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PERANCANGAN SISTEM INFORMASI REKAM MEDIS PUSKESMAS SUKAMERINDU Ramadani, Niska; Heltiani, Nofri
Jurnal EDik Informatika Vol 6, No 1 (2019)
Publisher : STKIP PGRI Sumatera Barat

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.22202/ei.2019.v6i1.3694

Pusat Kesehatan Masyarakat (Puskesmas) adalah salah satu sarana pelayanan kesehatan masyarakat yang berfungsi sebagai pembangaun kesehatan, yang berfungsi sebagai unit pelaksana teknis dinas kabupaten/kota yang bertanggungjawab menyelenggarakan pembangunan kesehatan di suatau wilayah kerja salah satunya adalah Puskesmas Sukamerindu. Pada Puskesmas Sukamerindu dalam memberikan pelayanan kepada pasien, mulai dari pendaftaran, sampai pasien mendapatkan resep obat serta pengolahan data laporan Puskesmas masih dilakukan dengan cara manual atau belum terkomputerisasi. Dimana sistem pendaftaran pasien di catat ke dalam Buku Register, belum tersedianya Sistem Inoformasi Manajemen Puskesmas, dimana media penyimpanan data pasien dan rekam medis pasien masih di simpan secara konvensional, sehingga mengakibatkan pencarian data dilakukan dengan cara menelusuri berkas rekam medis dengan membutuhkan waktu yang cukup lama dalam pendaftaran masih dilakukan dengan tulisan tangan dimana bisa terjadi kesalahan pencatatan serta pembuatan laporan-laporan yang berhubungan dengan rekam medis masih dikerjakan secara manual dengan cara merekap data pasien, data kunjungan pasien yang membutuhkan banyak waktu selain itu juga rentan terjadi kesalahan.Untuk melakukan pengembangan Sistem Informasi Rekam Medis penulis melakukan analisis terhadap permasalahan pada sistem yang berjalan pada saat sekarang ini menggunakan metode waterfall dengan menggunakan alat bantu pengembangan sistem berupa diagram konteks, DFD, dan alat perancangan database yang diusulkan berupa ERD. Pengumpulan data dilakukan dengan cara wawancara, observasi dan studi pustaka terkait dengan perancangan sistem informasi rekam medis. Implementasi program yang digunakan pada sistem informasi rekam medis ini menggunakan bahasa pemrograman PHP dengan database MySQL. Tujuan dari penelitian ini adalah untuk merancang sistem informasi untuk membantu mengurangi permasalahan-permasalahan dalam pelayanan rekam medis di Puskesmas Sukamerindu, pengolahan data pasien, rekam medis, sudah dilakukan secara komputerisasi sehingga proses pelayanan kesehatan masyarakat dapat dilakukan dengan cepat dan mudah serta terhindar dari kesalahan.

ANALISIS BED TURN OVER DI RUANG MINA RUMAH SAKIT HARAPAN DAN DOA KOTA BENGKULU Heltiani, Nofri; Duri, Iin Desmiany; Lestari, Endah Dwi
Jurnal Informasi Kesehatan Indonesia (JIKI) Vol 7 No 1 (2021): Jurnal Informasi Kesehatan Indonesia (JIKI)
Publisher : Politeknik Kesehatan Kemenkes Malang (State Health Polytechnic of Malang)

