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All Journal Jurnal Rekam Medis dan Informasi Kesehatan Indonesia
Elystia Vidia Marselina
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Computer Science & IT Public Health

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FAKTOR PENYEBAB KETIDAKTEPATAN KODE DIAGNOSIS PADA DOKUMEN REKAM MEDIS RAWAT INAP DI RUMAH SAKIT ISLAM AISYIYAH MALANG Fakhrur Rozi; Elystia Vidia Marselina
Jurnal Rekam Medis dan Informasi Kesehatan Indonesia Vol. 1 No. 2 (2022): Jurnal Rekam Medis dan Informasi Kesehatan Indonesia
Publisher : program studi Rekam Medis dan Infomasi Kesehatan ITSK RS dr Soepraoen Malang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.62951/jurmiki.v1i2.19

Abstract

One of the competencies of a medical recorder is being able to carry out coding of diseases and actions in accordance with applicable regulations. Errors in determining codes can cause losses to health service facilities. Based on the results of the observations that have been made, it was found that the activity of giving diagnosis codes at Aisyiyah Islamic Hospital still contains errors, namely there is a mismatch between the diagnosis and the diagnosis code. This occurs because the coder is not careful, thus causing errors in coding. The aim of this research is to determine the factors that cause inaccurate diagnosis codes in inpatient medical record documents at the Aisyiyah Islamic Hospital, Malang. This research method uses a qualitative descriptive method. By analyzing the elements that produce inaccuracies in coding based on the man and method elements. This study aims to develop a plan to solve coding errors from patient medical records. Qualitative research was used, with data collection techniques in the form of informant interviews and observational research. Conformity of diagnoses and diagnosis codes at Aisyiyah Islamic Hospital Malang for the 2023 period from a total of 52 samples taken, there were 13.4% incorrect diagnosis codes according to ICD 10 and 86.6% correct diagnosis codes according to ICD 10. The results of the study showed that the cause of inaccuracy in coding Inpatient patient medical record files include unclear doctor's writing, non-standard writing of diagnosis abbreviations, medical record officers are less thorough in coding diagnoses and medical record officers rarely open ICD-10 to ensure the code is accurate or inaccurate.
EVALUASI KEGIATAN PELAYANAN PENDAFTARAN PASIEN DI RS X MALANG Chyntia Vicky Alvionita; Elystia Vidia Marselina
Jurnal Rekam Medis dan Informasi Kesehatan Indonesia Vol. 3 No. 2 (2024): Jurnal Rekam Medis dan Informasi Kesehatan Indonesia
Publisher : program studi Rekam Medis dan Infomasi Kesehatan ITSK RS dr Soepraoen Malang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.62951/jurmiki.v3i2.52

Abstract

The registration service is the first service and directly interacts with the patient and the place where they will register at the polyclinic they are going to. Observational data has revealed that a number of issues, including SIMRS and the network, continue to impede patient registration services. Evaluating patient registration service activities is one approach taken to address this issue. The aim of this research is to evaluate activities in patient registration services. The instrument used was an interview sheet. This type of research uses qualitative descriptive analysis to describe the results of evaluation of patient registration services. The study's findings indicate that although RS X Malang's registration service is functioning effectively, a number of issues continue to arise. Patient registration is frequently hampered by sluggish and unreliable internet connections. Delays in the registration procedure are possible, and SIMRS disruptions happen frequently. In addition, the tracer is still manual, which increases the possibility that the registration officer will overlook recording the patient's medical record information. Another issue is that there is currently no bridging between SIMRS and BPJS, which makes BPJS patient registration more time-consuming due to its multiple steps.
PERSEPSI PERAWAT DALAM PENERAPAN BUDAYA KESELAMATAN PASIEN DI RS X KOTA MALANG Elystia Vidia Marselina; Chyntia Vicky Alvionita
Jurnal Rekam Medis dan Informasi Kesehatan Indonesia Vol. 3 No. 2 (2024): Jurnal Rekam Medis dan Informasi Kesehatan Indonesia
Publisher : program studi Rekam Medis dan Infomasi Kesehatan ITSK RS dr Soepraoen Malang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.62951/jurmiki.v3i2.53

Abstract

The quarterly report in 2022 shows that the incidence rate is not expected to reach 99 cases. One effort that can be made to prevent patient safety incidents is to implement a patient safety culture. Nurses as health workers who interact most with patients are the main component who are required to carry out their work in accordance with standard operational procedures to avoid patient safety incidents. Perception is very important in the success of communication, when all nurses have the same perception about the importance of implementing patient safety culture then patient safety incidents can also be prevented. The aim of this research was to measure nurses' perceptions of patient safety culture. The research instrument used a questionnaire based on the HSOPSC which was distributed to 55 nurses as research respondents. This type of research uses descriptive analysis to describe 12 dimensions of patient safety culture. The results show that the cooperation dimension within the unit has the highest positive perception, namely 87% in the good category, while the staffing dimension has the lowest positive perception, namely 61% in the medium category. RS X Kota Malang in its commitment to preventing patient safety incidents can focus on staffing dimensions.
Co-Authors Chyntia Vicky Alvionita Fakhrur Rozi