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All Journal Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Jurnal Pengabdian Masyarakat (ABDIRA)
Sitompul, Osayku Inesa
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Aerospace Engineering Computer Science & IT Health Professions Languange, Linguistic, Communication & Media Nursing Public Health Social Sciences Other

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Tahapan Audit Koding Rekam Medis dengan Menggunakan Analisa Kualitatif pada Pasien Rawat Inap di RS Khusus Mata SMEC Tahun 2025 Hutasoit, Theresia; Daeli, Cosmas Samuel; Sitorus, Mei Sryendang; Simanjuntak, Marta; Rotonga, Zulham Andi; Hasibuan, Ali Sabela; Liem, John Barker; Valentina, Valentina; Zulfahmi, Zulfahmi; Sitompul, Osayku Inesa
Jurnal Pengabdian Masyarakat (ABDIRA) Vol 6, No 1 (2026): Abdira, Januari
Publisher : Universitas Pahlawan Tuanku Tambusai

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31004/abdira.v6i1.1278

Abstract

Medical records are crucial documents that document all healthcare services. Accurate coding forms the basis for claims billing, research, and clinical decision-making. However, incomplete and inaccurate recording often presents obstacles, necessitating a coding audit. This Community Service project aimed to identify the stages of a coding audit using qualitative analysis of inpatients. The audit was conducted on four cases. The analysis used six review components: consistency of diagnosis and treatment, clinical recording, treatment justification, informed consent, documentation practices, and potential for compensation. The results of the medical record coding audit indicated that most components were consistent and met standards, including diagnosis, treatment, clinical recording, and completion of informed consent. However, inconsistencies were still found in instructions for discontinuing or replacing medications. There were no incidents that could potentially result in compensation. However, improvements are still needed in the documentation of instructions for discontinuing or replacing medications. The results emphasize the importance of ongoing socialization and monitoring to optimize the quality of medical records.
Analisis Kesiapan Implementasi Rekam Medis Elektronik Menggunakan Pendekatan DOQ-IT Di Klinik Pratama Wulandari Tahun 2025 Daeli, Cosmas Samuel; Sitorus, Mei Sryendang; Hutasoit, Theresia; Sitompul, Osayku Inesa
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Vol. 11 No. 1 (2026): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Februari
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v11i1.2185

Abstract

The implementation of Electronic Medical Records (EMR) is a mandatory requirement for all healthcare facilities in Indonesia to improve service quality, accelerate patient information access, and support data interoperability through a national platform. The purpose of this study was to analyze the readiness for the implementation of EMR using the DOQ-IT approach by assessing the influence of human resources, organizational work culture, governance and leadership, and IT infrastructure in healthcare services. This research used a descriptive quantitative method with total sampling of 16 respondents from various healthcare professions at Wulandari Primary Clinic. Data were collected using the DOQ-IT questionnaire consisting of multiple-choice questions. The analysis results showed that the overall assessment score was 74.44, which falls into Category II (fairly ready). This indicates that while there are strong capabilities in certain readiness components, weaknesses remain in others. Based on the four readiness aspects, only IT Infrastructure had the lowest classification score (2.50). The most prepared aspect was Human Resources (2.86), followed by Organizational Culture (2.67), and Governance and Leadership (2.58). Recomendation that need to be considered: Improve IT infrastructure, conduct regular training for staff, strengthen the role of leaders, conduct regular evaluations so that RME runs effectively
Co-Authors Cosmas Samuel Daeli Liem, John Barker Rotonga, Zulham Andi Sabela Hasibuan, Ali Simanjuntak, Marta Sitorus, Mei Sryendang Theresia Hutasoit Valentina Valentina, Valentina Zulfahmi Zulfahmi