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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. 9 No. 2 (2024)" : 22 Documents clear
Analysis of the Completeness of Integrated Patient Progress Notes (CPPT) in Mental Health Care Medical Records at Prof. HB. Sa'anin Mental Hospital, Padang: - Nasution, Nurhasanah; Mandia, Sayati
Jurnal Manajemen Informasi Kesehatan (Health Information Management) Vol. 9 No. 2 (2024): 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.v9i2.590

Abstract

Good healthcare services are not only provided to patients; they also require documentation containing patient information, known as medical records. Medical records are a comprehensive record of all information and services provided at a healthcare facility, from admission to discharge. These records are crucial and must be properly maintained and managed. One such record is the patient progress note, known as CPPT. Based on a preliminary study conducted through surveys and interviews at Prof. HB. Sa'anin Mental Hospital, incompleteness in the CPPT was still found. Therefore, the authors were interested in conducting research on the completeness of the CPPT, both quantitatively and qualitatively, in the mental health care medical records at Prof. HB. Sa'anin Mental Hospital, Padang City. The study was conducted in March 2024, using a quantitative descriptive method. The study results showed the highest score for identification review was 99% complete, and the lowest score for authentication review was 53% incomplete. The researchers recommended that the head of medical records immediately disseminate medical record guidelines and standard operating procedures (SOPs) for filling out medical records.
Comparison of Routine Hematology Test Results: Venous Blood versus Capillary Blood Using a Hematology Analyzer in the Juanda Kuningan Hospital Laboratory Wandriono, Andri; Rizki Nurul Aeni, Suci; Nuralifah Anggraeni, Ayu
Jurnal Manajemen Informasi Kesehatan (Health Information Management) Vol. 9 No. 2 (2024): 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.v9i2.595

Abstract

Hematology tests using automated equipment typically use venous blood samples. However, in certain cases where venous blood cannot be obtained, such as when veins cannot be clearly palpated due to obesity or burns at the sampling site, capillary blood samples can be used to address these issues. To understand the differences in venous and capillary blood test results using a hematology analyzer, capillary blood can be used as an alternative. This study will be a comparative study with a cross-sectional design to examine the comparison of venous and capillary blood in hemoglobin levels, leukocyte counts, erythrocyte counts, and platelet counts. The study population consisted of 30 venous blood samples and 30 capillary blood samples taken from outpatients in the Juanda Kuningan Hospital laboratory. Research Results: The results showed that routine hematology tests using venous blood yielded an average leukocyte count of 11.54 × 103/µL. The average hemoglobin was 12.47 g/dL. The average hematocrit was 35.28%. The average erythrocytes were 4.24 106/uL and the average platelets were 308 103/uL. The results of routine hematology examinations using capillary blood showed that the average leukocyte examination results were 11.39 103/ul, the average hemoglobin was 12.33 g/dL. The average hematocrit was 35.04%, the average erythrocytes were 4.15 106/uL and the average platelets were 299 103/uL. There was no significant difference in the results of leukocyte, hemoglobin, hematocrit and platelet examinations using venous blood and capillary blood, while there was a significant difference in the results of erythrocyte examinations using venous blood and capillary blood.
The Influence of Staff Knowledge Level on Health Information System Use at Community Health Centers in Malang City Soultoni Akbar, Prima; Maulidah Hariez, Tsalits
Jurnal Manajemen Informasi Kesehatan (Health Information Management) Vol. 9 No. 2 (2024): 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.v9i2.596

Abstract

One important ICT implementation in the healthcare sector is the Health Information System (HIS). There is limited research specifically examining the knowledge of community health center staff regarding readiness to use a HIS. This study aims to determine the level of staff knowledge regarding HIS use. The researchers used this approach to determine the influence of community health center staff knowledge (the independent variable) on readiness to use a health information system. The sample size in this study was 41 respondents. The sampling technique used in this study was random sampling (probability sampling). There was an effect of knowledge level on readiness to use a health information system (t = 17.96, p = <0.001). The level of knowledge of community health center staff regarding readiness to use a health information system was quite good.
Evaluation of the Quality of Diagnosis Coding for Pediatric Cases in Inpatient Medical Records Widyaningrum, Linda
Jurnal Manajemen Informasi Kesehatan (Health Information Management) Vol. 9 No. 2 (2024): 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.v9i2.598

