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All Journal Cerdika: Jurnal Ilmiah Indonesia
Rosmala Dewi, Deasy
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Humanities Economics, Econometrics & Finance Education Health Professions Public Health Social Sciences

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Journal : Cerdika: Jurnal Ilmiah Indonesia

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Tinjauan Kelengkapan Pengisian Formulir Assesment Awal Poli Klinik Pasien Rawat Jalan Menggunakan Metode IAR Safitri, Dinda Melani; Fannya, Puteri; Indawati, Laela; Rosmala Dewi, Deasy
Cerdika: Jurnal Ilmiah Indonesia Vol. 2 No. 4 (2022): Cerdika: Jurnal Ilmiah Indonesia
Publisher : Publikasi Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.59141/cerdika.v2i4.371

Abstract

The hospital is one of the health care facilities with various services helping people who have health probems. Medical record is a file that contains records and data related to patient identity, examination results, treatment history that has been given, other actions and services that have been carried out to patients. This study aimed to describe the completeness of filling the initial polyclinic assessment form. The methode of this study was descriptive analysis. The population of this study were the initial assessment of the physiotherapy clinic 312 medical records, surgery poly 177 medical records, and internal medicine clinic 457 medical records. And the sample of this research is 91 medical records. The results showed that from 91 medical records, 70 (77%) of forms is complete and 21 (23%) of forms is incomplete, which consisted of complete patient identification 80 (88%) and incomplete 11 (12%), completeness of important reports/notes 54 (59%) and incomplete 37 (41%), completeness of author authentication 73 (80%) and incomplete 18 (20%), and completeness of good records 72 (79%) and incomplete 19 ( 21%).
Tinjauan Ketepatan Pengodean Diagnosis Penyebab Dasar Kematian pada Pasien Diabetes Mellitus di RSU UKI Jakarta Nurmalasari, Dinda; Widjaja, Lily; Rosmala Dewi, Deasy; Indawati, Laela
Cerdika: Jurnal Ilmiah Indonesia Vol. 2 No. 4 (2022): Cerdika: Jurnal Ilmiah Indonesia
Publisher : Publikasi Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.59141/cerdika.v2i4.374

Abstract

Determination is a precaution and the accuracy of disease codes can be easily identified into correct and incorrect codes, Correct codes are adjusted in ICD-10 then incorrect codes are inappropriate codes in ICD-0. The cause of death was hospital reporting. The uncertainty of the diagnostic code consists of 5m (man, money, method, machine, material) based on the interview of the coding officer that the precision of the cause of death in the diabetes mellitus diabetes is not optimum because of poor doctors' writing, the use of abbreviations in the diagnosis, the lack of human resources in rmic education, no charge in coding, The method of conducting a death certificate from the medical certificate form is the cause of death at the point of immediate cause, the cause between and the underlying cause and the absence of a specialized chamber. Hence, the authors conducted a study on the correctness of the causes of death in diabetes patients mellitus according to the icd-10. The purpose of this study was to understand the precision of the diagnosis of the causes of death in the diabetes patient mellitus in Jakarta general hospital. Based on a study of the 72 medical records of patients dying of the precision of the cause of death in diabetes patients mellitus in Jakarta general in 2017-2020.
Co-Authors Fannya, Puteri Indawati, Laela Nurmalasari, Dinda Safitri, Dinda Melani Widjaja, Lily