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Jurnal Manajemen Informasi Kesehatan Indonesia (JMIKI)
Published by Asosiasi Perguruan Tinggi Rekam Medis dan Informasi Kesehatan Indonesia
ISSN : 2337585X     EISSN : 23376007     DOI : -
Core Subject : Health, Science,
Computer Science & IT Health Professions Public Health
Jurnal Manajemen Informasi Kesehatan Indonesia (JMIKI) diterbitkan oleh Asosiasi Perguruan Tinggi Rekam Medis dan Manajemen Informasi Kesehatan Indonesia (APTIRMIKI) bekerjasama dengan Perhimpunan Profesional Perekam Medis dan Informasi Kesehatan Indonesia(PORMIKI). JMIKI diterbitkan 2 kali dalam satu tahun ( Maret dan Oktober). Jurnal ini menerbitkan hasil penelitian (original) tentang Rekam Medis dan Manjemen Informasi Kesehatan, terutama dalam studi manajemen informasi kesehatan, Klasifikasi Kodifikasi Penyakit dan Tindakan, Sistem Informasi Kesehatan, Teknologi Informasi Kesehatan, Manajemen Mutu Informasi Kesehatan.
Arjuna Subject : -
Articles 336 Documents
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STUDI DESKRIPTIF KELENGKAPAN DOKUMEN REKAM MEDIS RAWAT INAP PADA KASUS BEDAH ORTHOPEDY DI RSUD KOTA SEMARANG Angga Ferdianto; Lutfiati -
Jurnal Manajemen Informasi Kesehatan Indonesia (JMIKI) Vol 5, No 2 (2017)
Publisher : Asosiasi Perguruan Tinggi Rekam Medis dan Informasi Kesehatan Indonesia- APTIRMIKI

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33560/jmiki.v5i2.175

Abstract

The purpose of this study is to find the percentage of completeness in inpatient medical record documents in cases of orthopedic surgery at General District Hospital Semarang. The kind of research is descriptive quantitative. Research design with  retrospective analysis approach. The technique of collecting data used is purposive sampling. The variable research consists of all review components in the quantitative analysis. The method of collecting data is observation using cheklist.The method of analysing data is descriptive quantitative analysis.The results of the quantitative analysis shows that there is incompleteness inpatient medical record documents in the case of surgery. Identification review of the highest incompleteness on date of birth found in an output form and anesthesia report is 99%. Authentication review of the highest incompleteness on time in surgical operation reports is 70,7%. The review from documentation of the highest incompleteness on blank found in input and output summary forms is 100%. The important report of the highest incompleteness  in input and output summary forms is 100% .
PERENCANAAN KEBUTUHAN TENAGA REKAM MEDIS DENGAN METODE WORKLOAD INDICATORS OF STAFFING NEED (WISN) DIPUSKESMAS GONDOKUSUMAN II KOTA YOGYAKARTA Lily Widjaya; Siswati Siswati
Jurnal Manajemen Informasi Kesehatan Indonesia (JMIKI) Vol 1, No 2 (2013)
Publisher : Asosiasi Perguruan Tinggi Rekam Medis dan Informasi Kesehatan Indonesia- APTIRMIKI

