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Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI)
Published by Universitas Imelda Medan
ISSN : 25027786     EISSN : 25977156     DOI : https://doi.org/10.2411/jipiki
Core Subject : Health,
Health Professions Public Health
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) (p-ISSN : 2502-7786 ) (e-ISSN : 2597-7156) is a national, peer-reviewed journal. It publishes original papers, reviews and short reports on all aspects of the medical record and health information. It is aimed at all medical record and health information practitioners and researchers and those who manage and deliver medical record and health information services and systems. It will also be of interest to anyone involved in health information management, health information system, and health information technology.
Arjuna Subject : Profesi Kesehatan - Menejmen Informasi Kesehatan
Articles 254 Documents
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Analisis Kelengkapan dan Ketepatan Kodefikasi Penyakit Neoplasma Berdasarkan ICD-10 Suryandari, Endang Sri Dewi Hastuti; Muttaqien, Anis Nurul Fataya; Gunawan; Sangkot, Hartaty Sarma; Wijaya, Avid
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Vol. 9 No. 1 (2024): 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.v9i1.1530

Abstract

Diagnosis coding in neoplasm diseases should be complete and precise in accordance to ICD-10 by providing topography codes and morphology codes. Incompleteness and inaccuracy of codes could have an impact on inaccuracies of morbidity reports and inappropriate treatment, as well as increased medical costs. Preliminary studies at UOBK RSUD Dokter Mohamad Saleh Probolinggo showed the percentage of topography code accuracy in 5 medical record documents (MRDs) for neoplasm diseaes was 100%, and the completeness of the neoplasm diagnosis code was 0%. This study objective was to ascertain the completeness and precision of codes in neoplasm diseases based on ICD-10. The research’s design was a quantitative descriptive study with a retrospective strategy using the population of all MRDs of neoplasm diseases in September-November 2022. The sample of 112 MRDs which taken utilizing the technique of total sampling. The factors in the research was the completeness and accuracy of neoplasm diagnosis codes based on ICD-10. Data were collected through observation in the coding section and checklist sheets. The outcome presented the precision of the topography codes was 90.18%, the precision of the morphology codes was 0%, and the precision and thoroughness of the codes in neoplasm diseases was 0%. The incompleteness and inaccuracy of the codes was caused by the absence of morphological code in the patient's medical resume and errors in selecting the topography code block. Coders should complete the morphological code on the patient's medical resume to obtain the neoplasma diagnosis code’s accuracy and completeness.
Faktor-Faktor Yang Mempengaruhi Ketepatan Kode Diagnosa External Cause Kasus Kecelakaan Sepeda Motor Di RSU Imelda Pekerja Indonesia Medan Tahun 2023 Simanjuntak, Marta; Christy, Johanna; Erlindai, Erlindai; Berutu, Novita Sari
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Vol. 9 No. 2 (2024): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Agustus
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v9i2.1533

Abstract

Codefication classification is an activity that groups diseases based on certain. Coding of disease diagnoses must be carried out accurately and completely. The assignment of disease diagnosis codes is in accordance with ICD-10 rules. External cause is a code used to classify the external cause of an illness whwther caused by accidents, injuries, burns, poisoning, side effects of other cause. Factors thar influence the accuracy of external cause diagnosis codes are discrepancies in giving diagnosis codes, erros and discrepancies in giving additional codes for descriptions of activity and place of occurrence. As a passenger or driver, do not include the external cause code in the wxisting diagnosis. This research was conducted at RSU Imelda Pekerja Indonesia Medan with the aim of research to determine the factors that influence the accuracy of the external cause diagnosis code for motorbike accident cases at RSU Imelda Pekerja Indonesia Medan in 2023. This research uses quantitative analytical methods with a cross sectional approch. The research results showed that there was a significant influence of the variable completeness of assessment eith coding accuracy with a value (p value 0.002 < 0,05), there was an influence of completeness of laboratory examination with coding accuracy with a value ( p value 0.045 < 0,05), there was an influence og the quality of code officers according to length of service with value (p value 0.003 < 0,05) and there is an influence on the quality of code officers according to training followed by value (p value 0.017 < 0,05).
Perancangan Sistem Informasi Pendaftaran Pasien Menggunakan Bahasa Pemrograman Visual Basic Pada Puskesmas Pelabuhan Sambas Sibolga Nengsih, Yeyi Gusla; Sitorus, Mei Sryendang; Hutasoit, Theresia; Tanjung, Hizraini
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Vol. 9 No. 1 (2024): 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.v9i1.1540