Abstract

Diagnosis codes are used for policy-making and determining healthcare costs, so they must be of high quality. Therefore, evaluation of diagnosis codes is necessary. The evaluation includes consistency (reliability), accuracy (validity), completeness, and timeliness. This study aimed to evaluate the quality of diagnosis coding for pediatric cases in inpatient medical records at Bagas Waras Regional General Hospital, Klaten, in 2023. This was a descriptive study with a retrospective approach. The sample used was 95 pediatric medical records, using a simple random sampling technique. The research instruments were ICD-10, observation guidelines, and interviews. Data processing involved collecting, editing, classifying, tabulating, and presenting data. Data analysis was descriptive. The quality of diagnosis codes can be seen from indicators such as code consistency (97.89%) and inconsistency (2.11%). Code accuracy (91.57%) and inaccuracy (8.43%). The code completeness was 96.84% and the code incompleteness was 3.16%. The code timeliness was 98.94% and the code inaccuracy was 1.06%. The diagnosis accuracy with examination and action was 100%. Factors that influence the quality of diagnosis codes are medical personnel (doctors), medical records personnel (coders), and other health workers. The author recommends establishing regulations regarding time limits for coding diagnoses and actions. Hospitals should hold training or seminars on coding more regularly to improve the skills and knowledge of coding staff and support code quality.
Accuracy of Dengue Hemorrhagic Fever (DHF) Diagnosis Codes in Terms of Completeness and Accuracy of Medical Information Widyawati, Dwi; Heltiani, Nofri; Oktavia, Nova
Jurnal Manajemen Informasi Kesehatan (Health Information Management) Vol. 9 No. 2 (2024): 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.v9i2.599

Abstract

The completeness of the physical examination and the accuracy of laboratory results are crucial in supporting the accuracy of diagnostic codes. A preliminary survey of 10 Dengue Hemorrhagic Fever (DHF) medical records revealed that 4 (40%) were accurate and 6 (60%) were inaccurate. This was due to incomplete and inaccurate physical examination and laboratory results, which affected diagnosis and coding. This resulted in decreased data, information, and reporting quality, as well as the accuracy of INA-CBG rates, which could negatively impact the quality of hospital services. This study aimed to determine the accuracy of DHF diagnostic codes in terms of the completeness of medical information. This study used an observational, quantitative descriptive design, with 86 DHF medical records as the population and sample. The data used were secondary data obtained through observation using a checklist. The data were then processed and analyzed univariately using a frequency distribution. The results of this study are that from 86 DHF medical record files, 33 (38%) were found to have complete physical examinations, 12 (10%) were accurate laboratory test results, 8 (9%) were accurate diagnoses, and 8 (9%) were accurate diagnosis codes. It is expected that medical record officers, especially in the assembling section, will conduct medical record audits through qualitative analysis and improve coder skills through coding classification training.
The Role of Patient Satisfaction as a Mediating Variable in the Influence of Outpatient Registration Service Quality on Patient Loyalty of BPJS Non-PBI Participants at Hospital "X" in Tulangan District, Sidoarjo Regency in 2023-2024 Iva Afkarina, Iin; Eka Gusti, Titis
Jurnal Manajemen Informasi Kesehatan (Health Information Management) Vol. 9 No. 2 (2024): 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.v9i2.604