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33560/.v1i2.44

Abstract

ABSTRAKPuskesmas adalah usaha pelaksana teknis dinas kesehatan kabupaten/kota yang bertanggung jawab menyelenggarakan pembangunan kesehatan di suatu wilayah kerja. Sebagai bentuk pertanggungjawaban dalam manajemen puskesmas maka puskesmas harus melaksanakan manajemen rekam medis yang efektif dan efisien da(am memberikan pe(ayanan kesehatan. Dengan terpenuhinya jum(ah petugas rekam medis yang sesuai dengan uraian pekerjaannya maka pelayanan akan menjadi lebih maksimal. Penelitian ini bertujuan untuk mengetahui uraian pekerjaan dan jumlah kebutuhan petugas rekam medis di Puskesmas Gondokusuman II Kota Yogyakarta dengan menggunakan metode Workload Indicator Staff Need (WISN).Penelitian ini merupakan studi kasus yang bersifat deskriptif kualitatif dengan pendekatan induktif. Pengambilan data dilakukan dengan metode observasi, wawancara, dan studi dokumentasi.Hasil penelitian berupa uraian kegiatan tenaga pendaftaran dan pengelolaan rekam medis di Puskesmas Gondokusuman II yang secara garis besar meliputi kegiatan registrasi pasien serta pengelolaan rekam medis. Selain itu, tenaga pendaftaran dan rekam medis juga turut serta dalam kegiatan rapat, lokakarya serta seminar di bidang rekam medis.Berdasarkan basi( perbitungan kebutuban SDM dengan metode WISN, kebutuban tenaga pendaftaran dan rekam medisyang ideal di Puskesmas Gondokusuman II adalah sejumlah 5 orang. Dengan jum(ab tenaga saat ini yang banya 3 orang maka diper(ukan penambaban sebanyak 2 orang.Tentu saja, penambaban SDM tersebutjuga dengan mempertimbangkan kua(ifikasi dan kompetensi tenaga di bidang rekam medis agar tertib administrasi pada pengelolaan rekam medis semakin baik.Kata Kunci : Puskesmas, rekam medis, kebutuhan SDM, WISN
Kesehatan Dan Keselamatan Kerja (K3) Di Bagian Filing Irmawati Irmawati; Lily Kresnowati; Edy Susanto; Teni Ikhsan Nurfalah
Jurnal Manajemen Informasi Kesehatan Indonesia (JMIKI) Vol 7, No 1 (2019)
Publisher : Asosiasi Perguruan Tinggi Rekam Medis dan Informasi Kesehatan Indonesia- APTIRMIKI

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33560/jmiki.v7i1.215

Abstract

ABSTRACTOccupational health and safety is not only important for medical record officers but also can support work productivity. Health and safety of a good medical record worker will have a positive impact on work productivity of medical recorder so that will improve health service and benefit to hospital. Occupational risk can result in the decrease of work productivity, so efforts should be made to minimize the occurrence of the impact of occupational risk. Health and safety is intended to prevent, reduce, protect and even eliminate the risk of work accident (zero accident). Behavior of medical recorder filing section in work is one of the causes of risk of work accident, namely unsafe action and unsafe condition. Therefore it is necessary to conduct research on health and safety of medical records officer. To know health and safety of medical record employee of filing department at RSUD Banyumas based on human factor, work equipment factor, and work environment factor. This research type is case study with qualitative approach and cross sectional research design. The subject of this research is the medical recorder of the filing department of RSUD Banyumas while the object of the research is health and safety. Technique of collecting data by way of division of questioner, interview, observation, and study documentation. Data analysis techniques use reduction, data presentation and conclusion. The technique of data validity by means of technique triangulation.       The results of this study indicate that the health and safety of medical record officer filing section seen from human factors, work equipment factors, and work environment factors. In Human Factors knowledge recorder filing Health and Safety (K3) is good enough. In environmental factors temperature and humidity are in accordance with the standard, while for lighting need to be a contrast setting light so as not too dim and too bright. On the work equipment factor need maintenance, repair, improvement, replacement, and addition as needed, while for shelf filing integrated mental health needs to be replaced so as not to harm filing officer.ABSTRAKKesehatan dan keselamatan kerja tidak hanya penting bagi petugas rekam medis tetapi juga dapat menunjang produktivitas kerja. Kesehatan dan keselamatan kerja petugas rekam medis yang baik akan berdampak positif terhadap produktivitas kerja petugas rekam medis sehingga akan meningkatkan pelayanan kesehatan dan menguntungkan bagi rumah sakit. Risiko kecelakaan kerja dapat menimbulkan turunnya produktivitas kerja, sehingga perlu dilakukan usaha untuk meminimalisasi terjadinya dampak risiko kecelakaan kerja. Kesehatan dan keselamatan kerja dimaksudkan untuk mencegah, mengurangi, melindungi bahkan menghilangkan resiko kecelakaan kerja (zero accident). Perilaku petugas rekam medis bagian filing dalam bekerja merupakan salah satu penyebab risiko terjadinya kecelakaan kerja, yaitu unsafe action dan unsafe condition. Oleh karena itu perlu dilakukan penelitian tentang kesehatan dan keselamatan kerja petugas rekam medis.Tujuan Penelitian adalah Mengetahui kesehatan dan keselamatan kerja petugas rekam medis bagian filing di RSUD Banyumas berdasarkan faktor manusia, faktor peralatan kerja, dan faktor lingkungan kerja. Jenis penelitian ini adalah penelitian deskriptif dan rancangan penelitian secara cross sectional. Subjek penelitian ini adalah petugas rekam medis bagian filing RSUD Banyumas sedangkan objek penelitiannya adalah kesehatan dan keselamatan kerja. Teknik pengambilan data dengan cara pembagian kuisioner, wawancara, observasi, dan studi dokumentasi. Teknik analisis data menggunakan editing, verifikasi organizing, analizing dan tabulasi.Hasil penelitian ini menunjukkan bahwa kesehatan dan keselamatan kerja petugas rekam medis bagian filing berdasarkan faktor manusia, peralatan kerja, dan lingkungan kerja. Pada Faktor manusia pengetahuan petugas rekam medis bagian filing menganai Kesehatan dan Keselamatan Kerja (K3) sudah cukup baik. Pada Faktor lingkungan suhu belum sesuai standar,kelembapan sudah sesuai dengan standar,sedangkan untuk pecahayan perlu adanya pengaturan kontras cahaya agar tidak terlalu redup dan terlalu terang.  Pada faktor peralatan kerja perlu pemeliharaan, perbaikan, peningkatan, penggantian, dan penambahan sesuai kebutuhan ,sedangkan untuk rak filing kesehatan jiwa terpadu perlu dilakukan penggantian agar tidak membahayan petugas filing.
TINJAUAN KONDISI FISIK RUANGAN TERHADAP KINERJA PETUGAS DALAM PENGOLAHAN REKAM MEDIS DI RSUD M. ZEIN PAINAN Yoga Utomo; Hosizah Markam
Jurnal Manajemen Informasi Kesehatan Indonesia (JMIKI) Vol 4, No 1 (2016)
Publisher : Asosiasi Perguruan Tinggi Rekam Medis dan Informasi Kesehatan Indonesia- APTIRMIKI

