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All Journal J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Indonesian Journal of Health Information Management (IJHIM)
Menna, Yasinta Rosalia
Unknown Affiliation
Health Professions Public Health

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Inactive Medical Record Governance at St. Carolus Hospital Jakarta Menna, Yasinta Rosalia; Widjaja, Lily; Muniroh, Muniroh; Putra, Daniel Happy
Indonesian Journal of Health Information Management Vol. 2 No. 2 (2022)
Publisher : Sekolah Tinggi Ilmu Kesehatan Mitra Husada Karanganyar

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.54877/ijhim.v2i2.62

Abstract

Medical record depreciation is an activity of reducing archives from storage shelves by moving inactivated medical records archives from active shelves to inactivated shelves according to the year of visit. Preliminary observation results show the process of media transfer in the medical record unit has not reached the target of a minimum number of 50 medical records per day. This research aims to find out the governance of inactivated medical records at St. Carolus Hospital Jakarta. The research methodology used is a descriptive method. It can be concluded that the standard operating procedure for shrinking medical records in St. Carolus Jakarta already exists but is not complete because the depreciation stage related to transfer, value assessment, media transfer has not been listed in the standard operating procedure. The medical records unit has carried out the depreciation process with the male medical record officer as its executor but the implementation is not based on the assessment of the value for medical records due to the absence of an assessment team. The constraint factors in the medical record unit are related to the man, money, material, method, and machine.
Hubungan Ketepatan Penulisan Diagnosis Dengan Keakuratan Kode Diagnosis Obstetri Di RSIJ Sukapura Menna, Yasinta Rosalia; Muchlis, Husni Abdul; Hosizah, Hosizah; Yulia, Noor
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 7 No 2 (2026): March (Issue in Progress)
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v7i2.5435

Abstract

Accurate documentation of diagnoses in medical records is essential, as inaccurate diagnostic statements may lead to incorrect diagnostic coding. Preliminary observations indicated that among 18 medical records, 61% of diagnoses were written accurately, while 78% of diagnostic codes were accurate. This study aimed to examine the relationship between the accuracy of diagnostic documentation and the accuracy of obstetric diagnostic coding at RSIJ Sukapura Hospital. This quantitative study employed a cross-sectional design and utilized the Chi-square test, with Fisher’s exact test applied as appropriate. Based on the analysis of 92 medical records, 77.2% of diagnoses were documented accurately and 88.0% of diagnostic codes were accurate. The results revealed a statistically significant association between the accuracy of diagnostic documentation and the accuracy of obstetric diagnostic coding (p = 0.002 < 0.05; OR = 8.375). This indicates that accurate diagnostic documentation increases the likelihood of producing accurate obstetric diagnostic codes by 8.375 times. Physicians in charge are therefore expected to pay closer attention to appropriate medical terminology when documenting diagnoses to ensure greater accuracy.
Co-Authors Daniel Happy Putra Hosizah Hosizah Husni Abdul Muchlis Muniroh, Muniroh Widjaja, Lily Yulia, Noor