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All Journal Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Jurnal Ilmiah Pengabdian Kepada Masyarakat
Simanjuntak, Marta
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Computer Science & IT Economics, Econometrics & Finance Health Professions Medicine & Pharmacology Nursing Public Health

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Journal : Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI)

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Tinjauan Kelengkapan Pengisian Formulir Persetujuan Tindakan Kedokteran Pasien Bedah Rawat Inap Di Rumah Sakit Tere Margareth Tahun 2022 Sabela Hasibuan, Ali; Ritonga, Zulham Andi; Simanjuntak, Marta; Nababan, Edward Ramos
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Vol. 8 No. 2 (2023): 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.v8i2.1357

Abstract

Completeness of filling in the informed consent form is very important because it can affect the quality of medical records and the legal aspects contained in the medical records themselves. This type of research is descriptive with an observational approach, namely research that describes the current situation. The study population was the medical record document of the informed consent form of inpatients with the sample in this study being a portion of the total population. An overview of the completeness of filling out informed consent sheets in surgical cases at Tere Margareth General Hospital can be seen from the sample count with a total population of (235) divided by 1+235 (precision level/10%=0.1) which results in a sample of 70. Completeness of filling in the identification of providing information is 97% filled and 3% not filled. Completeness of filling in important report items is 92% filled and 8% not filled. Completeness of filling in medical action items is 98% filled and 2% not filled. Completeness of filling in authentication items is 87% filled and 3% not filled. The medical record unit is trying to be able to ask the nurse in charge to fill out the informed consent form so that it can fill it out completely.
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).
Co-Authors Berutu, Novita Sari Christy, Johanna Erlindai, Erlindai Lubis, Siti Permata Sari Nababan, Edward Ramos Octaviana Caisara, Dewi Ritonga, Zulham Andi Sabela Hasibuan, Ali Siallagan, Happy Simanjuntak, Esraida Valentina Valentina, Valentina