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33560/jmiki.v4i1.102

Abstract

AbstractThe purpose in this study was to determine how the physical condition of the room to the performance of staff in the processing of medical records. This study dilakanakan in hospitals M.Zein Painan begin April 22 until May 4, 2015. The population in this study is the medical record room, and the average number of files per day approximately 150 files. The sample in this research that file processing is done during the study as many as 60 files. Data collected by observation and measuring and then the data is processed, analyzed using univariate and presented in narrative and tabular form. The results showed that the area of data processing room 3,8m x 3,4m. Spacious storage room (I) 3,8m x 7,4m. Spacious storage room (II) 1,7m x 10,6m. Medical record room temperature 29oC - 31oC. The lighting in the room medical record 21.6 Lux - Lux 142.2. This can greatly affect the performance of medical records clerk. The conclusions of this study is the ambient conditions do not meet the standards of medical records comprehensive, temperature and lighting.Keywords: medical record processing, the physical condition of the roomAbstrakTujuan penelitian ini adalah untuk mengetahui bagaimana kondisi fisik ruangan terhadap kinerja petugas dalam pengolahan rekam medis. Penelitian ini dilakanakan di RSUD M.Zein Painan mulai tanggal 22 April sampai dengan 04 Mei 2015. Populasi dalam penelitian ini adalah ruang rekam medis dan jumlah rata-rata berkas per harinya kurang lebih 150 berkas. Sampel dalam penelitian ini yaitu berkas yang pengolahannya dilakukan saat penelitian yaitu sebanyak 60 berkas. Data dikumpulkan dengan teknik observasi dan mengukur kemudian data diolah, dianalisa secara univariat dan disajikan dalam bentuk narasi dan tabular. Hasil penelitian menunjukkan bahwa luas ruangan pengolahan data 3,8m x 3,4m. Luas ruangan penyimpanan (I) 3,8m x 7,4m. Luas ruangan penyimpanan (II) 1,7m x 10,6m. Suhu ruangan rekam medis 29oC – 31oC. Pencahayaan di ruangan rekam medis 21,6 Lux – 142,2 Lux. Hal ini sangat mempengaruhi kinerja petugas rekam medis. Simpulan penelitian ini adalah kondisi ruangan rekam medis belum memenuhi standar luas, suhu dan pencahayaan.Kata kunci: pengolahan rekam medis, kondisi fisik ruangan
TINJAUAN PENERAPAN MANAJEMEN RISIKO DI UNIT FILING RSUD Dr. MOEWARDI Bayu Aji Santoso; Sri Sugiarsi
Jurnal Manajemen Informasi Kesehatan Indonesia (JMIKI) Vol 5, No 2 (2017)
Publisher : Asosiasi Perguruan Tinggi Rekam Medis dan Informasi Kesehatan Indonesia- APTIRMIKI

