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<![CDATA[Analisis Kuantitatif Informed Consent pada Tindakan Sectio Caesarea di Rumah Sakit Patria IKKT Jakarta Barat ]]>
<![CDATA[Nurmayantih]]>;
<![CDATA[Nanda Aula Rumana]]>;
<![CDATA[Daniel Happy Putra]]>;
<![CDATA[Puteri Fannya]]>
<![CDATA[ SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat Vol. 1 No. 1 (2022): Januari 2022 ]]>
Publisher : <![CDATA[Yayasan Literasi Sains Indonesia ]]>
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DOI: 10.55123/sehatmas.v1i1.32
<![CDATA[Informed Consent is the consent given by the patient or his family on the basis of an explanation of the medical/surgical action to be performed on the patient and this informed consent must be complete. In performing sectio caesarea, the informed consent sheet is not filled in, so any action taken can be categorized as malpractice. Researchers found that there were still many incomplete informed consent forms, especially informed consent for sectio caesarea surgery. The purpose of the study was to determine the quantitative analysis of informed consent for sectio caesarea at the Patria IKKT Hospital for the period March - April 2021 based on 4 components, namely knowing the completeness of patient identification, author authentication, and completeness of important reports, good records. This type of research is quantitative with descriptive design and data collection techniques are observation, checklist. This research was conducted using systematic random sampling method. The results of the study of 90 informed consent sheets for sectio caesarea, the average completeness of the patient identification filling component was 100%, the important component of filling out the report was an average of 86%, the author's authentication component had an average of 97.9%, the component of filling out good notes had an average of 97.9%. the average completeness is 93.7%. The results of the recapitulation of quantitative analysis have an average completeness of 94.4%.]]>
<![CDATA[Penerimaan Pengguna Terhadap Sistem Informasi Manajemen Rekam Medis (SIMRM) Di RSUD Tebet Jakarta Selatan Tahun 2021 ]]>
<![CDATA[Anggi Alpiyani]]>;
<![CDATA[Nanda Aula Rumana]]>;
<![CDATA[Daniel Happy Putra]]>;
<![CDATA[Laela Indawati]]>
<![CDATA[ SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat Vol. 1 No. 1 (2022): Januari 2022 ]]>
Publisher : <![CDATA[Yayasan Literasi Sains Indonesia ]]>
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DOI: 10.55123/sehatmas.v1i1.34
<![CDATA[Rumah Sakit Umum Daerah Tebet, South Jakarta, has been using a computerized management information system for medical record services called the Hospital Information System (HIS) since 2017. The presence of the Medical Record Management Information System (SIMRM) at the Rumah Sakit Umum Daerah Tebet, has brought many influences to services. Along with the implementation of SIMRM, it is necessary to assess whether the system is running properly and has been accepted by its users, in this case the medical record officer. The research method used The research method that the researcher uses is a quantitative descriptive method using the Technology Acceptance Model (TAM) to assess the perception of technology users as seen from 5 constructs, namely perceived ease of use, perceived usefulness. , perceptions of attitudes toward using, behavioral intention to use and actual usage by distributing questionnaires to 16 respondents consisting of 7 medical record unit officers and 9 registration unit officers. The results showed that the average user acceptance of SIMRM in South Jakarta Hospital as seen from the 5 TAM constructs was 75% received and 25% did not receive which means SIMRM was received by the user. It is recommended for the hospital to conduct socialization and training in accordance with the needs of officers.]]>
<![CDATA[Tinjauan Kelengkapan Resume Medis Pasien Rawat Inap di Rumah Sakit Islam Jakarta Sukapura ]]>
<![CDATA[Sansy Dua Lestari]]>;
<![CDATA[Daniel Happy Putra]]>;
<![CDATA[Deasy Rosmala Dewi]]>;
<![CDATA[Laela Indawati]]>
<![CDATA[ SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat Vol. 1 No. 2 (2022): April 2022 ]]>
Publisher : <![CDATA[Yayasan Literasi Sains Indonesia ]]>
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DOI: 10.55123/sehatmas.v1i2.130
