation of shrinkage at the Kembangan Regional General Hospital. This research method uses a qualitative descriptive method by means of interviews and observations in the medical records unit. So it can be concluded from the results of the study that the Kembangan Regional General Hospital already has SOP related to shrinkage which is divided into SOP sorting, media transfer and destruction. In the implementation of shrinkage, officers carry out the process of sorting, transferring and transferring media every day. But officers do not conduct an assessment based on use value. The destruction process is carried out when the number of medical records has reached 2 tons by using a third party to make medical records in the form of pulp. The main obstacles to the implementation of shrinkage are officers who do not have a decree on duties and teams so that officers often delay the implementation of shrinkage, paper quality that makes it difficult for officers to see medical record sheets in the past year and scan machines that heat up quickly due to continuous use. Therefore, the Kembangan Regional General Hospital should complete the SOP related to shrinkage, make a decree of duties and conduct an assessment stage so that the implementation of shrinkage is carried out properly, and add a scan machine so that the implementation of media transfer is not delayed.
Audit Kode Klinis Pasien Rawat Inap Jaminanan BPJS Kesehatan Di Rumah Sakit Tipe C Dan D Wilayah DIY Hosizah, Hosizah; Puspita Ningsih, Kori; Nisak, Umi Khoirun; Widjaja, Lily
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.v9i2.1707

Abstract

The quality of diagnosis codes is an important part of the hospital management level. The impact of a lack of quality diagnosis codes is the potential to reduce hospital income. A clinical coding audit needs to be conducted to review and analyze discovered errors and attempt to trace their source. The purpose of this research is to audit the code. The research approach was carried out through a quantitative descriptive approach. The research population was inpatient medical records of BPJS Health patients. Sample calculations use Slovin, with a margin of error of 10%. In this study, the clinical coding audit involved 3 coders in each hospital, coding experts from senior practitioners from Type B Hospitals and experts from academics. The results of the clinical code audit showed that the timeliness aspect was 100%, accuracy was 92.5%, completeness was 91.0%, relevance, and legitimacy were 87.5% each, while the lowest was in the reliability aspect at 80.0%. The results of the legibility aspect are in line with the results of relevance. This shows that determining clinical codes for case mix purposes must be supported by complete documentation of the patient's medical records.
ANALISIS FAKTOR YANG MEMPENGARUHI PERILAKU PENGGUNAAN SISTEM REKAM MEDIK ELEKTRONIK MENGGUNAKAN METODE UTAUT Bangun, Evi Vania; Suriyantoro, Suriyantoro; Widjaja, Lily
Journal of Hospital Management Vol 5, No 02 (2022): Journal of Hospital Management
Publisher : Lembaga Penerbitan Universitas Esa Unggul

