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PELS (Procedia of Engineering and Life Science)
Published by Universitas Muhammadiyah Sidoarjo
ISSN : -     EISSN : 28072243     DOI : https://doi.org/10.21070/pels
Core Subject : Science, Engineering,
Computer Science & IT Control & Systems Engineering Electrical & Electronics Engineering Engineering
PELS (Procedia of Engineering and Life Science) is an international journal published by Faculty of Science and Technology Universitas Muhammadiyah Sidoarjo. The research article submitted to this online journal will be double blind peer-reviewed (Both reviewer and author remain anonymous to each other). The accepted research articles will be available online following the journal peer-reviewing process. Language used in this journal is Bahasa (Indonesia) or English. Aims and Scope of this journal is science and technology.
Arjuna Subject : Teknik (semua kategori) - Teknik (Lain-Lain)
Articles 662 Documents
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Legal Protection for Medical Recorders and Health Information Personnel in the Management of Electronic Medical Records: Perlindungan Hukum Bagi Tenaga Perekam Medis dan Informasi Kesehatan dalam Pengelolaan Rekam Medis Elektronik Wardana, I Wayan Dody Putra; Sudarsana, I Gede Diki; Murcittowati, Putu Ayu Sri; Wirajaya, Made Karma Maha
Procedia of Engineering and Life Science Vol. 7 (2025): Prosiding Seminar Nasional dan Rakernas PORMIKI X
Publisher : Universitas Muhammadiyah Sidoarjo

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.21070/pels.v7i0.2091

Abstract

Medical recorders and health information workers are one type of health workers who have the authority to manage electronic medical record services in health service facilities in accordance with Minister of Health Regulation Number 24 of 2022 concerning medical records. Electronic medical records in their application pose risks in terms of privacy and confidentiality considering that they are vulnerable to changes in data, duplication of data, transfer and buying and selling by irresponsible people. In addition, intentional or unintentional negligence in managing medical record documents makes this profession very vulnerable to lawsuits and legal sanctions in carrying out its authority. Seeing these problems, legal certainty and protection is needed for medical record and health information workers in carrying out their professional principles in managing electronic medical record services. This research was carried out to find out how legal protection is for medical recording and health information workers in managing electronic medical record services. The method in this research is a normative legal method with a statutory approach and a conceptual approach. Based on the results of this research, it is known that medical recording and health information workers have legal certainty and protection, both preventive and repressive, in accordance with the mandate of the state constitution in the 1945 Constitution and confirmed in Law Number 17 of 2023 concerning Health and Minister of Health Regulation Number 55 of 2013 concerning the Implementation of Work Medical. As a profession that exercises its authority, medical recorders and health information have legal implications if they commit a violation. In this way, medical recorders and health information workers have received legal protection and legal implications in maintaining electronic medical records as long as they meet professional standards and health service standards.
Analysis of the Release of Medical Record Information as a Guarantee of Legal Aspects of Patient Data Confidentiality: Analisis Pelepasan Informasi Rekam Medis sebagai Penjamin Aspek Hukum Kerahasiaan Data Pasien Setyaningsih, Fahmi; Meylia, Nadira Zalfa; Mayasari, Winda Nur; Parmesti, Khoirunnisa Riski; Wahyudi, Rusli Diki; Indira, Zahrasita Nur; Siregar, Rahmadhani
Procedia of Engineering and Life Science Vol. 7 (2025): Prosiding Seminar Nasional dan Rakernas PORMIKI X
Publisher : Universitas Muhammadiyah Sidoarjo