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33560/jmiki.v5i2.158

Abstract

Based on preliminary survey at RSUD Dr. Moewardi who are at risk of being in the filing unit: filing officers may be exposed to cough disease if taking or deciding DRM without using masks, filing unit officers may be dropped or slipped when the medical record shooting is on a high shelf, in addition to filing units may be struck document record Medical and even some units of old filing units often found back pain due to up and down stairs to retrieve medical record documents. The purpose of this study was to determine the application of risk management in the hospital filing unit RSUD Dr. Moewardi.The type of research is descriptive with qualitative approach. The research methodology is observation and structured interview. The definition of concept in this research, factor management, factor control, risk control and control, risk attitude and monitoring. Research subjects are filing unit officer, medical record quality coordinator, filing unit coordinator and. The object of research is the filing unit RSUD Dr. Moewardi. Research result. In Dr. Moewardi is done internally, the risk factor in the filing unit is the most prominent is the risk of falling due to the high medical record rack, the attitude of the risks that occurred in the filing unit is to make incident reports and held the meeting, Monitoring carried out by the unit. Units of archiving.
PREDIKSI INCIDENCE DENGUE HEMORRHAGIC FEVER (DHF) MENGGUNAKAN JARINGAN SARAF TIRUAN (ARTIFIAL NEURAL NETWORK) Jerhi Wahyu Fernanda, S.Si, M.Si -; Forman Novrindo Sidjabat
Jurnal Manajemen Informasi Kesehatan Indonesia (JMIKI) Vol 6, No 2 (2018)
Publisher : Asosiasi Perguruan Tinggi Rekam Medis dan Informasi Kesehatan Indonesia- APTIRMIKI

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33560/.v6i2.199

Abstract

Time series analysis is one of the statistical methods used as tools to predict the incidence of a disease. Autoregressive Integrated Moving Average (ARIMA) model is a frequently used method. However, this method has some disadvantages as there are assumptions that must be met and can not explain nonlinear cases. This condition requires a more flexible method, namely Artificial Neural Network (ANN). This study aims to apply the ANN method to predict the incidence of Dengue Hemorrhagic Fever DHF 2018 in one district in East Java province. Selection of this district is based on the conditions in this area that experienced DHF Outbreak (KLB) in 2015. Data used in this reseach is incidence DHF from January 2013 to December 2017. Data is divided into two parts, namely training data consisting of incidence DHF januari 2013 until December 2016. Data testing consists of DHF incidence from 2017 to December 2017. The best ANN model is an ANN model with 9 nodes on a hidden layer with a Root Mean Square Error (RMSE) value of 7.914. DHF incidence prediction in 2018 January to December has tended to be constant at 9 and has a tendency to stagnate.
HUBUNGAN ANTARA KELENGKAPAN PENGISIAN KUESIONER AUTO PSI VERBAL DENGAN KEAKURATA N PENENTUAN SEBAB DASAR KEMAT IAN DI PUSKESMAS WILAYAH SURAKARTA Andi Suhenda
Jurnal Manajemen Informasi Kesehatan Indonesia (JMIKI) Vol 3, No 1 (2015)
Publisher : Asosiasi Perguruan Tinggi Rekam Medis dan Informasi Kesehatan Indonesia- APTIRMIKI