Abstract

The patient information system at the community health center is an information system that has activities such as queuing, registration and medical records. Registration services that are still manual make registration ineffective and inefficient. Officers needed a lot of time to search for documents and take notes and there was a buildup of patient queues at the registration unit. Apart from that, the manual system for making reports is not effective, so to improve registration services for patients, a health center information system is needed that is able to provide good and fast service to patients. The aim of this research is to design a registration information system application to assist registration officers in providing patient registration services. Data collection methods consist of observation methods, interview methods and documentation methods. This research approach is the SDLC (System Development Life Cycle) approach, which is a cycle used in creating or developing information systems that aims to solve problems effectively. The results obtained from this research are the design of a patient registration information system using the Visual Basic programming language. The results of the interface display from the design of the Sambas Port Health Center information system are login form, main menu form, user menu, patient registration form, patient data search menu, queue menu and patient data report menu. The conclusions obtained by this information system design can help officers in the registration unit at the Community Health Center to be more effective and efficient.
Analisis Efisiensi Penggunaan Tempat Tidur Di RSJD Dr. Arif Zainudin Surakarta Septiyowati, Shela Anik; Igiany, Prita Devy; Pertiwi, Julia
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Vol. 9 No. 1 (2024): 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.v9i1.1557

Abstract

Health Statistics provide information about people’s health and use of health services. The percentage of bed use in health service facilities been formulated consists of 4 parameters, namely BOR, LOS, TOI, BTO which can be depicted in a graphic known as Barber Johnson. The purpose of this study is to analyze the efficiency of bed use based on Barber Johnson at RSJD Dr. Arif Zainudin Surakarta in 2021. The type of research used is quantitative descriptive with Cross sectional design. Population in the form of monthly SHRI recapitulation. The results of this study show that the BOR calculation in 2021 was 48.43% in (Quarter 1), 58.82% (Quarter II), 46.56% (Quarter III), 42.63% (Quarter IV). 20-day AVLOS (Quarter I), 20 days (Quarter II), 18 days (Quarter III), 19 days (Quarter IV), TOI 21 days (Quarter I), 14 days (Quarter II), 21 days (Quarter III), 26 days (Quarter IV), BTO 2 times (Quarter I), 3 times (Quarter II), 2 times (Quarter III and IV). From the analysis conducted, the use of beds in RSJD has not been efficient. To improve the efficiency of bed use, hospital management further improves quality of service and limits value of inpatient indicators according to mental hospitals.
Tinjauan Faktor Yang Mempengaruhi Waktu Tunggu Pelayanan Pendaftaran Pasien Rawat Jalan Di RS DKT Sidoarjo Zein, Eiska Rohmania; Mujizah, Ahfil
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Vol. 9 No. 1 (2024): 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.v9i1.1599

Abstract

One form of administrative service at the hospital is the medical record service. The problem in the medical record installation at DKT Sidoarjo Hospital is the waiting time for outpatient medical record services. Based on Permenkes RI No.129/Menkes/SK/II/2008 for patient medical record services at outpatient registration, namely > 10 minutes. This study aims to determine the factors that influence the waiting time for medical record services at outpatient registration at DKT Sidoarjo Hospital. The research method is descriptive with instruments in the form of observations and interviews conducted with the head of medical records and medical records officers in the registration section. The results of this study indicate that the factor that greatly influences the waiting time for medical record services at TPPRJ DKT Sidoarjo Hospital is medical record activities, namely the provision of medical records in the storage section. On the Man Factor, namely the number of officers and educational qualifications of officers who are not from medical records. On the Money Factor there are no funds for the education and training of registration officers and no rewards for officers who are disciplined and friendly in service. In the Methode Factor the use of Registration SOP is not optimal. In Material Factors there is no use of tracers on storage racks. On the Machine Factor, namely frequent errors on SIMRS when performing services.
Analisis Ketepatan Kode Diagnosis Pada Kasus Penyakit Infeksi Saluran Pernapasan di Rumah Sakit Umum Daerah Ajibarang Syifani, Annisa Zahra; Fauzi, Harry; Marini, Budiana
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Vol. 9 No. 2 (2024): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Agustus
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v9i2.1628

