Rizka Andika Sari
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Development of the Register Assembling Method for Inpatient Patient Data Integration at RSUD Lawang Salsabila Syahda Maharani; Retno Dewi Prisusanti; Rizka Andika Sari
KESMAS UWIGAMA: Jurnal Kesehatan Masyarakat Vol 10 No 2 (2024): December
Publisher : Universitas Widya Gama Mahakam Samarinda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.24903/kujkm.v10i2.2966

Abstract

Background: A register is a notebook or list containing names, addresses and so on that are contained in a person’s identity. The inpatient assembling register activity at Lawang Hospital is still not carried out optimally, officers in the assembling until still record the register of medical record files manually by writing in the register book, this affects the accuracy of writing patient data from medical record files returning from the ward and efficiency when providing medical record files. Objectives: The purpose of this study is to improve the quality of patient data recording in register activities in the integrated assembling unit using an electronic system. Research Metodes: The research method uses qualitative descriptive with 1 respondent who has been interviewed directly and by direct observation. Results: The results of this study show an overview of the Google Form and spreadsheet designs that have been created and also show significant changes after the switch method using electronic systems. Conclusion: The development of the register assembling method for inpatient medical record files has brought positive changes in the efficiency of health information management at Lawang Hospital. This study shows that the application of innovative technology can make it easier for medical record officers to register patient files more efficiently. With the use of Google Forms which is integrated with the spreadsheet of patient data that is inputted, it is easier to read and faster to trace the existence of files that have been assembling. Keywords: Method; Register; Assembling
Development of an Evaluation Method to Measure the Accuracy of Inpatient Diagnosis Codes at Lawang Regional Hospital Diva Nur Asmianova; Achmad Jaelani Rusdi; Rizka Andika Sari
KESMAS UWIGAMA: Jurnal Kesehatan Masyarakat Vol 10 No 2 (2024): December
Publisher : Universitas Widya Gama Mahakam Samarinda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.24903/kujkm.v10i2.2967

Abstract

Background: The provision of diagnosis codes on medical record documents needs to be carried out accurately based on the ICD-10 book. The role of medical personnel and coding officers affects the accuracy of the diagnosis code. The coding officer must ensure that the medical record data is clear and complete such as severe or critical conditions, spesific anatomical positions, the course of health disorders, complications or the patient’s history to support the primary diagnosis. Objectives: The research objevtives to be achieved in this study evaluate and examine several causes that affect the accuracy of the selection of patient diagnosis codes at Lawang Hospital. Research Metodes: The type of research implemented is descriptive with a quantitative approach. Data collection is taken by observation, interviews, and code accuracy checklist. The population used in this study is all medical record files of inpatients in May with a total of 645 medical record documents. The sample was taken using a simple random sampling technique with as many as 25 medical record files of inpatients. Data analysis was carried out by univariate analysis by looking at the percentage of each research variable. Results: This study shows that the level of code accuracy is still said to be low because it still reaches 84% with as many as 21 documents and the code inaccuracy reaches 16% with as many as 4 documents. . Conclusion: The cause of inaccuracy will be due to the completeness of the primary and secondary diagnoses that are less specific, lack of communications between officers regarding clarity in writing in medical record documents, and some diagnoses do not include the 4th character in the case of fracture, namely the close or open description. For the development of evaluation, officers can take part in codification training and make help books such as pocket books that contain a collection of diagnosis codes. Keywords: Accuracy; Diagnosis Code; Medical Record; Hospital