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.21070/pels.v7i0.2092

Abstract

Medical records are certainly very close to maintaining the security and confidentiality of patient data in the means of releasing information by ensuring the legal aspects of the security and confidentiality of patient data. Maintaining the security and confidentiality of patient data during the process of releasing medical record file information is very important in order to facilitate access to information on lawsuits by health services and health practitioners, as well as authorized third parties. This study aims to provide an overview of the release of medical record information in the legal aspect of confidentiality. The things that were studied were the procedures for releasing medical record information, the requirements for releasing medical information, the parties involved in releasing medical information, information on the use of releasing medical information and looking at the security aspects of the process of releasing medical record information, as well as facilities and infrastructure in the information release room. The data collection methods used in this study were interviews and observations. The results of the research on the process of releasing medical information show that two patients are in accordance and two patients are not in accordance with the SOP (Standard Operating Procedure) that applies at JIH Purwokerto Hospital, the human resources involved in the process of releasing information are Medical Recorder and Health Information (PMIK) officers and non PMIK, and inadequate facilities and infrastructure available in the information release room.
Analysis of Verification Aspects Associated with the Return of BPJS Health Claims for Inpatients at RSU Surya Husadha Denpasar: Analisis Aspek-Aspek Verifikasi yang Berhubungan dengan Pengembalian Klaim BPJS Kesehatan Pasien Rawat Inap di RSU Surya Husadha Denpasar Yunawati, Ni Putu Linda; Aridayana, I Putu Mega; Faidah, Nurul; Murcittowati, Putu Ayu Sri
Procedia of Engineering and Life Science Vol. 7 (2025): Prosiding Seminar Nasional dan Rakernas PORMIKI X
Publisher : Universitas Muhammadiyah Sidoarjo

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.21070/pels.v7i0.2093

Abstract

Submission of claims by hospitals to the Social Security Agency (BPJS) Health will go through a verification process and requires compliance with verification aspects. However, they often experience refunds or delays in payments due to non-compliance with established regulations. This results in negative impacts such as disruption to hospital cash flow, increased workload, and failure to achieve service quality indicators. It is necessary to have claim data ready before submitting a claim by the hospital. The aim of this research is to determine the relationship between aspects of membership administration, service administration and health services with the return of BPJS Health claims. This type of research uses quantitative descriptive analysis with a cross sectional approach. This research was conducted on 145 pending claims selected using a simple random sampling technique. Based on the results of the discrepancy analysis in the aspects of membership administration, namely 6 files (4.1%), service administration, namely 103 files (71%), and health services, namely 36 files (24.8%). These three aspects of verification are related to the return of BPJS Health claims, resulting in a p-value = 0.000, meaning H0 is rejected. To increase efficiency and reduce the number of claim returns, it is necessary to carry out internal verification before claims are sent to BPJS Health.
Hospital Cost Containment Efforts on the Differences between Hospital Real Rates and INA CBG's Rates for Inpatients with Pneumonia Complications at Dr. Sardjito Hospital: Upaya Pengendalian Biaya Rumah Sakit terhadap Perbedaan Tarif Riil Rumah Sakit dengan Tarif INA CBG’s Pasien Rawat Inap pada Kasus Komplikasi Pneumonia di RSUP Dr. Sardjito Kurniawati, Indrati Dwi; Sugeng, Sugeng
Procedia of Engineering and Life Science Vol. 7 (2025): Prosiding Seminar Nasional dan Rakernas PORMIKI X
Publisher : Universitas Muhammadiyah Sidoarjo