Abstract

Coding is one of the activities of processing medical record data by providing codes with letters or numbers or a combination of letters and numbers that represent data components. Coding is the activity of providing codes for the main diagnosis and secondary diagnosis in accordance with the 2010 version of ICD-10 published by WHO and providing action and procedure codes in accordance with the 2010 version of ICD-9-CM. Accuracy in coding disease diagnoses and actions is something that must be considered by medical recorders. The accuracy of coded data is crucial for medical recorders. The purpose of this research was to ascertain the level of coding accuracy in cases of respiratory tract infections at Ajibarang Hospital. The research was conducted using the descriptive quantitative analysis method with a sample of 90 medical records of patients with respiratory tract infections in August–October 2023 at RSUD Ajibarang. The conclusion of this research showed that of the 90 medical records of respiratory tract infection cases at Ajibarang Regional Hospital in August–October 2023 studied, there were 19 medical records with inappropriate codes (21.11%) and 71 medical records with appropriate codes (78.89%), which were identified as inaccurate factors using 5M (man, money, material, method, and machine).
Analisis Kelengkapan Desain Formulir Pasien Rawat Jalan Di Puskesmas Purwokerto Timur I Cahyani, Lintang Dwi; Hakim, Agya Osadawedya; Indira, Zahrasita Nur; Permatasari, Merdiana Ika
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Vol. 9 No. 2 (2024): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Agustus
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v9i2.1649

Abstract

Puskesmas is one of the health service institutions provided by the Indonesian government and is the spearhead of the national health system. Efforts in establishing quality health centre service quality, that is, by paying attention to every aspect of it. The anatomical and physical aspects are used here. Please note the number of measurement cards for patients. One of them is processing the patient's medical record form design. Medical record forms are designed and used for maintenance and monitoring. The design of the form aims to improve and complete aspects of the outpatient form design that are currently still in use and to improve the quality of health services at the Purwokerto Timur I Health Center. The objective of this research is to identify the completeness of the outpatient forms available at the Purwokerto Health Center. Timur I. This analysis uses a quantitative method with a cross-sectional descriptive approach. The subject of this study was the outpatient form at the Purwokerto Timur I Health Center. The results obtained from this study were quite good, that is, there was an outpatient form at the Purwokerto Timur I Health Center, but the results of the analysis of this form still need to be improved in completeness. There is a completeness of 76,92% in the form. The aspect of the content that has the best completeness of the form.
Analisis Penyebab Pengembalian Klaim BPJS Pasien Rawat Inap Ditinjau Dari Proses Pengkodean Di RSUD Majenang Zahra, Awlia Varasemitha; Hakim, Agya Osadawedya; Fauzi, Harry; Gunawan, Gunawan
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Vol. 9 No. 2 (2024): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Agustus
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v9i2.1651

Abstract

Pending Claim is a refund because there is no agreement between BPJS Health and FKRTL regarding coding rules and medical determination (claim dispute). The correct diagnosis and action code will determine the smooth process of submitting claims for medical services to BPJS Health and reduce the number of claim returns. This study aims to determine the causes of inpatient claim returns in terms of the coding process at Majenang Hospital. The research method used is a qualitative method with an observational descriptive design. Data was obtained from pending claims from July to September 2023. Data collection methods were observation and interviews. Majenang Hospital research results showed that 371 claims were returned and 187 claims were returned due to coding confirmation. Factors inhibiting the accuracy of a diagnosis or action code are the use of combined codes, errors in determining the main diagnosis, differences in perception, and discrepancies in supporting results with the diagnosis. Efforts that can be made to minimize the number of claim returns include reviewing diagnosis or action codes, communicating between DPJP, the casemix team and BPJS verifiers, coding training and having an SPO.
Faktor - Faktor Yang Mempengaruhi Proses Pengkodean Diagnosis Di Rumah Sakit Umum Daerah Cilacap Febriana, Dina; Hakim, Agya Osadawedya; Indira, Zahrasita Nur; Anggraeni, Okti
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Vol. 9 No. 2 (2024): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Agustus
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v9i2.1654