<![CDATA[Medical discharge is a summary of every action and treatment provided to the patient during hospitalization and must be signed by the DPJP doctor. The purpose of this study was to identify SOPs, determine the percentage of completeness of medical discharge and identify the factors causing the incompleteness. In this study, the method used is quantitative analysis method and data collection techniques are carried out through observation, quantitative analysis and interview guidelines, using the formula for estimating the proportion of the population of hospitalized patients in June and samples taken as many as 62 medical records. Based on the results of research and discussion, the completeness of the medical discharge at the Islamic Hospital of Jakarta Sukapura, the average percentage of completeness of the four components is 85.57% and the average incompleteness is 14.43%. Judging from the 4 components of quantitative analysis, the highest component of completeness analysis was found in the patient identification component 91.94% and the lowest was in the important note component 73.45%. Factors causing the incomplete filling of medical discharges are the absence of policies that regulate filling out medical discharges, the tight schedule of doctor's practice, and the lack of socialization of discipline in filling out medical discharges.]]>
<![CDATA[Tinjauan Waktu Pengembalian Berkas Rekam Medis Pasien Covid Di Rumah Sakit Sumber Waras ]]>
<![CDATA[Dede Lisda Nurjanah Dede Lisda Nurjanah]]>;
<![CDATA[Daniel Happy Putra]]>;
<![CDATA[Puteri Fannya]]>;
<![CDATA[Deasy Rosmala Dewi]]>
<![CDATA[ SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat Vol. 1 No. 2 (2022): April 2022 ]]>
Publisher : <![CDATA[Yayasan Literasi Sains Indonesia ]]>
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DOI: 10.55123/sehatmas.v1i2.247
<![CDATA[The return of patient documents is a component part that has a role for medical records. Standard Operating Procedures (SOP) for Sumber Waras Hospital for the standard time for returning patient documents is 1 x 24 hours after the patient is declared home. The return of patient documents at the Sumber Waras Hospital in March - April 2021 for Covid patients is known from 80 medical record documents the rate of inaccuracy of returns is 25 (31.25%). So the reason for this research is to find out the timeliness of returning the medical record documents of Covid patients at Sumber Waras Hospital. This research uses quantitative descriptive method. The sample in this observation was obtained from the length of time the medical record was returned to the medical record unit. Sampling using Simple Random Sampling. Information was collected using checklists, expedition books and interview guides. The factor causing the inaccuracy of the medical record documents for Covid patients at the Sumber Waras Hospital is the 5M component with the delay in returning medical records. This problem will cause delays in services for Covid patients who will carry out re-control. Therefore, it is necessary to disseminate the Standard Operating Procedure (SOP), with the aim that the reporting of patient medical data can run well.]]>
<![CDATA[Tinjaun Ketepatan Kode Diagnosis Pasien Diabetes Mellitus Rawat Inap dengan Lama Rawat ]]>
<![CDATA[Wini Wini]]>;
<![CDATA[Deasy Rosmala Dewi]]>;
<![CDATA[Daniel Happy Putra]]>;
<![CDATA[Nanda Aula Rumana]]>
<![CDATA[ SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat Vol. 2 No. 2 (2023): April 2023 ]]>
Publisher : <![CDATA[Yayasan Literasi Sains Indonesia ]]>
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DOI: 10.55123/sehatmas.v2i2.1826
<![CDATA[The accuracy of the diagnosis code is the conformity between the diagnosis code determined by the coder and the patient's medical record, in accordance with ICD-10 rules. Length of stay is a term used in a hospital that describes the length of time a patient is treated as measured in days and is one aspect of care and service at the hospital. The aim of the study was to find out the description of the accuracy of the diagnosis code for inpatient diabetes mellitus patients with length of stay at the Islamic Hospital of Jakarta Pondok Kopi. The research method uses a quantitative descriptive. The results of the research on Standard Operating Procedures (SPO) which regulate the determination of codes in inpatient care already exist, but there is no specific coding for diabetes mellitus. For the length of stay of diabetes mellitus patients 3-5 days, the percentage of correctness of diabetes mellitus diagnosis codes for inpatients at the Jakarta Islamic Hospital Pondok Kopi in 2022 resulted in 40 medical records (48.20%) diagnosis codes and 40 medical records (48.20%) inaccurate diabetes mellitus diagnosis codes 43 medical records (51.80%). Suggestions in this study the head of medical records submits an update of the SPO regarding coding and specifically so that the results of the work go according to the applicable and effective policies, an increase in the number of medical records officers in the coding section and communication between the coding officer and the doctor giving the diagnosis needs to be improved in order to produce a code right.]]>
<![CDATA[Gambaran Ketersediaan Rekam Medis Rawat Jalan Berdasarkan Standar Pelayanan Minimal di Rumah Sakit Islam Jakarta Pondok Kopi ]]>
<![CDATA[Paryati Paryati]]>;
<![CDATA[Deasy Rosmala Dewi]]>;
<![CDATA[Daniel Happy Putra]]>;
<![CDATA[Nanda Aula Rumana]]>
