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Julia Indriaty
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Dentistry Health Professions Nursing Public Health Veterinary

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Pengaruh Perilaku Petugas Rekam Medis Terhadap Penyimpanan Rekam Medis di Rumah Sakit Julia Indriaty
Jurnal Kesehatan STIKes Sumber Waras Vol 6 No 1 (2024): Jurnal Kesehatan STIKes Sumber Waras
Publisher : Sekolah Tinggi Ilmu Kesehatan Sumber Waras

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.63704/jksw.v6i1.56

Abstract

Rekam medis merupakan dokumen penting dalam pelayanan kesehatan yang berfungsi sebagai sumber informasi bagi tenaga medis dan sebagai bukti hukum dalam berbagai situasi. Penyimpanan rekam medis yang baik sangat bergantung pada perilaku petugas rekam medis dalam menjalankan tugasnya. Penelitian ini bertujuan untuk menganalisis pengaruh perilaku petugas rekam medis terhadap kualitas penyimpanan rekam medis di rumah sakit. Metode penelitian yang digunakan adalah desain cross-sectional dengan pendekatan kuantitatif. Data dikumpulkan melalui kuesioner dan observasi langsung terhadap petugas rekam medis di beberapa rumah sakit. Hasil penelitian menunjukkan bahwa kedisiplinan, kepatuhan terhadap standar operasional prosedur (SOP), serta tingkat pemahaman petugas terhadap pentingnya rekam medis berpengaruh signifikan terhadap kualitas penyimpanan rekam medis. Oleh karena itu, peningkatan pelatihan bagi petugas serta optimalisasi sistem informasi manajemen rumah sakit (SIMRS) dapat menjadi solusi untuk meningkatkan efisiensi dan akurasi penyimpanan rekam medis.
Pengaruh Kinerja Petugas Rekam Medis Terhadap Keakuratan Pengkodingan Fraktur Julia Indriaty
Jurnal Kesehatan STIKes Sumber Waras Vol 5 No 1 (2023): Jurnal Kesehatan STIKes Sumber Waras
Publisher : Sekolah Tinggi Ilmu Kesehatan Sumber Waras

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.63704/jksw.v5i1.58

Abstract

Background: Accurate fracture coding is crucial in medical record systems as it affects patient data validity, insurance claims, and the planning and evaluation of healthcare services. The performance of medical record officers plays a crucial role in ensuring the accuracy of coding diagnoses and medical procedures. Objective: This study aims to analyze the impact of medical record officers' performance on the accuracy of fracture coding in hospitals. Methods: This study employs a quantitative approach with a cross-sectional design. Data were collected through direct observation, interviews, and analysis of medical records of patients diagnosed with fractures. Statistical tests were conducted to analyze the relationship between medical record officers' performance and the accuracy of fracture coding. Results: The study results indicate a significant relationship between the performance of medical record officers and the accuracy of fracture coding. Factors such as understanding of the disease classification system, meticulousness in documentation, and the level of experience of officers contribute to coding accuracy. Conclusion: The performance of medical record officers significantly influences the accuracy of fracture coding. Therefore, improving staff competence through training and periodic evaluations is essential to ensure optimal medical record data quality.
Pengaruh Pelatihan Manajemen Rekam Medis Terhadap Kualitas Dokumentasi Medis di Pelayanan Kesehatan Julia Indriaty
Jurnal Kesehatan STIKes Sumber Waras Vol 5 No 1 (2023): Jurnal Kesehatan STIKes Sumber Waras
Publisher : Sekolah Tinggi Ilmu Kesehatan Sumber Waras

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.63704/jksw.v5i1.59

Abstract

The quality of medical documentation is a crucial factor in healthcare services, playing a role in the continuity of patient care, clinical decision-making, and legal aspects. Proper medical record management can enhance the accuracy, completeness, and efficiency of patient data documentation. This study aims to analyze the impact of medical record management training on the quality of medical documentation in healthcare facilities. The research method used is a quantitative design with a cross-sectional approach. Data were collected through questionnaires and direct observations before and after training sessions for medical record officers in various hospitals and clinics. The results indicate that medical record management training significantly contributes to improving the completeness, timeliness, and compliance in patient data documentation. Therefore, regular training and the implementation of electronic record-keeping systems are recommended to enhance the quality of medical documentation.
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