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.21070/pels.v7i0.2094

Abstract

Based on preliminary studies conducted by researchers at the Medical Records and Health Information Installation of Dr. Sadrjito Hospital, it was found that the difference between the hospital’s real rates and INA-CBG’s rates for pneumonia patients from January to May of 2024 had very significant changes in rates and could cause losses to hospital agencies. The purpose of this study was to determine how efforts made by the hospital to the difference in hospital real rates and INA-CBG’s so that hospital costs are efficient. The research method used was a descriptive research method with a quantitative approach. The results of a study of 52 inpatient pneumonia cases analyzed by the researchers found that the real hospital rates were higher than the INA CBG’s rates, causing huge losses for the hospital. The factor that causes the difference in real hospital rates is the lack of JKN claim guarantee costs, while cases of penumonia with complications have a long stay (LOS) of more than 12 days with high action costs, then the hospital must make cost control efforts by implementing standardized services so that hospital costs become more efficient and not the occurrence of higher hospital riil rates than INA-CBG’s.Suggestions for the hospital to reduce losses are to evaluate the calculation of unit costs in each inpatient unit service, monitor and evaluate claims for inpatient service costs through monitoring the coding process, verification and implementing clinical pathways in all services.
Analysis of the Accuracy of Diagnosis and Action Codification with Reconfirmation of BPJS Inpatient Patient Claims for the January-April Period of 2024 at SLG Kediri Hospital: Analisis Keakuratan Kodifikasi Diagnosis dan Tindakan dengan Konfirmasi Ulang Klaim Pasien BPJS Rawat Inap Periode Bulan Januari-April Tahun 2024 di RSUD SLG Kediri Puspitasari, Syndia; Hidayat, Andra Dwitama; Pangestuti, Ayu
Procedia of Engineering and Life Science Vol. 7 (2025): Prosiding Seminar Nasional dan Rakernas PORMIKI X
Publisher : Universitas Muhammadiyah Sidoarjo

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.21070/pels.v7i0.2095

Abstract

The accuracy of the coding of diagnoses and procedures is determined based on the completeness of the medical record documents. A dispute case or dispute claim is a claim submitted by a hospital that is declared Dispute by BPJS Health if there is a discrepancy or disagreement between BPJS and the hospital regarding claims involving services or clinical actions that impact payment of patient claims. Accurate disease and procedure coding is very important to support the smooth submission of health service claims health service cost claims. The purpose of this study was to analyze the accuracy of coding diagnoses and actions with reconfirmation of claims for inpatient BPJS patients for the period January-April 2024. The research method used is a case study approach. Techniques data collection techniques in the form of observation, literature study and interviews. The population in this study is the number of BPJS patient claim files returned in January-April 2024. The sample used in this study is the number of BPJS inpatient claim files that are returned with coding inaccuracies in January-April 2024. The research results show that from January to April 2024, reconfirmation of inpatient BPJS patients tends to fluctuate. The highest reconfirmation was in April with a total of 89 documents. Meanwhile, reconfirmation with the highest codification inaccuracy was in January with a total of 26 documents. This reconfirmation is sent in Excel form which must be confirmed by the hospital. From the results of the research conducted, the cause of re-confirmation of inpatient BPJS patients related to coding inaccuracies is still high. Accurate coding can minimize hospital losses and the risk of fraud in health service facilities.
Analysis of the Use of Electronic Medical Records on the Effectiveness of Outpatient Services at the Siulak Mukai Health Center in 2024: Analisis Penggunaan Rekam Medis Elektronik terhadap Efektivitas Pelayanan Rawat Jalan di Puskesmas Siulak Mukai Tahun 2024 Mandasari, Cica Puspita
Procedia of Engineering and Life Science Vol. 7 (2025): Prosiding Seminar Nasional dan Rakernas PORMIKI X
Publisher : Universitas Muhammadiyah Sidoarjo

