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All Journal J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan
Jayanti, Asykar
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Health Professions Public Health

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Pengembangan Modul Rekam Medis Elektronik (RME) Rehabilitasi Medik Rawat Jalan Jayanti, Asykar; Sugiarsi, Sri; Rohmadi, Rohmadi
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 5 No 4 (2024): September
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v5i4.4890

Abstract

The outpatient medical record documentation at RSUP dr. Soeradji Tirtonegoro already uses Electronic Medical Records (EMR), except for the Medical Rehabilitation clinic. This results in patient medical records data not being integrated into the EMR, requiring consulting doctors to access physical medical record files to view notes from the Medical Rehabilitation clinic. The aim of this research is to develop an electronic medical record system for outpatient medical rehabilitation. The research method used is Research and Development (R&D), with system development employing the Rapid Application Development (RAD) method. The outcome of this research is an electronic medical record module for outpatient medical rehabilitation, used by nurses, doctors, and therapists visiting the Medical Rehabilitation clinic to document patient records. It is recommended for future researchers to add a patient initial assessment module for nurses and doctors. It is also hoped that this system can be integrated with the billing system and digital claims, enabling the information system to be fully utilized in the services provided at the Medical Rehabilitation clinic.
Analisis Kelengkapan Rekam Medis Dengan Kelayakan Klaim BPJS Pasien Rawat Inap Jayanti, Asykar; Waskito, Dito Yogo; Sugiarsi, Sri
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 6 No 4 (2025): September
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v6i4.6198

Abstract

Dr. Soeradji Tirtonegoro General Hospital, as a Public Service Agency in collaboration with BPJS Kesehatan, has encountered challenges in achieving patient service claim targets. In June 2024, 71.23% of submitted claims were deemed eligible, while 28.77% were pending out of 1,950 total claims, resulting in the hospital’s Director Performance Index target of 93.75% for resolving pending BPJS Kesehatan claims not being met. This study aims to analyze the relationship between medical record completeness and the eligibility of inpatient BPJS Kesehatan claims. An observational analytic approach with a cross-sectional design was applied to a sample of 361 inpatient BPJS Kesehatan claim files submitted between September and November 2024. Data analysis was conducted using the Fisher Exact Test with SPSS version 23. The results revealed a significant relationship between medical record completeness and claim eligibility (p = 0.000). It is therefore recommended that healthcare professionals and coders pay greater attention to aspects influencing the accuracy of claim documents by providing specific diagnoses and procedures, strengthening coder competencies to ensure precise diagnostic coding, and implementing concurrent analysis prior to patient discharge with the involvement of case managers, in order to minimize incomplete medical records and reduce pending claims.
Co-Authors Rohmadi Rohmadi Sri Sugiarsi Waskito, Dito Yogo