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All Journal Jurnal Kesehatan Tambusai PELS (Procedia of Engineering and Life Science)
Azizah, Syifa Khurotun
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Computer Science & IT Control & Systems Engineering Dentistry Electrical & Electronics Engineering Engineering Health Professions Medicine & Pharmacology Nursing Public Health

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TINJAUAN FAKTOR KEAMANAN DAN KERAHASIAAN REKAM MEDIS DI RUANG FILING RSUD DR. SOEDIRMAN KEBUMEN Azizah, Syifa Khurotun; Sari, Arum Astika; Praptanti, Agustina Fitri
Jurnal Kesehatan Tambusai Vol. 6 No. 2 (2025): JUNI 2025
Publisher : Universitas Pahlawan Tuanku Tambusai

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31004/jkt.v6i2.45211

Abstract

Rekam medis bersifat rahasia dan harus dilindungi. Oleh karena itu, rumah sakit perlu memiliki ruang penyimpanan yang dapat memenuhi standar untuk menjamin keamanan dan kerahasiaan rekam medis. Mutu pelayanan rumah sakit dapat ditingkatkan apabila faktor keamanan dan kerahasiaan rekam medis pasien di ruang penyimpanan terjamin dengan baik. Ruang filing dapat dikatakan baik apabila keamanannya terjamin dan terlindungi dari ancaman kelalaian, kehilangan, bencana, dan berbagai hal lain yang membahayakan rekam medis. Tujuan dari penelitian ini adalah untuk menggambarkan faktor keamanan dan kerahasiaan rekam medis di ruang penyimpanan RSUD dr. Soedirman Kebumen, dimana faktor keamanan terdiri dari aspek fisik, aspek biologis, dan aspek kimiawi. Penelitian ini merupakan penelitian deskriptif kualitatif dengan teknik pengumpulan data dilakukan melalui wawancara dan observasi. Hasil penelitian ini didapatkan pada aspek fisik ditemukan rak penyimpanan rekam medis tidak cukup untuk menampung rekam medis, dalam pengambilan rekam medis tidak menggunakan tracer, tidak menggunakan rak penyimpanan Roll O’Pack, dan masih terdapat rekam medis yang tercecer di lantai dekat rak penyimpanan. Aspek biologis tidak ditemukan jamur. Pada aspek kimiawi: tidak ada kerusakan yang disebabkan oleh tinta, tetapi masih terdapat petugas yang makan dan minum di sekitar area rekam medis. Dalam hal kerahasiaan rekam medis, masih terdapat orang lain di luar petugas rekam medis yang dapat mengakses ruang penyimpanan rekam medis.
Analysis of the Diagnosis’s Inaccuracy Codes for Infection Cases in Dahlia Ward’s Inpatients at Majenang Regional Hospital Azizah, Syifa Khurotun; Hakim, Agya Osadawedya; Gunawan , Gunawan
Procedia of Engineering and Life Science Vol. 6 (2024): The 3rd International Scientific Meeting on Health Information Management (3rd ISMoHI
Publisher : Universitas Muhammadiyah Sidoarjo

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.21070/pels.v6i1.1925

Abstract

The large number of infection cases in Indonesia has caused the number of BPJS claims related to these cases to continue to increase. The claim process carried out by the hospital must go through various stages in order to be claimed, including the coding process. The medical recorder's role as a coder is responsible for the correctness and accuracy of the code for a diagnosis that has been determined by medical personnel (doctors). Inaccuracies in diagnosis codes will impact the effectiveness of health service data and information management as well as pending claims. Pending claims that occur due to inaccuracies can impact hospital cost profit which will result in the hospital experiencing losses. Based on a preliminary study conducted in the Dahlia Ward, Majenang Regional Hospital, 3 medical records with incorrect codes were found (3.54%) out of 58 medical records. This study aims to calculate the inaccuracy of diagnosis codes for cases of infection for inpatients in the Dahlia Ward, Majenang Regional Hospital and identify the factors that cause inaccurate diagnosis codes for cases of infection for inpatients in the Dahlia Ward, Majenang Hospital.The research method used is a qualitative method with a narrative descriptive design. Data collection techniques were carried out using two methods, namely observation and interviews. Interviews were conducted to obtain reasons for inaccurate diagnosis codes, while observations were used to verify interview results. There were 3 resource persons in this study, namely the head of medical records and 2 inpatient coders. The research results showed that inaccuracies occurred due to incomplete diagnosis writing by the DPJP, such as doctors tending to write abbreviations, and coders tending to use rote memorization in determining diagnosis codes.
Co-Authors Gunawan , Gunawan Hakim, Agya Osadawedya Praptanti, Agustina Fitri Sari, Arum Astika