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33560/.v3i1.68

Abstract

AbstractVerbal autopsy (AV) is a new technique that is fairly representative and can be trusted to record and determinethe cause of the deaths that occurred outside of health care facilities. This study is aims to get an overviewof the completeness of filling the verbal autopsy questionnaire and the relationship of the determinationaccuracy with the main causes of death in Surakarta health centers. Analytic observation with the correlationstudy which find a relationship between the completeness fillings of the verbal autopsy questionnaire with theaccuracy of the determination of the main causes of death. The sample size is 65 people taken by multistagerandom sampling technique with a 2058 population, of the entire document of 17 health centers in the regionof the city of Surakarta. The researcher collected the data by questionnaires. Analytical analysis is using Chisquaretest. The results of the research showed that only found 52% of charging the symptoms of death wascompleted by nurses. The highest completeness is in the item description summary cause of death is filled bya doctor who will determine the cause of death. In summary item complete history of disease progression by54%, while the percentage of completeness of health care items received by patients is 66%. And there is asignificant relationship between the filling completeness of the verbal autopsy with the accuracy determinationof the cause of death.Keywords: Verbal autopsy, accuracyAbstrakAutopsi Verbal (AV) merupakan teknik baru yang cukup representatif dan dapat dipercaya untuk mencatatdan menentukan penyebab kematian yang terjadi di luar sarana pelayanan kesehatan. Penelitian ini bertujuanmendapatkan gambaran tentang kelengkapan pengisian kuesioner autopsi verbal dan hubungannya dengankeakuratan penentuan sebab utama kematian di puskesmas Surakarta. observasi analitik dengan studikorelasi yakni mencari hubungan antara kelengkapan pengisian kuesioner autopsi verbal dengan keakuratanpenentuan sebab utama kematian. Besar sampel adalah 65 orang yang diambil dengan teknik multistagerandom sampling dengan jumlah populasi 2058 dokumen dari keseluruhan 17 puskesmas di wilayah kerjaKota Surakarta. Pengumpulan data melalui kuesioner. Analisis analitik menggunakan uji Chi-square. Hasilpenelitian menunjukkan bahwa ditemukan hanya 52% pengisian gejala kematian yang diisi lengkap olehperawat. Kelengkapan tertinggi adalah pada item ringkasan keterangan sebab kematian yang diisi oleh dokteryang nantinya akan menentukan sebab kematian. Pada item ringkasan riwayat perjalanan penyakit lengkapsebanyak 54%, sedangkan persentase kelengkapan item pelayanan kesehatan yang diterima pasien sebesar66%. Dan ada hubungan yang signifikan antara kelengkapan pengisian autopsi verbal dengan keakuratanpenentuan sebab dasar kematian.Kata Kunci : Autopsi Verbal, keakuratan
PENINGKATKAN KUALITAS PENGKODEAN PADA KETEPATAN DAN KECEPATAN PENGKODEAN PENYAKIT UNTUK PENAGIHAN KLAIM BPJS DI RSUD PETALA BUMI PEKANBARU Haryani Octaria
Jurnal Manajemen Informasi Kesehatan Indonesia (JMIKI) Vol 4, No 1 (2016)
Publisher : Asosiasi Perguruan Tinggi Rekam Medis dan Informasi Kesehatan Indonesia- APTIRMIKI

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33560/jmiki.v4i1.92

Abstract

AbstractRSUD Petala Bumi Pekanbaru in encoding the disease is still found inaccuracies coding thus slowing the process of claim BPJS. The aim of research to know the difference before and after the officer received training pengkodingan as enhancing the quality of the encoding on accuracy and speed of disease coding for billing claims BPJS in RSUD Petala Bumi Pekanbaru Year 2015 Type of research using quantitative analytical method with pre post test with control and intervention of each variable by coding training. The data were analyzed using univariate and bivariate with marginal homogeneity test. Results of the study there are differences in reliability (P = 0.000), validity code (P = 0.002), completeness diagnosis (P = 0.000), accuracy and speed of encoding disease (P = 0.000) before and after training in RSUD Petala Bumi Pekanbaru. RSUD Bangkinang (controls) there was no difference in reliability (P = 0.083), validity (P = 0.180), completenss (P = 0.083), accuracy and speed (P = 0.083) in assessment I and II without training. In this study, researchers concluded there is a difference in the disease coding quality reliability, validity, completeness and accuracy of the speed of coding after coding training is suggested the need for technical development and training material coding diseases, and monitoring and evaluation of the quality of coding diseases.Keywords: Coding Quality, Accuracy and speedAbstrakRSUD Petala Bumi Pekanbaru dalam pengkodean penyakit masih ditemukan ketidaktepatan pengkodean sehingga memperlambat proses klaim BPJS. Tujuan penelitian mengetahui perbedaan ketepatan dan kecepatan pengkodean sebelum dan sesudah petugas mendapatkan pelatihan pengkodingan untuk penagihan klaim BPJS di RSUD Petala Bumi Pekanbaru Tahun 2015. Jenis penelitian adalah kuantitatif analitik dengan pre post test. Analisis data dilakukan secara univariat dan bivariat dengan uji marginal homogeneity. Hasil penelitian ada perbedaan reliability (kehandalan) (P=0.000), validity (keakuratan) kode (P=0.002), completeness (kelengkapan) diagnosa (P= 0.000), ketepatan dan kecepatan pengkodean penyakit (P=0.000) sebelum dan setelah pelatihan di RSUD Petala Bumi Pekanbaru. Sedangkan RSUD Bangkinang (Kontrol) tidak ada perbedaan pada reliability (kehandalan) (P=0.083), validity (keakuratan) (P=0,180), completenss (kelengkapan) (P=0,083), ketepatan dan kecepatan (P=0,083) pada penilaian I dan II tanpa pelatihan. Simpulan penelitian ini adalah ada perbedaan kualitas pengkodean penyakit pada reliability, validity, completeness dan kecepatan ketepatan pengkodean setelah dilakukan pelatihan pengkodean Disarankan perlunya pengembangan materi dan teknis pelatihan pengkodean penyakit, dan monitoring dan evaluasi kualitas pengkodean penyakit.Kata Kunci: Kualitas Pengkodean, Ketepatan dan kecepatan
KETIDAKTEPATAN KODE KOMBINASI HYPERTENSI PADA PENYAKIT JANTUNG DAN PENYAKIT GINJAL BERDASARKAN ICD 10 DI RUMAH SAKIT ISLAM IBNU SINA PEKANBARU I Made Sudarma Adiputra; Ni Luh Putu Devhy; Kadek Intan Puspita Sari
Jurnal Manajemen Informasi Kesehatan Indonesia (JMIKI) Vol 5, No 1 (2017)
Publisher : Asosiasi Perguruan Tinggi Rekam Medis dan Informasi Kesehatan Indonesia- APTIRMIKI