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.21070/pels.v7i0.2096

Abstract

To improve the quality of health services, health workers are needed who have competencies in accordance with their education and training. Competent health workers are able to provide appropriate services and one of the outpatient health services provided by the government is the Siulak Mukai Health Center. In an effort to modernize and increase the efficiency of the health service system, the government provides a medical record supporting information system, namely the Electronic Medical Record (RME). Siulak Mukai Community Health Center has implemented an electronic medical record system (RME) as an effort to improve the quality and quality of its services. However, there are still some polyclinics that do not fill in complete electronic data due to several obstacles such as network problems at the end of the service and busy nurses and doctors on certain days, as well as the lack of responsibility of health workers in filling in data. on RME. This study aims to determine the impact of using electronic medical records on the effectiveness of outpatient services at the Siulak Mukai Community Health Center. This type of research is quantitative descriptive research. The data analysis method uses quantitative descriptive statistical analysis with the help of SPSS. The research results show that the use of RME has a positive impact on the effectiveness of outpatient services in terms of the aspects of function, program, provisions, objectives and systems at the Siulak Mukai Community Health Center.
Overview of the Accuracy of Inpatient Dyspepsia Diagnosis Codes Based on ICD-10 at Hospital X Bengkulu City: Gambaran Keakuratan Kode Diagnosis Dyspepsia Rawat Inap Berdasarkan ICD-10 di Rumah Sakit X Kota Bengkulu Putri, Liza; Agusianita, Agusianita; Khairunnisa, Alfi
Procedia of Engineering and Life Science Vol. 7 (2025): Prosiding Seminar Nasional dan Rakernas PORMIKI X
Publisher : Universitas Muhammadiyah Sidoarjo

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.21070/pels.v7i0.2097

Abstract

Problem of Coding activities for disease diagnosis are very important during medical record services in hospital installations. To get the correct coding, the activities carried out look at the medical resume, admission and discharge summary and supporting sheet where the coding is carried out by the medical record staff, who is responsible for the accuracy of the Dyspepsia code. If coding is not carried out accurately, it will result in errors in disease recording indexes and procedures, inaccurate report information data and inaccurate INA-CBG rates. Objective for Known description of the accuracy of inpatient dysspecia diagnosis codes based on ICD-10 at Rafflesia Hospital, Bengkulu City. Method:This type of research is descriptive observational through direct observation of the population and a sample of 57 medical record files with a diagnosis of dyspepsia cases. The data used in this research is secondary data which was processed univariately. Results of the 57, the majority, namely 36(63,1%) of the dyspepsia diagnosis codes in the medical record files were accurate and 21 (36,9%) of the dyspepsia diagnosis codes in the medical record files were inaccurate. The completeness of the recording files was 36 files (63,1%), the completeness of the incomplete recording files was 31 files (36.9%). Suggestion: Coders should refer to ICD-10 in assigning codes and attend training to deepen their understanding of the implementation of classification and codification.
Clarity of Diagnosis Writing and Accuracy of Coding in Heart Failure Based on ICD-10 at Hospital X: Kejelasan Penulisan Diagnosa dan Keakuratan Kodefikasi pada Heart Failure Berdasarkan ICD-10 di Rumah Sakit X Harmanto, Deno; Budiarti, Anggia; Rahayu, Dinda Sri
Procedia of Engineering and Life Science Vol. 7 (2025): Prosiding Seminar Nasional dan Rakernas PORMIKI X
Publisher : Universitas Muhammadiyah Sidoarjo

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.21070/pels.v7i0.2098

Abstract

It is very important to code the diagnosis of Heart Failure correctly and accurately, inaccuracies in codes are often found in medical record files such as unclear writing of the diagnosis or even incomplete supporting documents and the absence of a 4th character code in the diagnosis of Heart Failure. If coding is not carried out accurately, it will result in errors in disease recording indexes and actions, inaccurate report information data and inaccurate INA-CBG rates. The purpose of this study aims to determine the clarity of writing diagnoses and the accuracy of heart failure coding based on ICD-10 at Rafflesia Hospital, Bengkulu. The type of research is descriptive. The data used are primary data and secondary data which are processed univariately, data collection methods are through interviews and observation. The tool used is a checklist sheet with direct observation of 176 medical record files for the diagnosis of heart disease. Of the 176 medical record files for the diagnosis of Heart Failure, there is clarity in writing the diagnosis on the medical resume, a small number of 56 files (32%) are clear, but the majority of 120 files (68%) are unclear and the accuracy of codes based on ICD-10 is mostly 64 files (36% ) were accurate and as many as 112 files (64%) were inaccurate.
Evaluation of Panti Rapihku Hospital Online Registration Application Based on Android: Evaluasi Aplikasi Pendaftaran Online Rumah Sakit Panti Rapihku Berbasis Android Kurniawan, Henokh Sony; Sutrisno, Trismianto Asmo; Wariyanti, Astri Sri
Procedia of Engineering and Life Science Vol. 7 (2025): Prosiding Seminar Nasional dan Rakernas PORMIKI X
Publisher : Universitas Muhammadiyah Sidoarjo

