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Tinjauan Studi Literatur: Analisis Gambaran Pelaksanaan Sensus Harian Rawat Inap Yulfa Yulia; Oktamianiza Oktamianiza; Deni Maisa Putra; Rahmadhani Rahmadhani; Indah Oktavia
Jurnal Rekam Medis dan Informasi Kesehatan Vol 4, No 1 (2021): Maret 2021
Publisher : Poltekkes Kemenkes Semarang

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (102.874 KB) | DOI: 10.31983/jrmik.v4i1.6793

Abstract

Sensus harian adalah suatu cara untuk mengetahui jumlah pasien yang masuk, keluar, meninggal dan perpindahan antar ruangan. Tujuan dari penelitian ini adalah untuk mendeskripsikan input (SDM, SOP, sarana prasarana) dan Proses (Monitoring evaluasi) terhadap pelaksanaan sensus harian rawat inap dengan metoda studi literatur. Pelaksanaan penelitian secara studi literatur dengan melakukan analisis deskriptif dengan mendeskripsikan fakta-fakta yang ada, kemudian di analisis, mencari kesamaan, pandangan, dan ringkasan terhadap beberapa penelitian. Hasil dari penelitian ini didapatkan bahwa  sebagian besar 50% pelaksanaan sensus hariannya masih banyak mengalami keterlambatan. Keterlambatan dalam pengembalian sensus disebabkan oleh karena kurangnya kesadaran SDM terhadap pentingnya data yang telah dikumpulkan bagi kepentingan rumah sakit. SOP belum telaksana dengan optimal, sarana dan prasarana pendukung kegiatan sensus tidak memadai. Disamping itu kurangnya pengawasan pimpinan terhadap pelaksanaan kegiatan pengisian data sensus. Hal ini akan memberikan dampak terhadap informasi yang akan dikeluarkan oleh rumah sakit terkait aktivitas pelayanan kesehatan yang telah diberikan kepada pasien. Dan disamping itu data yang akan dilaporkan untuk berbagai pihak-pihak yang membutuhkan data tersebut menjadi tidak akurat.
Studi Literatur Riview: Gambaran Kesesuaian Dan Ketepatan Kode Diagnosa Pasien Rawat Inap Berdasarkan ICD-10 Rahmadhani Rahmadhani; Deni Maisa Putra; Hiddati Aulia; Oktamianiza Oktamianiza; Yulfa Yulia
Jurnal Rekam Medis dan Informasi Kesehatan Vol 4, No 1 (2021): Maret 2021
Publisher : Poltekkes Kemenkes Semarang

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (379.013 KB) | DOI: 10.31983/jrmik.v4i1.6787

Abstract

Rekam medis berkualitas dapat dilihat dari ketepatan dan kesesauian diagnosa di pelayanan kesehatan mengingat sangat pentingnya ketepatan dan kesesauian kode diagnosa. Tujuan penelitian untuk mengetahui, mengidentifikasi, menilai, dan menginterpetasikan terkait dengan gambaran kesesuaian dan ketepatan kode diagnosa pasien rawat inap dengan ICD-10 berdasarkan tinjauan literature review. Metode yang digunakan yaitu studi literature riview dengan Metode analisis deskriptif dilakukan dengan analisis teknik review literatur diantaranya mencari kesamaan (compare), ketidaksamaan (contrast), pandangan (critize), bandingkan (synthesize), dan ringkasan (summarize) dengan sumber pustaka yang digunakan adalah 6 jurnal. Hasil dari literatur review yang penulis talaah yaitu masih di temukan ada ketidaksesuaian dan ketidaktepatan pengkodean diagnosa pasien di fasilitas kesehatan di karenakan hambatan pelaksanna SOP dan komuniksi antar pengcode/coder dan tenaga medis yang sehingga berdampak pada ketepatan dan kesesuaian kode diagnosa berdasarkan ICD-10. Diharapkan pada penelitian selanjutnya agar peneliti bisa memahami terhadap tahapan literature review dan metode ananlisis data dalam penelitian terkait tentang ketepatan dan kesesauian kode diagnosa pasien rawat inap serta penyenggaraan rekam medis di tinjau dari sisi input, proses, dan output untuk melihat lebih jelas penyebab terjarjadinya ketidak lengkapan dan ketidak sesauian kodefikasi.
Literatur Riview Tentang Faktor Penyebab Klaim Tidak Layak Bayar BPJS Kesehatan Di Rumah Sakit Tahun 2020 Oktamianiza; Rahmadhani; Yulfa Yulia; Helmi Mazra Putri
Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Vol. 6 No. 1 (2021): Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda Edisi Februari
Publisher : Akademi Perekam dan Informasi Kesehatan Imelda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.52943/jipiki.v6i1.487