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31290/jiki.v7i1.2261

Bed Turn Over (BTO) is the average number of patients who use each bed in a certain period. The ideal BTO value is 40-50 times/year. Inpatient indicators related to BTO are very important to pay attention to in efforts to improve service quality. The high BTO has the potential to disrupt the balance of clinical aspects such as hospital nosocomial infections. Based on the initial survey, the BTO value for the last three years at the Bengkulu City Hope and Prayer Hospital has increased, namely in 2016 (58.23 times/year), 2017 (64-65 times year) and 2018 (65 times/year) . This shows that the change of patient beds is very fast so that the use of the bed exceeds the provisions, namely 40-50 times/year, meaning that 1 bed is used by more than 50 patients a year which can cause nosocomial infections. The purpose of this study was to determine the value of BTO in the Mina Room of Harapan Hospital and Prayer in Bengkulu City for the 2019 period. The type of research used in this study was quantitative descriptive with a cross sectional approach. The population and sample were 2,060 inpatients in the Mina Room for the period 2019 with the sampling technique being the total population. The data used is secondary data which is processed by collecting, editing, classification and tabulating and analyzed using the BTO formula. The results of data analysis, the number of patients treated in the 2019 period in the Mina Room were 2,060 patients, with length of care (LD) of 7,435 days/year and an average of 3-4 days/year and the number of patients discharged (living or dead) in the Mina Room. 2,045 patients came out alive and 15 patients died, so that the BTO value in the Mina Room reached 93.58 times/year. The high BTO value in the Mina Room in the 2019 period resulted in a fairly high nosocomial infection of 12%. It is hoped that the hospital will add more beds in the Mina Room to prevent or reduce the occurrence of nosocomial infections.

ANALISIS KELENGKAPAN BERKAS KLAIM RAWAT INAP DIRUMAH SAKIT HARAPAN DAN DOA KOTA BENGKULU Putri, Liza; Heltiani, Nofri
Mitra Raflesia (Journal of Health Science) Vol 15, No 2 (2023)
Publisher : LPPM STIKES BHAKTI HUSADA BENGKULU

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.51712/mitraraflesia.v15i2.263

ABSTRAK Latar Belakang: Klaim BPJS adalah pengajuan biaya perawatan pasien peserta BPJS oleh pihak rumah sakit kepada pihak BPJS Kesehatan, dilakukan secara kolektif dan ditagihkan kepada pihak BPJS Kesehatan setiap bulannya. Klaim BPJS yang tidak layak untuk rawat jalan dan rawat inap di Harapan dan Doa Kota Bengkulu selama 1 tahun (2022) sebanyak 67 berkas rawat jalan dan 205 berkas untuk rawat inap. Penelitian ini bertujuan Untuk menganalisis prosedur pengajuan klaim Badan Penyelenggara Jaminan Sosial (BPJS) Kesehatan di Rawat Inap Rumah Sakit Harapan dan Doa Kota BengkuluMetode : Menggunakan metode kualitatif dengan indepth interview yang diambil dari 4 informan. Pemeriksaan atau pengecekan keabsahan data menggunakan triangulasi sumber dan triangulasi metode.Hasil : Hasil penelitian diperoleh untuk rekapitulasi pelayanan masih terdapat hal- hal yang perluh diperbaiki antara lain banyak perawat dan juga DPJP yang masih sering salah dalam mengisi tanggal masuk perawatan dan tanggal keluar, berkas yang tidak terisi diagnosa penyakit dan perlu konfirmasi lagi dengan dokter yang menangani pasien tersebut selain itu untuk berkas pendukung pasien dan bukti pelayanan lainnya masih ada hal-hal yang perluh diperbaiki oleh pihak rumah sakit mulai dari diagosa dari dokter yang tidak tepat, perbedaan koding antara rumah sakit dan koding BPJS dan hasil pemeriksaan penunjang yang tidak ada berkasnya.Simpulan : Kesimpulan yang di dapat adalah Prosedur pengajuan klaim untuk poin rekapitulasi pelayanan dan berkas pendukung pasien dan bukti pelayanan lainnya masih ada hal-hal yang masi perlu di perbaiki lagi oleh pihak rumah sakit. Saran bagi Rumah Sakit Harapan dan Doa Kota Bengkulu untuk memperkuat kerja sama dengan dokter dan perawat agar tidak terjadi kesalahan penulisan data pasien dan untuk BPJS agar lebih memperbanyak pelatihan mengenai pengajuan klaim BPJS kesehatan dengan pihak Rumah Sakit Harapan dan Doa Kota BengkuluKata Kunci: Klaim BPJS, Rawat Inap, Rumah Sakit, BPJS Kesehatan ABSTRACTBackground : BPJS claims are submissions for the costs of treating BPJS participant patients by the hospital to BPJS Health, carried out collectively and billed to BPJS Health every month. BPJS claims that are not eligible for outpatient and inpatient care at Harapan and Doa Bengkulu City for 1 year (2022) are 67 files for outpatient care and 205 files for inpatient care. Method : This study aims to analyze the procedures for filing claims for the Health Social Security Administering Body (BPJS) at Inpatient Hope and Prayer Hospitals in Bengkulu City using qualitative methods with in-depth interviews taken from 4 informants. Results : Checking or checking the validity of the data using source triangulation and method triangulation. The research results obtained for the recapitulation of services there are still things that need to be corrected, including many nurses and also DPJP who are still often wrong in filling in the date of admission and date of discharge, files that do not contain disease diagnoses and need confirmation again with the doctor who treats these patients besides that for patient support files and other evidence of services there are still things that need to be corrected by the hospital starting from the diagnosis from the doctor who is not right, the difference in coding between the hospital and the BPJS coding and the results of supporting examinations where there is no file. Conclusion : The conclusion that can be obtained is that the procedure for submitting claims for service recapitulation points and patient support files and other evidence of services there are still things that still need to be improved by the hospital. Suggestions for Hope and Prayer Hospital of Bengkulu City to strengthen cooperation with doctors and nurses so that there are no errors in writing patient data and for BPJS to increase training on filing BPJS health claims with Harapan and Prayer Hospital in Bengkulu CityKeywords: BPJS Claims, Hospitalization, Hospitals, BPJS Health