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.21070/pels.v7i0.2099

Abstract

Electronic Government (e-government) utilizes information technology to enhance government performance and public services. Electronic Medical Records (EMR) are mandatory to be implemented in all healthcare facilities in Indonesia to improve services and maintain data confidentiality. Usability is a crucial aspect in the success of applications and websites, including in the healthcare context. Observations of the PantiRapihku application revealed several issues: difficulties in use by patients, absence of a direct payment menu, account limitations, and mismatched doctor schedules. This study aims to evaluate the online registration application of Panti Rapih Hospital using the System Usability Scale (SUS).This descriptive study involved users who tried the PantiRapihku application. The sampling technique used was simple random sampling with a total sample of 30 respondents. Data were collected using the System Usability Scale (SUS) and analyzed descriptively using computer software.The SUS evaluation results showed a score of 83.4, indicating that the PantiRapihku application is in the “Acceptabel” category. The application’s grade scale level is in category B, and the adjective rating is in the “Excellent” category. The PantiRapihku application is well-rated and acceptabel to users. However, it is recommended that the hospital improves the application’s consistency and coherence, such as synchronizing patient registration history with doctor leave schedules and surgery schedules.
The Role of Electronic Medical Records as a Professional Communication Tool for Caregivers at Nyi Ageng Serang Hospital: Peran Rekam Medis Elektronik sebagai Alat Komunikasi Profesional Pemberi Asuhan di RSUD Nyi Ageng Serang Nurdiyansyah, Andi Karisma; Wuryanto, Sis; Asgiani, Piping; Setiawan, Fendi
Procedia of Engineering and Life Science Vol. 7 (2025): Prosiding Seminar Nasional dan Rakernas PORMIKI X
Publisher : Universitas Muhammadiyah Sidoarjo

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.21070/pels.v7i0.2100

Abstract

To improve the quality and efficiency of health services in hospitals, there needs to be good communication from care professionals working at the service facility. Communication between care-giving professionals can be done by data communication through Electronic Medical Records (RME). RSUD Nyi Ageng Serang has implemented an outpatient RME to support patient care. However, the existing application has not been optimally utilised. The aim was to determine the role of RME as a communication tool between care professionals at Nyi Ageng Serang Hospital. The type of research used was descriptive qualitative research with a cross sectional design. This study used observation and focused group discussion (FGD) methods for data collection. The subject of this research is professional caregivers in outpatient installations while the object is RME. The data analysis technique used was qualitative data analysis technique starting with data reduction, data presentation, and continued with conclusion drawing. The role of electronic medical records in the implementation of interprofessional communication and collaboration is as a means of communication, especially where every finding and opinion of health professionals by care-giving professionals is poured and put together in electronic medical records, the findings of the medical history and actions given to patients and documented in writing or recorded. However, all of these provide benefits such as more complete RM content, business and communication efficiency, strategic benefits, and easy access to information. The completeness of patient data documentation in the RME at Nyi Ageng Serang Hospital can be improved through strengthening supporting regulations for documentation, training on the completeness of patient data filling for PPAs, adding features to check the completeness of documentation and designing a reward and punishment system for PPAs in terms of completeness of documentation in the RME. The addition of optional features to determine the diagnosis of disease by adding a list of disease diagnoses based on ICD-10 to the RME system database which makes writing a patient's medical diagnosis more concise and standardised and writing the main diagnosis is only written one diagnosis.

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