Abstract

The amount of payment made by BPJS Kesehatan to health facilities is determined based on an agreement between BPJS Kesehatan and the relationship of health facilities in the area where the health facilities are located and refers to the INA-CBG's tariff standard. During the leveraging process by the BPJS verifier, several claims were found, one of which was an unfeasible claim. Therefore, the researchers are interested in further examining the factors that cause the BPJS health unfit claims at the hospital. The purpose of this review literature is to describe the factors that cause claims for not worth paying BPJS health at the hospital in 2020. The literature review research uses descriptive analysis which is carried out by describing the facts. The library sources used are 4 libraries from journals. Analyze the data by looking for several groups (comparing), inequality (contrasting), views (criticizing), comparing (synthesizing) and summarizing (summarizing) the research. Based on a review of 4 journals on the appropriateness of the Participation Administration an average of 66%, the suitability of service administration as much as 25%, the accuracy of disease diagnosis as much as 75%, the accuracy of the main diagnosis and the accuracy of the secondary diagnosis as much as 88%, the accuracy of the diagnosis code was 55% correct and the effect of the administrative completeness of the claim requirements on average is still <75%, which means that the administrative completeness of the BPJS Health requirements is still incomplete because it does not meet the BPJS Health standards and regulations in the submitted requirements file. Based on the results of the study, it can be ignored that the administrative completeness of the BPJS Health claim requirements in the hospital is still incomplete, due to the perception of perceptions between internal verifiers and external verifiers, the knowledge and responsibilities of health service workers on the importance of filling in complete, accurate and trustworthy medical record files. . So the researchers suggest that there is periodic socialization to equalize perceptions about policies and standards in the process of submitting BPJS Health claims between internal verifiers and external verifiers and health service workers who participate in filling out medical record files so that problems related to claims not worth paying can be minimized so that services health can run well and smoothly.
HUBUNGAN KETEPATAN TERMINOLOGI MEDIS DENGAN KEAKURATAN PENGODEAN BERDASARKAN ICD-10 DI RUMAH SAKIT SECARA STUDY LITERATURE REVIEW Deni Maisa Putra; Yulfa Yulia; Rahmadhani Rahmadhani; Athiyah Holindra
Denta Journal Kedokteran Gigi Vol 5 No 1 (2022): Oceana Biomedicina Journal Volume 5 Issue (No) 1
Publisher : Universitas Hang Tuah

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.30649/obj.v5i1.67

Abstract

Background: Accurate coding using appropriate diagnosis writing with appropriate medical terminology. And help the coding officer to code the disease according to ICD-10. This study aims to determine the relationship between medical terminology and the accuracy of coding based on ICD-10 in hospitals. Methods: The method used is a literature study carried out by describing the facts that exist and then being analyzed. Searching for articles through Google Scholar, with inclusion and exclusion criteria, the final results obtained 5 analyzed journals. Furthermore, the analysis is carried out by looking at the compare, contrast, critize, synthesize, summarize. Result: The results of this literature review show that from the 5 journals that have been analyzed there are 3 journals that have medical terminology accuracy with a percentage of more than 50%, 4 journals that have coding accuracy with a percentage of more than 50%, and 4 journals that have a relationship between terminology accuracy. Medical with coding accuracy. Conclusion: Based on the results of the literature review, it can be concluded that there is a need for uniformity and consistency in the use of medical terminology according to ICD-10 to further improve the accuracy of the code. So there should be communication between the coder and the doctor so that the perception between the two is the same and produces an accurate code.
HUBUNGAN KETEPATAN TERMINOLOGI MEDIS DENGAN KEAKURATAN PENGODEAN BERDASARKAN ICD-10 DI RUMAH SAKIT SECARA STUDY LITERATURE REVIEW Deni Maisa Putra; Yulfa Yulia; Rahmadhani Rahmadhani; Athiyah Holindra
Oceana Biomedicina Journal Vol 5 No 1 (2022): Oceana Biomedicina Journal Volume 5 Issue (No) 1
Publisher : Universitas Hang Tuah