Perancangan Sistem Informasi Registrasi Pasien Rawat Jalan RSUD Kebupaten Lebong arifin, ismail; heltiani, nofri; fatolla, devri
Jurnal Manajemen Informasi Kesehatan (Health Information Management) Vol. 8 No. 1 (2023)
Publisher : Sekolah Tinggi Ilmu Kesehatan Sapta Bakti

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.51851/jmis.v8i1.398

RSUD Kabupaten Lebong merupakan Rumah Sakit bertipe C mulai beroperasi sejak 2015. Pada pelayanan pasien di bagian pendaftaran masih bersifat manual, dimana ketika pasien registrasi untuk berobat akan dicatat dalam buku register oleh petugas, sehingga menyebabkan pasien cukup lama mengantri untuk mendapatkan pelayanan yang berpengaruh pada kepuasan pasien. Tujuan penelitian adalah melakukan perancangan sistem informasi regsitrasi pasien rawat jalan dalam upaya untuk meningkatkan pelayanan di bagain pendaftaran. Metode yang digunakan dalam penelitian ini adalah menggunakan software microsoft acces dandatabase MySql dengan metode pengembangan sistem berbasis DFD (Data Flow Diagram). Hasil penelitian ini menghasilkan sistem informasi Registrasi untuk mempermudah proses registrasi pasien khususnya di unit rawat jalan. Diharapkan rumah sakit mengimplementasikan hasil perancangan sistem infromasi registrasi pasien rawat jalan dan melakukan evaluasi secara berkala.

Faktor Penyebab Pengembalian Berkas Klaim dari BPJS ke Rumah Sakit Triyulia Citra, RACHMI; anggita, frisya; Heltiani, Nofri
Jurnal Manajemen Informasi Kesehatan (Health Information Management) Vol. 8 No. 1 (2023)
Publisher : Sekolah Tinggi Ilmu Kesehatan Sapta Bakti