Abstract

One measure of the quality of health services is a survey of patient satisfaction. Good quality health services will have an impact on their loyal attitude. Increased loyalty proves that medical services are acceptable and recognized for their quality. The aim of this research is to analyze the reciprocal relationship between the quality of outpatient registration services and the loyalty of non-PBI BPJS participant patients through satisfaction levels at Aisyiyah Fatimah Tulangan Sidoarjo Hospital in 2023–2024. This research method is quantitative analytical and the design approach is cross sectional. The sample used was 96 respondents using purposive sampling. Data analysis is path analysis with multiple linear regression statistical tests. The research test results were obtained from the analysis of the influence of service quality on patient loyalty with a p-value of (0.000), service quality had an influence on patient satisfaction with a p-value of (0.000), a p-value of (0.000) on the influence of satisfaction on patient loyalty and test the effect of service quality on loyalty through patient satisfaction p-value (0.001). It is known that the R-square of the variables of service quality, patient satisfaction and loyalty is 0.530. In this research, it was found that there was an influence of service quality variables on patient loyalty which was mediated by patient satisfaction variables with a percentage contribution level of influence of 53%.
User Acceptance of Electronic Medical Records Implementation at Kijang Community Health Center Using the Technology Acceptance Model Pradita, Riska; Kusumo, Retno
Jurnal Manajemen Informasi Kesehatan (Health Information Management) Vol. 9 No. 2 (2024): 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.v9i2.607

Abstract

Currently, all Primary Health Facilities (FKTP) are required to implement electronic medical records. Their use can improve efficiency in patient data management, ease access to medical information, and enable real-time data sharing. Analyzing user acceptance is necessary for the transition to electronic medical records. Some users are unfamiliar with how to operate electronic medical records due to a lack of socialization, and unrestricted user access rights are also a barrier. The lack of standard operating procedures (SOPs) for electronic medical records implementation also contributes to inadequate implementation. The purpose of this study was to analyze user acceptance of the implementation of electronic medical records using the Technology Acceptance Model (TAM) based on perceived ease of use, perceived usefulness, attitude toward use, behavioral intention to use, and actual use. This study was a quantitative descriptive study with a cross-sectional design. The study location was Kijang Community Health Center, with electronic medical record users as the subjects. Data collection was conducted through questionnaires, with questionnaires serving as the research instrument. The results of the analysis of user acceptance of electronic medical records using the TAM method on the aspect of perceived ease of use of 87.5%, on the aspect of perceived usefulness of 80.5%, on the aspect of attitude toward using of 86.1%, on the aspect of behavioral intention to use of 84.7%, and related to the aspect of actual use of 85.1%. Conclusion: user acceptance of the implementation of electronic medical records at the Kijang Health Center based on the TAM method is that electronic medical records are considered easy to use, and provide benefits in carrying out work by users. In addition, it is considered to provide comfort when doing work, users also want to continue using it, and its implementation is in accordance with the modules and guidelines.
Analysis Accuracy of Diagnosis Codes and Procedure Code in JKN Patient Delivery Cases at RS X Special Region of Yogyakarta Mazaya Fitriana, Syarah; Pradita, Riska; Widowati, Vidya; Reni Tahayu, Kavita
Jurnal Manajemen Informasi Kesehatan (Health Information Management) Vol. 9 No. 2 (2024): 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.v9i2.608