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33560/.v5i1.148

Abstract

Code is provision fixing code by using letters and numbers or combination of letters and numbers that represent data component. Based on the preliminary survey result from 10 medical record file on diagnosis of hypertension combination, heart disease and kidney disease founded 6 (six) of them are wrong code. The objective of this research is to determine of inaccuracy disease code for hypertension complication of heart disease and kidney disease at Islamic Hospital Ibnu Sina Pekanbaru. The method use in this research is mix method (quantitative & qualitative). The populations in this research are 52 of inpatient medical record file taken by total sampling. The result of this research obtained that inpatient medical record file which accurate in determining of combination code are 21 (40%) and inpatient medical record file which inaccurate in determining of combination code are 31 (60%). The factor that causes inaccuracy of hypertension code combination in heart disease and kidney disease is due to lack competence of medical recorder in coding.
HUBUNGAN KELENGKAPAN INFORMASI DENGAN KEAKURATAN KODE DIAGNOSIS DAN TINDAKAN PADA DOKUMEN REKAM MEDIS RAWAT INAP Kholida Syiah Nasution; Hosizah Hosizah
Jurnal Manajemen Informasi Kesehatan Indonesia (JMIKI) Vol 2, No 2 (2014)
Publisher : Asosiasi Perguruan Tinggi Rekam Medis dan Informasi Kesehatan Indonesia- APTIRMIKI

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.33560/.v2i2.25

Abstract

AbstractThis study aims to analyze the relationship between the accuracy of the information completeness diagnosiscode and action on a document medical records of hospitalized patients. This is a type of observational studyusing cross-sectional design. The population of this research is all the patient’s medical record documentson 5 major diseases by 2013 variables in this study are the completeness and accuracy of the diagnosis codeinformation. The research instrument is a check list, ICD-10 book. The analysis in the study using the chisquaretest. The results showed no significant relationship completeness of the information in the medical recorddocuments with the accuracy of the diagnosis codes on the inpatient medical record documents (p = 0.000).Keywords: completeness of information, accuracy of the codeAbstrakPenelitian ini bertujuan menganalisis hubungan kelengkapan pengisian informasi dengan keakuratan kodediagnosis penyakit dan tindakan pada dokumen rekam medis pasien rawat inap. Jenis penelitian ini adalahobservasional dengan menggunakan rancangan secara cross sectional. Populasi penelitian ini adalah seluruhdokumen rekam medis yang pasien pada 5 besar penyakit pada tahun 2013. Variabel dalam penelitian iniadalah kelengkapan informasi dan keakuratan kode diagnosis. Instrumen penelitian berupa check list, bukuICD-10. Analisis dalam penelitian dengan menggunakan uji chi-square. Hasil penelitian menunjukkanada hubungan secara signifikan kelengkapan informasi dalam dokumen rekam medis dengan keakuratankode diagnosis penyakit pada dokumen rekam medis rawat inap (p=0,000).Kata kunci : kelengkapan informasi, keakuratan kode

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