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.47007/.v5i02.5862

Abstract

Latar Belakang dan Tujuan Rekam medis elektronik adalah sistem informasi kesehatan berbasis komputerisasi yang menyediakan dengan rinci catatan tentang data demografi pasien, riwayat kesehatan, alergi, dan riwayat hasil pemeriksaan laboratorium serta beberapa diantaranya juga dilengkapi dengan sistem pendukung keputusan. Tujuan penelitian adalah untuk menganalisis pengaruh faktor ekspektasi kinerja, ekspektasi usaha, pengaruh sosial, dan kondisi fasilitas dengan variabel intervening niat perilaku yang dimoderasi faktor umur dan pengalaman terhadap perilaku penggunaan sistem rekam medis elektronik. Metode: Model yang digunakan untuk menguji penerimaan dan penggunaan teknologi adalah Unified Theory of Acceptance and Use of Technology (UTAUT).  Penelitian ini menggunakan pendekatan kuantitatif dengan desain  penelitian explanatoris causalitas dengan sampel sebanyak 109 orang. Tehnik pengambilan data dengan kuesioner dan wawancara, diuji dengan analisis jalur. Hasil: Berdasarkan hasil penelitian diatas dapat dirangkum bahwa temuan pada penelitian ini adalah sejalan dengan teori UTAUT dengan variabel faktor ekspektasi kinerja, ekspektasi usaha, pengaruh sosial dan kondisi fasilitas berpengaruh terhadap perilaku penggunaan rekam medis elektronik melalui niat perilaku yang dimoderasi faktor umur baik secara masing-masing maupun simultan. Selain itu, faktor moderasi umur berpengaruh terhadap perilaku penggunaan sistem rekam medis elektronik namun faktor moderasi pengalaman tidak berpengaruh terhadap perilaku penggunaan sistem rekam medis elektronik.  Implikasi: Penelitian ini membantu manajemen rumah sakit menyadari pentingnya dukungan manajemen dalam implementasi penerapan sistem yaitu penyediaan fasilitas dan tenaga pendukung IT yang akan membantu user jika mengalami kendala, juga membantu manajemen dalam mengembangkan fitur dan aplikasi sistem rekam medis elektronik ini untuk lebih mudah digunakan sesuai kebutuhan professional pemberi asuhan. 
Pemanfaatan Personal Health Record Dalam Mengontrol Kesehatan Individu (Literature Riview) Regina Yulianti T. S; Laela Indawati; Lily Widjaja; Daniel Happy Putra
Jurnal Medika Nusantara Vol. 2 No. 2 (2024): Mei : Jurnal Medika Nusantara
Publisher : Stikes Kesdam IV/Diponegoro Semarang, Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.59680/medika.v2i2.1126

Abstract

Individuals are authorized to access, maintain, and share their Personal Health Record (PHR), which is an electronic application, in a private, secure, and confidential setting. Using PHR will facilitate patient-provider communication. PHR has two-way communication that allows patients and providers to communicate with each other. The main effect of using PHR is that patients will be involved and take an active role in their health and disease prevention. The act of recording health information in PHR will increase patient awareness, such as weight, diet and glucose, and other health checks. Through PHR which stores health information, and consultations, patients feel safe knowing their health. The purpose of this writing is to determine the Utilization of Personal Health Record in controlling individual health. This study uses the Literature Review method. The results of this study are seen from the utilization and features of the Personal Health Record. Utilization of the Personal Health Record in controlling individual health can assist patients in accessing patient personal health information such as knowing blood sugar, blood pressure, laboratory results, and so on. The features used in the PHR have a main menu including health records, medical records, test results, medication reminders, health contacts, and education.
Co-Authors Adinda Pratiwi Alex Sander Alfi Shiddiq Syafrian Aliyani Aliyani Angelina Angelina 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 Dewi, Deasy Rosmala Dewi, Sisilia Kartika Dian Nur Muslimah Dina Sonia Dina Sonia Dwijayanti, Risma Mei Eka Widya Rita P. Elsa Chandra Gita Fadia Eka Septiawati Fannya, Puteri Fauziah Irfany Ferina Ferina Gabriella Eviana Bangun Gina Sonia Hosizah Hosizah Ilham Abdurohman Indawati, Laela Intan Rusdiana Dewi Khoirunnisa Sabiladina Laela Indawati Laela Indawati Laela Indawati Lautsan, Christina M. Fuad Iqbal Mega Puspita Azidah Muhamad Fazriyansah Muhammad Rezal Muniroh - Muniroh Muniroh Muniroh Muniroh Muniroh Muniroh Muniroh Muniroh Nanda Aula Rumana Nanda Aula Rumana Natsir Nugroho Noor Yulia Noor Yulia Nurmalasari, Mieke Octa Rina Sari Puspita, Kori Puteri Fannya Puteri Fannya Putri Nurindahsari Putri, Alifatul Aulia Sagita Rahelia Putri Ratna Indrawati Regina Yulianti T. S Rezal, Muhammad Risma Sisni Fadilla Rumana, Nanda Aula Saarah Salsabila Putri Yadita Sarah Khonsa Satrya, Bangga Agung Siti Rahmawati Handayani Suciyanti Suciyanti Suriyantoro, Suriyantoro Surlialy, Dewi Umi Khoirun Nisak Vania Rachma Putri Wiranata, Tyansa Eka Sampoerna Wiwik Viatiningsih Yenni Syafitri Yulia, Noor