Abstract

One of the activities in accordance with PMIK competency is the classification and coding of diseases and actions. The provision of diagnosis and action codes refers to the ICD-10 and ICD-9-CM rules. According to WHO (2016), coding of childbirth cases consists of conditions or complications (O00-O99), method of delivery (O80-O84), and Outcome of delivery (Z37,-). In practice in health care facilities, there are still inaccuracies in diagnosis and action codes in childbirth cases because they are classified as complex codes. The purpose of this study was to determine the process of implementing diagnosis and action codes, the process of implementing claims and factors causing pending claims, the percentage of accuracy of diagnosis and action codes and factors causing inaccuracy of diagnosis and action codes in childbirth cases of JKN patients at RS X Bantul. The type of research uses qualitative descriptive research. With a sample of objects of 75 medical records of childbirth cases of JKN patients with a simple random sampling technique and a sample of subjects of 4 informants with a purposive sampling technique. Data collection by observation, document study and in-depth interviews with 4 informants. The data validation technique in this study used source triangulation and technique triangulation. The results showed that the coding process was carried out by looking at medical records and then inputting the code into the SIMRS. The claim implementation process was carried out cumulatively and submitted to BPJS every 7th or 8th. In the case of pending labor, claims were caused by code incompatibility between the hospital and BPJS. The percentage of accuracy of the complication component was 54.7% (41), method of delivery (46.7)% (35), and outcome of delivery 94.7% (71), and action 29.3% (22). In addition, the results of the inaccuracy of the complication component were 45.3% (34), method of delivery 53.3% (40), and outcome of delivery 5.3% (4), and action 70.7% (53). The factors causing inaccuracy of diagnosis codes and actions were influenced by human resources who verified the code did not meet the competence of medical recorders, and there was no special training for coding officers. There is no budget allocated specifically for the implementation of the codification process. There is already an SOP on coding but the written procedures are still incomplete. Inaccuracy of diagnosis and action codes in cases of JKN patient labor can cause delays in payments to the hospital.
Waterfall Method Design for Implementing Medical Record Retention at Rafflesia Hospital, Bengkulu -, Khairunnisyah; Heltiani, Nofri; Arifin, Ismail; Ayu, Elisa
Jurnal Manajemen Informasi Kesehatan (Health Information Management) Vol. 9 No. 2 (2024): 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.v9i2.611

Abstract

e-Retention is beneficial in supporting the efficient retention of medical record files. Retention is carried out by filing staff by selecting medical record numbers on the shelves by looking at the date/month/year of the patient's last visit and whether they have not returned for treatment for more than 5 years. A common problem in hospitals is that retained medical record data is not recorded or archived in the retention book. Consequently, when the patient returns for treatment, filing staff require considerable time to trace the medical record files to ensure they receive medical care. This impacts patient satisfaction with medical record services. This study aims to design a waterfall method for implementing medical record retention. Primary data were obtained through observation using a qualitative descriptive study using the waterfall method, with four staff members as subjects. The data used in this study were checklists, which were then processed and analyzed univariately. The result of this research is a design for an e-retention system for medical record files that is ready for implementation. This implementation is expected to improve the efficiency and accuracy of e-retention. Suggestions include making changes to the implementation of medical record file retention to make it more effective by using e-retention, providing training to staff on its use, and conducting an impact evaluation to measure efficiency and patient satisfaction resulting from the system changes.
Differences in Glasglow Coma Scale Scores in Ischemic Stroke Patients Receiving Neuroprotectant Therapy Oktavia, Nova; Wildhan Wisnu Wardaya, Ahmad
Jurnal Manajemen Informasi Kesehatan (Health Information Management) Vol. 9 No. 2 (2024): 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.v9i2.612

Abstract

Stroke is the leading cause of disability and the second leading cause of death worldwide after heart disease. In Indonesia, stroke is the leading cause of death. This study aims to determine differences in GCS scores in ischemic stroke patients receiving neuroprotective therapy. This is an observational analytical study with a cross-sectional design. The population was 150 ischemic stroke patients recorded in inpatient medical records, with a minimum sample size of 60. Sampling used a consecutive non-probability sampling technique. Data were analyzed univariately using frequency distribution tables and bivariately using computerized Wilcoxon and Mann-Whitney statistical tests. The results of univariate analysis showed that the majority of Ischemic Stroke patients hospitalized at RSUD 45 Kuningan received Citicoline therapy (45 patients) , 34 patients were male (56.7%), 25 patients were in the Early Elderly age range (41.7%) and 25 patients had comorbidities, namely Hypertension (41.7%). The results of bivariate analysis showed that there was a significant difference in GCS scores before and after administration of neuroprotectant therapy (p value = 0.000). There was no significant difference in GCS scores at the beginning of treatment between patients who received Citicoline and Piracetam therapy (p value = 0.090). However, there was a significant difference in GCS scores at the end of treatment between patients who received Citicoline and Piracetam therapy (p value = 0.004). Neuroprotectant therapy (Citicoline and Piratecam) can improve GCS scores at the Composmentis level of consciousness (fully conscious)

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