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All Journal JOURNAL OF MEDICAL RECORDS AND HELATH INFORMATION Manajemen Pelayanan Kesehatan
Dony Setiawan
Politeknik Negeri Jember
Humanities Dentistry Education Health Professions Medicine & Pharmacology Nursing Public Health Social Sciences Veterinary

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Analisis Faktor Penyebab Ketidakakuratan Kode Diagnosis Utama Injury dan External causes pada Rekam Medis Rawat Inap di RSD dr. Soebandi Jember Novita Nuraini; Dyah Palupi Budiningsih; Maya Weka Santi; Dony Setiawan; Hendyca Putra
Manajemen Pelayanan Kesehatan Vol. 1 No. 4 (2024): October
Publisher : Indonesian Journal Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.47134/mpk.v1i4.6024

Abstract

The inaccurate coding of primary injury and external causes diagnoses is a classification issue in the ICD-10, posing risks of financial loss for hospitals and compromising the validity of statistical data. Between 2020 and 2022, the coding accuracy for inpatient injury diagnoses at RSD Dr. Soebandi Jember was 70%, while external100% inaccuracy because were not coded at all. This research aimed to analyze the factors causing inaccuracies in coding these diagnoses based on the Robbin performance theory and propose improvement strategies through brainstorming. In this qualitative study, data was collected through in-depth interviews, observations, and document analysis. Findings revealed ablity factor cause by the lack of Emergency Room physicians knowledge’s in completing injury case histories and discrepancies in medical terminology selection by attending physicians. Motivation factors were identified suboptimal reward and punishment systems, and the absence of feedback in evaluating medical record quality. The opportunity factor encompassed unclear task boundaries between coders and internal verifiers, and the coding process deviated from standard operating procedures (SOP). Suggestion to address these issues, re-socialization of SOPs related to coding procedures, advocating for appropriate reward and punishment, and organizing internal training on injury and external causes diagnosis coding.
SYMPTOM-BASED SCREENING OF INFECTIOUS DISEASES: QUESTIONNAIRE SURVEY FOR EARLY DETECTION Khomsatun Ni’mah; Sabran Sabran; Dony Setiawan; Mochammad Choirur Roziqin
JRMIK Vol 7 No 2 (2026): JOURNAL OF MEDICAL RECORDS AND HEALTH INFORMATION
Publisher : Malang: Sekolah Tinggi Ilmu Administrasi Malang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.58535/jrmik.v7i2.100

Abstract

Skrining gejala penyakit menular merupakan upaya penting dalam deteksi dini dan pencegahan penyebaran infeksi. Penelitian ini bertujuan menggambarkan proporsi gejala klinis tuberkulosis (TBC), human immunodeficiency virus (HIV), dan demam berdarah dengue (DBD) pada populasi yang diperiksa. Hasil skrining menunjukkan bahwa mayoritas responden tidak memiliki gejala maupun faktor risiko utama terkait ketiga penyakit. Pada TBC, hanya sebagian kecil responden yang mengalami gejala klasik seperti batuk berkepanjangan dan demam persisten, tanpa temuan radiologis yang mendukung adanya kasus aktif. Untuk HIV, tidak ditemukan perilaku maupun riwayat medis berisiko, sementara gejala kronis tidak spesifik hanya dialami oleh sebagian kecil responden, sehingga risiko penularan HIV relatif rendah. Pada DBD, tidak terdeteksi kasus demam akut, dan gejala pendukung seperti nyeri otot, sakit kepala, atau nyeri sendi hanya muncul pada sebagian kecil responden tanpa bukti laboratorium maupun riwayat paparan signifikan. Temuan ini menegaskan bahwa prevalensi gejala penyakit menular dalam populasi penelitian tergolong rendah, namun skrining terintegrasi tetap diperlukan untuk deteksi dini serta pemantauan berkelanjutan, terutama pada individu dengan gejala ringan atau faktor risiko tertentu.
Co-Authors Dyah Palupi Budiningsih Hendyca Putra Khomsatun Ni’mah Maya Weka Santi Mochammad Choirur Roziqin Novita Nuraini Sabran Sabran