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.30649/obj.v5i1.67

Abstract

Background: Accurate coding using appropriate diagnosis writing with appropriate medical terminology. And help the coding officer to code the disease according to ICD-10. This study aims to determine the relationship between medical terminology and the accuracy of coding based on ICD-10 in hospitals. Methods: The method used is a literature study carried out by describing the facts that exist and then being analyzed. Searching for articles through Google Scholar, with inclusion and exclusion criteria, the final results obtained 5 analyzed journals. Furthermore, the analysis is carried out by looking at the compare, contrast, critize, synthesize, summarize. Result: The results of this literature review show that from the 5 journals that have been analyzed there are 3 journals that have medical terminology accuracy with a percentage of more than 50%, 4 journals that have coding accuracy with a percentage of more than 50%, and 4 journals that have a relationship between terminology accuracy. Medical with coding accuracy. Conclusion: Based on the results of the literature review, it can be concluded that there is a need for uniformity and consistency in the use of medical terminology according to ICD-10 to further improve the accuracy of the code. So there should be communication between the coder and the doctor so that the perception between the two is the same and produces an accurate code.
IMPLEMENTASI KODEFIKASI PENYAKIT PADA KASUS KEHAMILAN, PERSALINAN DAN MASA NIFAS BERBASIS VBA EXCEL DI RSIA MUTIARA BUNDA PADANG TAHUN 2022 Oktamianiza Oktamianiza; Kalasta Ayunda Putri; Yulfa Yulia; Lengsi Annica Putri
Jurnal Salingka Abdimas Vol 2, No 2 (2022)
Publisher : Jurnal Salingka Abdimas

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (840.489 KB)

Abstract

Kegiatan ini dilakukan untuk dapat menfasilitasi sarana pelayanan kesehatan, diantaranya rumah sakit untuk melakukan kegiatan kodefikasi penyakit dengan lebih efektif dan efisien dengan menggunakan aplikasi yang telah dirancang melalui VBA Excel pada klasifikasi penyakit kemahmilan, persalinan dan nifas. Klasifikasi penyakit merupakan salah satu kegiatan yang dilaksanakan oleh petugas rekam medis di rumah sakit khususnya bagian kode yang dilaksanakan leh coder. Dengan adanya aplikasi ini coder akan terbantu menyelesaikan pekerjaanya lebih cepat lagi, sehingga waktu yang dibutuhkan akan lebih maksimal dalam hal bekerja dimana petugas tidak perlu lagi menggunakan ICD-10 untuk mencari kode dari diagnsis penyakit tersebut. Dalam pelaksanaan PkM ini pertama sekali kita melakukan pengenalan terhadap sistem yang telah dirancang, selanjutnya kita melakukan uji coba ke petugas untuk diimplementasikan ke pelaksanaan tugasnya kemudian dilanjutkan dengan kegiatan evaluasi dengan mengajukan beberapa pertanyaan untuk menilai kebermanfaatan aplikasi yang telah dirancang. Berdasarkan tanggapan dari petugas kode(coder) mereka menyatakan bahwa rancangan ini sangat bagus untuk di terapkan dalam pelaksanaan tugas mereka sehari-hari sebagai coder. Harapan kita mudahan aplikasi ini dapat digunakan untuk tahapan selanjutnya agar pekeerjaan mereka dapat terakomdir dengan baik.
PENERAPAN KETEPATAN WAKTU PENGEMBALIAN REKAM MEDIS RAWAT INAP Yulfa Yulia; Kalasta Ayunda Putri; Oktamianiza Oktamianiza; Deni Maisa Putra; Rahmadhani Rahmadhani; Nur Habibah Hakki
Jurnal LINK Vol 18, No 2 (2022): NOVEMBER 2022
Publisher : Pusat Penelitian dan Pengabdian kepada Masyarakat, Poltekkes Kemenkes Semarang

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (487.257 KB) | DOI: 10.31983/link.v18i2.9094

