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All Journal JURNAL KESEHATAN, SAINS, DAN TEKNOLOGI (JAKASAKTI) Jurnal Pengabdian Masyarakat dan Riset Pendidikan
Agusianita
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Agriculture, Biological Sciences & Forestry Humanities Biochemistry, Genetics & Molecular Biology Chemistry Computer Science & IT Education Health Professions Languange, Linguistic, Communication & Media Mathematics Medicine & Pharmacology Public Health Other

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Completeness of Cataract Medical Information Supports the Accuracy of RME Based Diagnosis and Action Codes at RS.X Heltiani, Nofri; Agusianita; Budiarti, Anggia
JURNAL KESEHATAN, SAINS, DAN TEKNOLOGI (JAKASAKTI) Vol. 4 No. 3 (2025): JURNAL KESEHATAN, SAINS, DAN TEKNOLOGI (JAKASAKTI)
Publisher : LPPM Universitas Dhyana Pura

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.36002/js.v4i3.5006

Abstract

The completeness of visual acuity (visual acuity) examination results, the completeness of slit lamp examination results, and the accuracy of diagnosis are very important in supporting the accuracy of diagnostic codes and action codes. The initial survey results of 10 e-RMs obtained 6 (60%) accurate and 4 (40%) inaccurate. This is because the results of the visual acuity examination and slit lamp examination are incomplete, resulting in inaccurate diagnostic codes and action codes that impact the quality of data, information, and reports, as well as the accuracy of INA-CBG's rates, which can result in a decrease in the quality of hospital services. This study aims to determine the accuracy of cataract diagnosis and treatment codes based on the completeness of e-RM-based medical information at Hospital X. This type of study is an observational study with a quantitative descriptive design. The study population was 548 e-RMs, with a sample of 85 e-RMs taken by simple random sampling. This study uses secondary data measured by observation sheets, and then the data is processed and analyzed univariately using frequency distribution. The results of this study obtained completeness of visual acuity examination results of 74 (87%), completeness of slit lamp examination results of 77 (91%), accuracy of diagnosis codes of 79 (93%), and accuracy of action codes of 72 (85%). The need to conduct periodic control of the completeness of medical information through medical record audits, establish communication if there is an inaccurate diagnosis, and improve coder skills through coding classification training.
Sosialisasi Kelengkapan Informasi Medis Elektronik Katarak Mendukung Keakuratan Kode Diagnosa dan Tindakan di RS.X Heltiani, Nofri; Anggia Budiarti; Reka Dwi Syaputra; Agusianita; Rezky Noviana; Emi Yela Utami Sari
Jurnal Pengabdian Masyarakat dan Riset Pendidikan Vol. 4 No. 3 (2026): Jurnal Pengabdian Masyarakat dan Riset Pendidikan Volume 4 Nomor 3 (Januari 202
Publisher : Lembaga Penelitian dan Pengabdian Masyarakat

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31004/jerkin.v4i3.4514

Abstract

Katarak adalah kekeruhan lensa yang menyebabkan penurunan ketajaman visual <6/18 yang dirasakan oleh pasien. Kelengkapan informasi medis katarak berupa hasil visus dan pemeriksaan slit lamp sangat penting dalam penegakkan diagnosa dan medukung keakuratan kode diagnosa dan tindakan yang diberikan. Keakuratan kode memengaruhi validitas data dalam pelaporan, pengambilan keputusan klinis serta pengajuan klaim pada pihak BPJS-Kesehatan. Kegiatan Pengabdian kepada Masyarakat ini bertujuan memberikan memberikan gambaran kepada PMIK dan Coder tentang pengaruh kelengkapan informasi medis elektronik kasus katarak terhadap keakuratan kode diagnosa dan tindakan di RS.X. Metode yang digunakan adalah sosialisasi dan diskusi interaktif dengan sasaran Kepala Unit Kerja Rekam Medis dan Informasi Kesehatan dan 10 orang petugas. Hasil evaluasi dilakukan melalui pretest dan posttest menunjukkan terjadinya peningkatan pengetahuan dan pemahaman PMIK dan Coder sebelum dan sesudah diberikan sosialisasi sebesar 55% dengan rerata pretest 58.00 dan posttest menjadi 90.00. Kegiatan ini dilakukan sebagai bentuk upaya meningkatkan kualitas pelayanan kesehatan serta meningkatkan kesadaran dan pemahaman PMIK dan Coder tentang pentingnya kelengkapan informasi medis elektronik kasus katarak ditinjau hasil visus dan pemeriksaan slit lamp dalam mendukung kakuratan kode diagnosa dan tindakan yang diberikan.
Co-Authors Anggia Budiarti Budiarti, Anggia Emi Yela Utami Sari Heltiani, Nofri Reka Dwi Syaputra Rezky Noviana