Abstract

Hospitals are health institutions that provide medical services to individuals as a whole, including inpatient, outpatient, and emergency care. Hospitals need to improve the quality of their services. This can be done by having a good medical record unit. Medical records are documents that contain information about the patient's identity, examination, treatment, procedures, and other services provided to the patient. An important data processing to store data in medical records is coding. Classifying and providing codes for disease diagnosis is known as coding. Writing codes on medical records must be precise and accurate. The impact of coding errors can affect the quality of medical records. Based on an initial survey related to coding carried out at Cilacap Regional Hospital, a problem was found that officers had difficulty reading the doctor's writing. This study aims to determine what factors influence the diagnosis coding process at Cilacap Regional Hospital. This research is a type of qualitative research with data collection method instruments through observation and interviews. The research subjects amounted to 2 people, namely coder officers and the head of the medical records unit. The results of the study obtained several factors that influence the coding process including; Writing a diagnosis that is difficult to read, incompleteness in medical records can affect the coding process that will be carried out by the coder, and the absence of a medical dictionary as a coding support book in finding unknown terms in coding.
Keselamatan dan Kesehatan Kerja (K3) Petugas Rekam Medis Ruang Filling di Rumah Sakit Bhayangkara Tingkat III Banjarmasin Husin, Husin; Yunita, Nirma
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Vol. 9 No. 2 (2024): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Agustus
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v9i2.1673

Abstract

Filling unit rekam medis mempunyai peran penting dalam pemeliharaan rekam medis terutama dalam hal penyimpanan dan perlindungan rekam medis. Penyimpanan rekam medis dapat berjalan dengan baik apabila fasilitas penunjang dalam kegiatan penyimpanan tersedia dan lingkungan kerja mendukung sehingga dapat memudahkan dalam pengambilan, penyediaan dan penyimpanan rekam medis. pengambilan dan penyimpanan dokumen rekam medis, petugas filling pernah tertimpa dokumen rekam medis, tergores dokumen rekam medis, rak rekam medis, petugas filling terjatuh saat mengambil dokumen rekam medis yang tinggi. Sehingga diteliti serta diketahui penerapan keselamatan dan kesehatan kerja (K3) berdasarkan faktor sumber daya manusia dan faktor lingkungan kerja di Rumah Sakit Bhayangkara Tingkat III Banjarmasin. Jenis penelitian dalam penelitian ini adalah kualitatif dengan pendekatan deskriptif. Subjek penelitian ini berjumlah 3 orang yaitu Kepala Unit Rekam Medis sebagai informan 1, Petugas filling rawat jalan sebagai informan 2 dan petugas filling rawat inap sebagai informan 3. Instrument penelitian ini menggunakan pedoman wawancara danobservasi. Hasil penelitian ini adalah Penerapan keselamatan dan kesehatan kerja (K3) di Rumah Sakit Bhayangkara Tingkat III Banjarmasin belum berjalan baik berdasarkan faktor sumber daya manusia dalam penggunaan alat pelindung diri (APD) sebagian besar menggunakan masker, berdasarkan faktor lingkungan kerja pada ruang filling rawat jalan pencahayaan dan jarak antar rak belum memenuhi standar, pada ruang filling rawat inap suhu, kelembaban, pencahayaan dan jarak antar rak belum memenuhi standar. Sehingga perlu sosialisasi penerapan penggunaan APD dan pengecekan sarana prasarana secara berkala terhadap sarana prasarana untuk pemenuhan standar ruang filling

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