<![CDATA[ SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat Vol. 2 No. 2 (2023): April 2023 ]]>
Publisher : <![CDATA[Yayasan Literasi Sains Indonesia ]]>
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DOI: 10.55123/sehatmas.v2i2.1860
<![CDATA[The availability of medical records is greatly influenced by fast and precise distribution. If the delivery of medical records to the intended polyclinic is not on time, it will affect the waiting time for patient services. The general objective of this study was to determine the length of time it took to provide outpatient medical records at RSIJ Pondok Kopi. This type of research uses descriptive, quantitative in nature, namely a survey conducted on a set of objects which usually aims to see a picture of what is happening in a certain population. From the results of research conducted in the medical record storage room, all procedures have been carried out properly. It's just that there is still a procedure that does not exist in this case, namely standardization of the time for providing medical records for outpatient services. Based on the conclusions that can be drawn from the results of the study, namely: in the implementation of taking and compiling medical records the officers carry out according to the SPO, it's just that there is no standardization of the length of time for providing medical records for outpatient services from the patient registering until the medical record is available / found. Some suggestions that can be useful for service providers are: it is hoped that there will be a standard time regarding the provision of medical records for outpatient services, so that officers can speed up the process of providing medical records.]]>
<![CDATA[Analisis Ketepatan Kode Diagnosis pada Kasus Persalinan Pasien Rawat Inap di Rumah Sakit Patria Ikkt Tahun 2022 ]]>
<![CDATA[Angela Marsiana Siki]]>;
<![CDATA[Deasy Rosmala Dewi]]>;
<![CDATA[Daniel Happy Putra]]>;
<![CDATA[Puteri Fannya]]>
<![CDATA[ SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat Vol. 2 No. 2 (2023): April 2023 ]]>
Publisher : <![CDATA[Yayasan Literasi Sains Indonesia ]]>
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DOI: 10.55123/sehatmas.v2i2.1201
<![CDATA[Diagnostic coding must comply with ICD-10 rules. According to WHO, the coding of delivery cases consists of the code for the mother's condition (O00-O75), the method of delivery (O80-084), and the Outcome of delivery Z37.-., while the code is Z37.-. used as an additional code to determine the outcome of labor. So that the coder officer must have knowledge in setting the diagnosis code. Coding accuracy is very necessary because it is used as a reporting material. To determine the Standard Operating Procedure (SOP), the percentage of accuracy of the diagnosis code for inpatient labor cases based on 3M (complications, delivery method, and outcome of delivery) and the cause of the inaccuracy of the diagnosis code for labor cases. Descriptive research type with a quantitative approach. The population is medical records of inpatients in labor cases with a sample of 100 medical records. The sampling technique is by systematic random sampling. Collecting data by means of observation, interviews, and documentation. Research results: SOPs already exist, but not yet complete. The percentage of accuracy of the correct diagnosis code for labor cases is 22.33% while the incorrect diagnosis code is 77.67%. The cause of the inaccuracy of the ICD-10 code for delivery cases is that the diagnosis does not include the method of delivery and the outcome of delivery, and has never been done. evaluation or audit coding. The accuracy of the diagnosis of labor cases is still incomplete. Improve the SOP entry and complete the delivery method and outcome of delivery in medical records and registers.]]>
<![CDATA[Analisis Perancangan Sistem Anjungan Pendaftaran Mandiri Untuk Pemilihan Dokter dan Waktu Pelayanan di Rumah Sakit: Literature Review ]]>
<![CDATA[Nerissa Adha Andrania]]>;
<![CDATA[Daniel Happy Putra]]>;
<![CDATA[Noor Yulia]]>;
<![CDATA[Adi Widodo]]>
<![CDATA[ SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat Vol. 2 No. 4 (2023): Oktober 2023 ]]>
Publisher : <![CDATA[Yayasan Literasi Sains Indonesia ]]>
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DOI: 10.55123/sehatmas.v2i4.2304