Abstract

Keterlambatan pengembalian rekam medis dapat menghambat kegiatan pengelolaan dan beresiko hilangnya rekam medis. Salah satu faktor penyebab keterlambatan pengembalian berkas rekam medis diantaranya terlambat karena berkas yang belum lengkap. Sehingga diperlukan motivasi perawat dengan ketepatan waktu pengembalian rekam medis rawat inap di rumah sakit. Penelitian ini menggunakan pendekatan deskriptif analitik korelasi dengan desain penelitian cross sectional. Populasi pada penelitian ini berjumlah 46 perawat dengan sampel 32 perawat menggunakan proportional sampling dengan analisis univariat dan analisis bivariate. Berdasarkan hasil bahwa perawat yang kurang baik tanggung jawabnya terbukti 86% tidak tepat waktu, perawat dengan pengembangan dirinya terbukti 71% tidak tepat waktu, sedangkan perawat yang kurang mandiri dalam bertindak terbukti 79% tidak tepat waktu. Tanggung jawab dan pengembangan diri perawat memiliki hubungan dengan ketepatan waktu pengembalian rekam medis rawat inap di Rumah Sakit Islam Ibnu Sina Padang, sebaiknya perawat terus melakukan pengembangan diri guna meningkatkan keterampilan dan memperbaiki efektifiktas kerja untuk mencapai hasil kerja yang diharapkan seperti selalu mengikuti sosialisasi, mengikuti pelatihan dan bebas mengeluarkan pendapat saat berdiskusi.
Tinjauan Ketepatan Kode Cedera Multiple Pada Kasus External Cause di RSUP Dr. M. Djamil Padang Oktamianiza Oktamianiza; Diah Salsa Billa; Kalasta Ayunda Putri; Yulfa Yulia; Afridon Afridon
Jurnal Rekam Medis dan Informasi Kesehatan Vol 6, No 1 (2023): MARET 2023
Publisher : Poltekkes Kemenkes Semarang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31983/jrmik.v6i1.9187

Abstract

The accuracy of the code is very necessary so that the information generated from the diagnosis and medical treatment is accurate. However, researchers found in Dr. M. Djamil Padang there are still 29 incorrect codes (76.3%). This is because the determination of multiple injury codes is written separately and fracture diagnosis is not equipped with a fifth character code. The purpose of this study was to determine the accuracy of multiple injury codes in external cause cases at RSUP Dr. M. Djamil Padang. This research was conducted from May to June 2022. The type of research conducted was quantitative with a descriptive approach. The number of samples was 38 using the purposive sampling method, the data collection instrument used a checklist table with univariate analysis. The results of the research that has been carried out found that the frequency of diagnostic accuracy is 27 (71.1%) incorrect diagnoses, the frequency of conformity of primary and secondary diagnoses is 19 (50.0%) incorrect diagnoses, and the frequency of accuracy of diagnostic codes is 29 (76, 3%) code is not correct. So it can be concluded that there are still causes of inaccuracy in coding, which can be seen from the 3 components of the analysis carried out that affects the accuracy of the code. Therefore, researchers suggest that coders should pay attention to the rules and procedures for coding diagnoses based on ICD-10.                                                                                  
Hubungan Kelengkapan Informasi Medis Pada RM A-1, RM I-1 dan RM L-8 dengan Keakuratan Pengkodean Diagnosis Appendic Pada Rekam Medis Rawat Inap di RS. TK. III dr. Reksodiwiryo Padang Tahun 2021 Yulfa Yulia; Oktamianiza Oktamianiza; Kalasta Ayunda Putri; Afridon Afridon; Ayunda Sandony
Jurnal Rekam Medis dan Informasi Kesehatan Vol 6, No 1 (2023): MARET 2023
Publisher : Poltekkes Kemenkes Semarang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31983/jrmik.v6i1.9192

Abstract

Appendix is included in the 20 most diseases in Kindergarten Hospital. III Dr. Reksowidiryo Padang where there are problems in terms of completeness of medical information on RM A-1, RM I-1 and RM L-8 with the level of accuracy of coding disease diagnosis is still low. This study aims to determine the relationship between completeness of medical information and the accuracy of coding appendic diagnoses based on ICD-10 in medical records at the Kindergarten Hospital. III Dr. Reksowidiryo Padang in 2021. The type of research is correlational, the research is carried out at the Kindergarten Hospital. III Dr. Reksowidiryo Padang, the initial survey was carried out in February with field research on 18 to 22 June 2021, the total population in January-December 2021 was 110 along with a sample of 110 appendic medical record files, the study was conducted by direct observation, data analysis used namely bivariate and univariate. With the results of the study, it was found that the completeness of complete medical information was 42 (38.2%), the completeness of incomplete medical information was 68 (61.8%), the accuracy of the accurate diagnosis code was 45 (40.9%), the accuracy of the code was There were 65 (59.1%) inaccurate diagnoses, with p-value = 0.003 (p0.05), which means that there is a relationship between the completeness of medical information and the accuracy of coding for appendic diagnoses. With the results of the study, it is known that the completeness of medical information and the accuracy of the disease diagnosis code is still not good, the researchers suggest that health workers can fill in each item of the medical record sheet completely and write down the diagnosis code accurately and clearly in order to increase efforts to complete the diagnosis and completeness of the diagnosis medical information.