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.51851/jmis.v8i1.401

Pengembalian berkas klaim dari BPJS ke rumah sakit merupakan hal yang sering terjadi, hal ini disebabkan berkas klaim diragukan kesimpulan data medisnya oleh verifikator BPJS. Berdasarkan wawancara dengan petugas coding diketahui pada bulan Januari terdapat 91(13,9%) berkas dan Februari 70(11,7%) berkas dikarenakan gagal purif dan pending, sedangkan pada bulan November dan Desember 2018 ada 70(11,2%) dan 77(13,1%) berkas klaim yang dikembalikan serta rumah sakit beum memiliki SPO pelaksanaan coding dan pengajuan klaim. Tujuan penelitian ini adalah mengetahui faktor penyebab pengembalian berkas klaim dari BPJS ke rumah sakit ditinjau dari ketidaksesuaian administrasi kepesertaan, ketidaktepatan kode diagnosa dan prosedur, serta ada tidaknya laporan penunjang yang dilampirkan. Jenis penelitian ini adalah observasional dengan rancangan deskriptif. Populasi dan sampel dalam penelitian ini adalah berkas klaim yang dikembalikan sebanyak 86 berkas yang diolah univariat menggunakan distribusi frekuensi. Hasil penelitian dari 86 sampel yang direview terdapat 10 berkas (11,6%) tidak sesuai administrasi kepesertaannya, 54 berkas (62,8%) yang kode diagnosa dan prosedurnya tidak tepat, dan 40 berkas (46,5%) yang tidak dilengkapi dengan laporan penunjang. Untuk meminimalisasi ketidaksesuaian administrasi dapat diterapkan bridging system, meminimalisasi angka ketidaktepatan kode diagnosa dan prosedur dengan mengadakan pelatihan coding serta pembuatan SPO pelaksanaan coding dan pengajuan klaim, serta membentuk petugas assembling untuk meminimalisasi laporan penunjang yang tidak dilengkapi.

Evaluasi Sistem Informasi Manajemen Rumah Sakit (SIMRS) di Rumah Sakit Rafflesia Bengkulu Arifin, Ismail; Heltiani, Nofri; Desmiany Duri, Iin
Jurnal Manajemen Informasi Kesehatan (Health Information Management) Vol. 8 No. 2 (2023)
Publisher : Sekolah Tinggi Ilmu Kesehatan Sapta Bakti

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.51851/jmis.v8i2.441

Hospital Management Information System (SIMRS) is a communication information technology system that processes hospital services. Rafflesia Bengkulu Hospital has been implementing SIMRS since 2021. Currently there has not been an evaluation of the features contained in SIMRS so that this will result in not achieving service improvements, not achieving efficiency and slowing down service to patients. The aim of this research is to describe the implementation of the hospital management information system (SIMRS) at Rafflesia Hospital Bengkulu. The research used is a descriptive method, namely a method that aims to describe the description of the implementation of the hospital management information system (SIMRS). The subjects of this research were 10 respondents. It is known from the evaluation results of the system performance aspect that research results show that the system performance is good by 80% and the system performance is not good by 20%. 90% of the information produced is good, 10% of the information produced is not good. data security is good as much as 60% and not good as much as 40%. It is necessary to develop the SIMRS menu display so that it can support all services, and also to develop the system so that it does not experience frequent errors (errors). And notifications/warnings need to be given if SIMRS is accessed by unauthorized parties, so that the system can be controlled properly and is not misused by unauthorized parties

Accuracy of Writing Diagnosis and Accuracy of Gastroenteritis Codes widyawati, Dwi Widyawati; Heltiani, Nofri; Andriansyah
Jurnal Manajemen Informasi Kesehatan (Health Information Management) Vol. 9 No. 1 (2024): Vol. 9 No. 1 (2024)
Publisher : Sekolah Tinggi Ilmu Kesehatan Sapta Bakti

