Ivana Putri Risyanti
Poltekkes Kemenkes Semarang

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RETENSI REKAM MEDIS DALAM UPAYA EFISIENSI RAK PENYIMPANAN Edy Susanto; Adhani Windari; Irmawati Irmawati; Ivana Putri Risyanti; Yogi Teguh Prakoso; Johninda Aulia Akbar; Rizky Febri Nugroho; Agustin Ira Krisnanita; Bernadeta Riski Kristiyani
Jurnal LINK Vol 14, No 2 (2018): NOVEMBER 2018
Publisher : Pusat Penelitian dan Pengabdian kepada Masyarakat, Poltekkes Kemenkes Semarang

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (191.211 KB) | DOI: 10.31983/link.v14i2.3770

Abstract

[MEDICAL RECORD RETENCE FOR EFFICIENCY OF THE STORAGE RACK] Medical records of hospitalized patients must be kept at least for a period of 5 (five) years calculated from the last date the patient was treated or returned (Permenkes 269 / Menkes / Per / III / 2008 in chapter IV article 8. Based on the preliminary study date December 12, 2016, the problems that occurred in the management of medical records at Tugurejo Hospital Semarang especially medical record retention were the last implementation of medical record document retention in 2011 due to a lack of knowledge of HR in the procedures for retention of medical records. The service at the hospital was aimed at increasing the knowledge of employees of the medical record work unit on medical record retention and the implementation of medical record retention to optimize the utilization of medical record storage space.The method used was through Health Education: exposure to theories about medical record retention (policy, flow, procedure), simulation, support and consultations then monitoring and evaluation in the retention was carried out for 20 days involving 5 students with an average of medical records which were retained 180 days from active medical records 6,364. community service related to medical record retention fosters knowledge to filing officers through exposure and assistance in implementing retention.
Pengaruh Ketepatan Kodefikasi Penyakit Terhadap Validasi Laporan Morbiditas Rawat Jalan Ivana Putri Risyanti; Syafira Atikah Yudianti
Jurnal Rekam Medis dan Informasi Kesehatan Vol 3, No 1 (2020): Maret 2020
Publisher : Poltekkes Kemenkes Semarang

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (338.65 KB) | DOI: 10.31983/jrmik.v3i1.5667

Abstract

According to the WHO in 2004 the coding implementation must be complete and accurate according to the direction of ICD 10. The accuracy of the code is influenced by the determination or determination of the patient's diagnosis. If the diagnosis is not accurate, it will affect the number of cases in making reports of morbidity, mortality and the calculation of various statistics of the hospital. There is an outpatient coding officer at RS X and also duty to make report morbiditas while making report morbiditas made manually because SIMRS not able to present data needed. In addition, the implementation of codification is performed on the main diagnosis only and outpatient morbidity reports have not been well documented. The objective of this research is to know the effect of the outpatient code on the  validation of outpatient morbidity report in RS X. This type of research uses analytic observation with Cross sectional approach. The population of this study is the number of outpatient cases in daily census outpatient dn report morbidity as many as 573 cases with total sampling technique. Statistical test using chi square on SPSS. The result of the research shows that there is an influence between the accuracy of disease codification on the validation of outpatient morbidity report in RS X with p = 0,000.AbstrakMenurut WHO tahun 2004 pelaksanaan pengkodean harus lengkap dan akurat sesuai arahan ICD 10. Keakuratan kode dipengaruhi oleh penetapan atau penentuan diagnosis pasien. Apabila dalam mengode diagnosis tidak akurat maka akan berpengaruh pada jumlah kasus dalam pembuatan laporan morbiditas, mortalitas serta penghitungan berbagai angka statistik rumah sakit. Petugas koding rawat jalan di RS X berjumlah satu dan bertugas pula membuat laporan morbiditas sedangkan pembuatan laporan morbiditas dibuat secara manual karena SIMRS belum bisa menyajikan data yang dibutuhkan. Selain itu, pelaksanaan kodefikasi dilakukan pada diagnosis utama saja dan laporan morbiditas rawat jalan belum terdokumentasikan dengan baik. Tujuan penelitian adalah mengetahui pengaruh ketepatan kodefikasi penyakit rawat jalan terhadap validasi laporan morbiditas rawat jalan di RS X. Jenis penelitian menggunakan observasi analitik dengan pendekatan Cross sectional. Populasi penelitian ini adalah jumlah kasus rawat jalan pada sensus harian rawat jalan dn laporan morbiditas sebanyak 573 kasus dengan teknik pengambilan total sampling. Uji statistik menggunakan chi square pada SPSS. Hasil penelitian menunjukan ada pengaruh antara ketepatan kodefikasi penyakit terhadap validasi laporan morbiditas rawat jalan di RS X dengan nilai p = 0,000.