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All Journal Abdimas Polsaka: Jurnal Pengabdian Masyarakat Jurnal Ilmiah Kesehatan Sandi Husada (JIKSH)
Ode Novi Angraeni, Wa
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Health Professions Medicine & Pharmacology Nursing Public Health

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Basic medical record education and training to prepare professional health human resources Asmi, A Syamsinar; Ihsan Kamaruddin, Muh; Ode Novi Angraeni, Wa; Hardi, Wahyudi; Andre Mangaya Takke, Jessy
Journal Pengabdian Masyarakat Politeknik Sandi Karsa Vol 4 No 2 (2025): Abdimas Polsaka: Jurnal Pengabdian Masyarakat
Publisher : Lembaga Penelitian dan Pengabdian Masyarakat,Politeknik Sandi Karsa

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.35816/abdimaspolsaka.v4i2.122

Abstract

Accurate and well-managed medical records are crucial for ensuring the quality of health services, supporting informed clinical decision-making, and enhancing health information systems. However, many health workers especially those in primary care and early-career stages lack adequate competence in basic medical record management. This community service program aimed to enhance participants’ knowledge and skills in fundamental medical record practices as part of preparing professional and reliable health human resources. This program was conducted through a structured educational and training intervention involving a one-day workshop delivered to 45 health workers and students. Activities included lectures, demonstrations, hands-on practice, and group discussions. Pre- and post-training assessments were used to measure improvements in knowledge and practical skills. Observational checklists evaluated participants’ accuracy in completing medical record components, including patient identification, documentation standards, coding basics, and confidentiality procedures. The results showed a significant improvement in participants’ understanding and performance. The mean knowledge score increased from 62.4 (pre-test) to 88.7 (post-test). Practical skills in completing standardized medical record forms improved from 54% to 90% accuracy. Participants reported increased confidence in maintaining documentation quality and understanding the legal and ethical responsibilities related to medical records. Feedback indicated high satisfaction with training methods and relevance to daily practice. This community service program effectively strengthened the foundational competencies required for health workers to manage medical records professionally. The combination of theory and practical sessions proved essential in building both conceptual understanding and hands-on skills. Continuous training and mentoring are recommended to ensure sustained quality and compliance with health information standards
Medical Record Analysis in Supporting BPJS Health Claims in a Hospital: A Retrospective Descriptive Quantitative Study Ode Novi Angraeni, Wa; Andre Mangaya Takke, Jessy; Sofia Zainuddin, NurZetty
Jurnal Ilmiah Kesehatan Sandi Husada Vol. 15 No. 1 (2026): January - June
Publisher : LPPM Politeknik Sandi Karsa, South Sulawesi, Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.35816/jiksh.v15i1.246

Abstract

Introduction: Delays in inpatient BPJS Health claims represent a persistent operational challenge within Indonesia’s National Health Insurance (JKN) system and may compromise hospital financial stability under case-based reimbursement (INA-CBGs). Inefficiencies are frequently attributed to incomplete medical documentation and weak integration with health information systems. This study aimed to analyze the role of the Hospital Management Information System (HMIS), medical record completeness, and coding accuracy in determining inpatient BPJS claim pending status at a tertiary teaching hospital. Research Methodology: An analytical cross-sectional study with retrospective document review was conducted at Hasanuddin University Hospital from November to December 2025. A total of 156 inpatient BPJS claim files for May 2025 were included using total sampling. Data were extracted from casemix records, HMIS databases, and medical documentation. Bivariate associations were tested using chi-square analysis, and multivariate predictors were identified through binary logistic regression (α = 0.05). Results: Of 156 claims, 66.7% were classified as pending. Incomplete medical records (AOR = 9.84; 95% CI: 3.21–30.18; p < 0.001), HMIS data non-conformity (AOR = 8.92; 95% CI: 3.45–23.06; p < 0.001), and coding inaccuracies (AOR = 6.17; 95% CI: 1.78–21.42; p = 0.004) were independently associated with increased odds of pending claims. Conclusion: Inpatient BPJS claim delays are primarily driven by weaknesses in documentation governance and digital system integration. Strengthening standardized clinical documentation, enhancing coder competency, and improving HMIS interoperability are critical to reducing claim discrepancies, improving reimbursement efficiency, and supporting the financial sustainability of Indonesia’s National Health Insurance system
Co-Authors Andre Mangaya Takke, Jessy Asmi, A Syamsinar Ihsan Kamaruddin, Muh Mangaya Takke, Jessy Andre Sofia Zainuddin, NurZetty Wahyudi Hardi