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Khairunnisyah
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INDONESIA
Jurnal manajemen informasi kesehatan
Published by Sekolah Tinggi Ilmu Kesehatan Sapta Bakti BENGKULU
ISSN : 2527368X     EISSN : 26214385     DOI : -
Core Subject : Health,
Public Health
JURNAL MANAJEMEN INFORMASI KESEHATAN is a journal that provides scientific writings for the exchange of ideas on theory, methodology and innovation related to the world of health, especially the scope of Medical Records and Health Information.
Arjuna Subject : Profesi Kesehatan - Profesi Kesehatan (Lain-Lain)
Articles 22 Documents
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Search results for , issue "Vol. 10 No. 1 (2025)" : 22 Documents clear
Physical Examination Results and Medical Supporting Evidence Affect the Accuracy of Pneumonia Diagnosis Codes in Hospitals Heltiani, Nofri; Arifin, Ismail; Khairunnisyah
Jurnal Manajemen Informasi Kesehatan (Health Information Management) Vol. 10 No. 1 (2025): Health Information and Management
Publisher : Sekolah Tinggi Ilmu Kesehatan Sapta Bakti

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.51851/jmis.v10i1.743

Abstract

The Ministry of Health of the Republic of Indonesia, Decree No. HK.02.02/Menkes/514/2015, states that pneumonia is one of the diseases frequently leading to medical disputes, resulting in losses for hospitals. Based on an initial survey of 10 pneumonia medical records, five files contained missing supporting examination results (chest x-ray), two files contained incomplete physical examinations, and three files contained complete records (chest x-ray, physical examination), leading to doubts about the pneumonia diagnosis codes written in the medical records. This study aimed to determine the accuracy of pneumonia diagnosis codes by examining the results of physical examinations and medical support at Hospital X in 2024. This study was a quantitative descriptive study with a population and sample of 96 medical records of pneumonia cases. The data used in this study were primary and secondary data, using interview guidelines and observation sheets. The data were then processed and analyzed univariately using frequency distribution. The results of the study revealed that the completeness of the physical examination results and medical support was 38 (39%), the accuracy of the physical examination results and medical support was 35 (36%), and the accuracy of the pneumonia diagnosis code was 47 (49%). It is hoped that the Head of Medical Records will conduct a medical record audit through qualitative analysis to minimize the occurrence of medical disputes.
Tracing Diabetes Mellitus Readmission Incidence Through Medical Records at Bhayangkara Hospital, Bengkulu Budiarti, Anggia; Heltiani, Nofri
Jurnal Manajemen Informasi Kesehatan (Health Information Management) Vol. 10 No. 1 (2025): Health Information and Management
Publisher : Sekolah Tinggi Ilmu Kesehatan Sapta Bakti

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.51851/jmis.v10i1.744

Abstract

Readmission can occur for all diseases, including diabetes mellitus. A preliminary survey showed an increase in readmission rates over the past three years. If readmissions occur more than once within a 30-day period, and within a short period of time, the hospital cannot claim funding. The BPJS (Social Security Agency) claims payment system for healthcare services is based on a per-case payment within a predetermined timeframe of ≤30 days. If the time limit is exceeded, the hospital bears the costs. The purpose of this study was to determine the incidence of diabetes mellitus readmissions at Bhayangkara Hospital, Bengkulu. This study was a descriptive quantitative study, with 25 medical records of inpatient diabetes mellitus readmissions collected from January to December 2023 as the population and sample. The data used in this study were secondary data using observation sheets. The data were then processed and analyzed univariately using frequency distribution. The results of the study showed that the incidence of readmission of diabetes mellitus was 100% with the majority being 48% in the 56 - ≥65 years age group, 64% female gender and 52% family history of the disease.

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