Show Abstract | Download Original | Original Source | Check in Google Scholar

Accurate diagnosis coding according to ICD-10 to assign accurate diagnosis codes for inpatients also requires additional information such as laboratory results to be taken into account. The results of initial observations made on 10 medical resume sheets for gastroenteritis cases showed that 3 (30%) had accurate diagnosis codes and 7 (70%) had inaccurate diagnosis codes. This can affect the quality of data, information and reports as well as the accuracy of rates for general patients and INA-CBG'S rates which are used as a payment method for BPJS patients so that it can have an impact on reducing the quality of hospital services. This research aims to determine the accuracy of writing diagnoses and the accuracy of gastroenteritis codes for inpatients at Rafflesia Hospital in 2023. The type of research used is descriptive research with a cross sectional method. The population in this study was 214 medical record files for inpatient gastroenteritis cases in 2022 with a sample of 140 files using a simple random sampling technique. The research data used is secondary data which was processed univariately. The results of this study were that from 140 inpatient gastroenteritis medical record files, 100(100%) had the results of supporting examinations but they did not match the diagnosis written on the patient's medical resume because in writing the diagnosis it was not stated whether the gastroenteritis was infected or non-infected, 29(21% ) writing the diagnosis correctly, 43(31%) wrote the diagnosis incorrectly because they used Indonesian and 68(48%) wrote the diagnosis incorrectly because they used non-standard abbreviations and 69(49%) had an accurate diagnosis code and 71(51%) Inaccurate diagnosis code because there is no 4th character.

Hospital Electronic Medical Record Storage Plan Heltiani, Nofri; Khairunnisyah; Arifin, Ismail
Jurnal Manajemen Informasi Kesehatan (Health Information Management) Vol. 9 No. 1 (2024): Vol. 9 No. 1 (2024)
Publisher : Sekolah Tinggi Ilmu Kesehatan Sapta Bakti

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.51851/jmis.v9i1.507

The Electronic Medical Record Storage System aims to increase efficiency at Bhayangkara Bengkulu Hospital. However, based on the initial survey conducted, it was discovered that the medical record storage system was still carried out manually. Borrowed medical records are recorded in the expedition book before being borrowed and distributed by officers so that it takes time to get to the unit concerned. Officers store medical records not according to the shelves based on the patient's medical record number and many medical records are damaged/recorded. This research aims to design an electronic medical record storage system at Bhayangkara Hospital, Bengkulu. This type of research is descriptive qualitative with the waterfall method. The subjects of this research were medical records and IT officers. The research data used is primary data obtained by observation using a checklist sheet, then the data is processed and analyzed univariately. The result of this research is a design for an electronic medical record storage system that is ready to be implemented. Through this implementation, it is hoped that efficiency and accuracy in medical record management can be improved. The suggestions put forward are to make changes to the medical record file storage shelves to make them more orderly, provide training to officers in using the new system, and carry out impact evaluations to measure efficiency and patient satisfaction due to system changes.

ANALISIS KETEPATAN KODE DIAGNOSA OBSTETRI TERHADAP KELANCARAN KLAIM BPJS RS.X KOTA BENGKULU Heltiani, Nofri; Asroni, Nurwahyu; Suryani, Tri Endah
Jurnal Informasi Kesehatan Indonesia (JIKI) Vol 9 No 1 (2023): Jurnal Informasi Kesehatan Indonesia
Publisher : Politeknik Kesehatan Kemenkes Malang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31290/jiki.v9i1.3634

Backgroud: The obstetric code is a code that is more detailed and has differences from other disease codes, so errors often occur in enforcing the code. Based on observations of 10 obstetric claim files submitted to BPJS, it was found that 6 (60%) files were pending due to diagnoses and codes entered on medical resumes that were not in accordance with BPJS, which resulted in delays in the claim payment process to the hospital. This study aims to analyze the accuracy of the obstetrical diagnosis code for the smoothness of BPJS RS.X claims in Bengkulu City.Subjects and Method: This type of research is descriptive with a cross sectional approach. The population in this study were 137 obstetrical claim files for 2021 with a sample of 58 files taken by simple random sampling. The data used in this study were primary and secondary data which were processed univariately.Results: 31(53%) obstetric files smooth BPJS claims and 27(47%) non-current BPJS claim files with details 3(5%) incomplete claim files, 22(38%) incorrect obstetric code and 2(3%) incomplete documentationConclusion: Most of the accuracy of the obstetric diagnosis code experienced smoothness of the BPJS when it was verified by the BPJS verifier.

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