<![CDATA[Self-Registration Patient is a health service facility related to registration independently by patients who are provided by the machine. The purpose of this study is to identify what the user/patient needs and also to analyze the design for the doctor's appointment in hospitals. The method used a literature review approach through a database of Google Scholar obtained by 6 national-based journals, while Google Patent obtained 4 international-based patents. The results are related to the process of basic needs that will be used by users/patients such as QR Barcodes; touch screen monitors; Numpad and mouse; speakers; receipt printing machine; SEP paper printing; and CPU. The design supported by distribution model system such as; Entity-Relationship Diagram (ERD); Data Flow Chart (DFD); Use Case Diagram (UCD); flow chart, and interface design. In conclusion, the research could help the hospital's needs and also the patients, including knowing the latest status of patients, making appointments according by intended polyclinic, doctors, and time visits based on doctor's time schedule. It is also could print SEP as well as the pharmacy queue number receipt after being examined. The system is also expected to reduce long queues at the Outpatient Registration Place (TPPRJ), especially for BPJS Insurance users.]]>
<![CDATA[Analisis Kualitatif Konsistensi Pencatatan Rekam Medis Rawat Inap Kasus Penyakit Dalam di Rumah Sakit Pelabuhan Jakarta ]]>
<![CDATA[Putri Nurindahsari]]>;
<![CDATA[Dina Sonia]]>;
<![CDATA[Lily Widjaja]]>;
<![CDATA[Daniel Happy Putra]]>
<![CDATA[ SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat Vol. 2 No. 4 (2023): Oktober 2023 ]]>
Publisher : <![CDATA[Yayasan Literasi Sains Indonesia ]]>
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DOI: 10.55123/sehatmas.v2i4.2352
<![CDATA[Qualitative analysis is an activity that examines the filling of medical records for inconsistent and incomplete contents, which indicates that the medical records are inaccurate and incomplete. The purpose of this study was to find out a qualitative analysis of the reliability of recording medical records of inpatient cases of internal medicine for the year 2022. This type of research uses a descriptive method with a quantitative approach and data collection by observation and interviews. Of the 99 medical records, the results obtained were 96% consistent and 4% inconsistent. And the results of the 4 subcomponents include: At the time of admission, namely the consistency of the initial assessment of nurses and inpatient doctors, the results were 98% consistent. On the subcomponent during hospitalization, namely the consistency of progress notes between doctors and nurses, obtaining results of 99% consistency, Consistency of Doctor's Instructions with delivery notes the drug gets 93% consistent results, when going home, namely the consistency of the doctor's return summary and the nurse gets 94% consistency results. Of the 4 sub-components that have the highest consistency, the consistency between the doctor's and nurse's developmental records obtains 99% consistent results. While the lowest was the consistency of the Doctor's Instructions with a record of drug administration obtaining 93% consistent results. The conclusion is that the qualitative analysis of medical record recording is not 100% consistent. It is recommended that the Jakarta Harbor Hospital make standard operating procedures and implement related qualitative analysis of medical records.]]>
<![CDATA[Tinjauan Penyebab Pengembalian Berkas Klaim Biaya Pelayanan Pasien Rawat Inap BPJS Kesehatan di Rumah Sakit Pelabuhan Jakarta Tahun 2022 ]]>
<![CDATA[Siti Rahmawati Handayani]]>;
<![CDATA[Lily Widjaja]]>;
<![CDATA[Daniel Happy Putra]]>;
<![CDATA[Dina Sonia]]>
<![CDATA[ SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat Vol. 2 No. 4 (2023): Oktober 2023 ]]>
Publisher : <![CDATA[Yayasan Literasi Sains Indonesia ]]>
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DOI: 10.55123/sehatmas.v2i4.2617
<![CDATA[In the process of submitting a BPJS Health Claim, some requirements must be completed by the Health Facility. Of these requirements, the BPJS Health party will know that the claim submission can be paid or returned/delayed. This research was conducted to find out the reasons for returning the claim file for BPJS Kesehatan inpatient care at the Jakarta Harbor Hospital in 2022. The method in this study used descriptive research with a quantitative approach. The results of the study were 118 samples (6.7%) of 1,762 files, the highest returned cause was an inaccuracy in the coding of diagnoses/actions of 49 (42%), and the second highest was not fulfilling inpatient administration 18 (15%), other causes - others as much as 51 (43%). 3 factors from 5M are the cause of returning claim files, namely the human factor: casemix officers who are not diligent, lack of coder understanding/knowledge, and lack of accuracy in the filing department so that files are missed/left behind, machine: there is an upgrade to the latest version of the INA-application CBGs and V-Claim are also the Ministry of Health's newest program which requires TB patients to be inputted into the SITB application, Material: incomplete claim requirements files. While the money and method factors are not an obstacle or a cause for returning claim files. It is recommended to evaluate and re-socialize the reasons for returning BPJS Health claims so that the process of submitting BPJS Health claims is carried out properly and is 100% accepted.]]>
