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All Journal SPIKESNAS Jurnal Ilmu Kesehatan
Faik Agiwahyuanto
Faculty of Health, Universitas Dian Nuswantoro
Dentistry Environmental Science Health Professions Medicine & Pharmacology Nursing Public Health

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Validasi Data Rekam Medis pada Klaim JKN Gagal Jantung Periode 2025 Dwi Gusma Sisharyanto; Faik Agiwahyuanto; Kriswiharsi Kun Saptorini; Fitria Wulandari
Jurnal Ilmu Kesehatan Vol. 1 No. 2 (2026): Edisi: Januari-Maret
Publisher : Pustaka Bangsa Indonesia

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Abstract

Kelengkapan data klinis merupakan faktor krusial dalam proses pengajuan klaim Jaminan Kesehatan Nasional (JKN) yang berdampak pada pendapatan rumah sakit. Penundaan klaim (pending claim), khususnya pada diagnosis umum seperti gagal jantung, sering kali disebabkan oleh ketidaklengkapan data. Penelitian ini bertujuan untuk meninjau kelengkapan data klinis pada klaim JKN untuk diagnosis gagal jantung di RSUD dr. Rehatta, Provinsi Jawa Tengah. Penelitian ini menggunakan metode deskriptif kualitatif melalui analisis dokumen terhadap 33 berkas klaim pasien gagal jantung periode Maret-April 2025. Analisis tersebut, yang mencakup kode diagnosis (ICD-10), kode tindakan (ICD-9 CM), dan informasi penunjang, menunjukkan tingkat ketidaklengkapan berkas sebesar 30,3%. Kekurangan tertinggi teridentifikasi pada pengodean diagnosis sekunder dan tindakan medis. Temuan ini mengindikasikan bahwa ketidakakuratan pengodean merupakan penyebab utama potensi penundaan klaim, yang berdampak langsung pada stabilitas keuangan rumah sakit. Audit rekam medis secara berkala dan pelatihan berkelanjutan bagi staf koding (coder) direkomendasikan untuk meningkatkan akurasi data dan mengoptimalkan proses klaim.
PENGEMBANGAN SISTEM AUDIT REKAM MEDIS BERBASIS WEB UNTUK EVALUASI KUALITAS DATA Faik Agiwahyuanto; Fitria Wulandari; Suyoko; Maulana Tomy Abiyasa
Prosiding SPIKesNas : Seminar Publikasi Ilmiah Kesehatan Nasional Vol 5 No 2 (2026): SPIKesNas - Mei 2026
Publisher : STIKES dan AKZI Karya Husada Kediri

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Abstract

The low quality of Electronic Medical Record (EMR) data can become a significant barrier in the insurance claim process, particularly within hospital settings. The problem identified at RS Pantiwilasa Citarum Semarang is caused by incomplete EMR data in the hospital information system used as the basis for insurance claim submissions. This incompleteness has the potential to cause substantial financial losses for the healthcare institution. The issue mainly stems from the lack of attention given by physicians in completing supporting medical data documents accurately and comprehensively. This study aims to provide a significant contribution by developing a quantitative and qualitative audit system designed to comprehensively evaluate EMR data quality. The research method combines several approaches, including system development methods, quantitative testing, and qualitative evaluation. The study applies the Software Development Life Cycle (SDLC) method to develop a web-based audit system covering requirements analysis, system design, system implementation, and system testing. The result of this study is SIMAURA (Medical Record Audit System Application), a website-based application currently being developed in the medical record laboratory of the Diploma-III Medical Record and Health Information program.
Co-Authors Dwi Gusma Sisharyanto Fitria Wulandari Fitria Wulandari Kriswiharsi Kun Saptorini Maulana Tomy Abiyasa Suyoko