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All Journal Jurnal Rekam Medik & Manajemen Informasi Kesehatan (RAMMIK) International Journal of Health and Information System (IJHIS)
Nada Savira Nurjannah
Politeknik Negeri Jember
Computer Science & IT Dentistry Health Professions Library & Information Science Medicine & Pharmacology Public Health Veterinary

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Determinan Ketepatan Kode Diagnosis Utama di RS Pusat Pertamina Jakarta Selatan Nada Savira Nurjannah; Demiawan Rachmatta Putro Mudiono; Sustin Farlinda; Djasmanto Djasmanto
Jurnal Rekam Medik & Manajemen Informasi Kesehatan Vol. 1 No. 1 (2022): April
Publisher : Indonesian Journal Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (217.023 KB) | DOI: 10.47134/rmik.v1i1.14

Abstract

The inaccuracy of the main diagnosis code will have an impact on the hospital in terms of financing and the quality of the information produced. This can also be influenced by the accuracy of writing the main diagnosis. The purpose of this study was to determinants of the accuracy of the main diagnosis code in the discharged summary of inpatient in February 2022 at Pertamina Central Hospital by paying attention to several components, namely the clarity of writing the main diagnosis and the accuracy of the main diagnosis code. The method used is descriptive qualitative. The total sample is 130 of inpatient discharged summary sheets from a total of 463 medical record files in February 2022. The results showed that 42% discharge summary sheets were not clear in writing the main diagnosis and 86% the main diagnosis code did not correct. It is suggested that the hospital can improve the evaluation of the accuracy of filling in the code and writing the main diagnosis in the summary of discharge, holding training and seminars related to doctor's compliance with the ICD-10 code, and socializing how to enforce the code and write a diagnosis according to the ICD-10 rules.
Design and Development of a Web-Based Medical Record Retention Information System at Polyclinic X Jember Regency Sustin Farlinda; Nada Savira Nurjannah; Muhammad Yunus; Mudafiq Riyan Pratama
International Journal of Health and Information System Vol. 1 No. 1 (2023): May
Publisher : Indonesian Journal Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.47134/ijhis.v1i1.5

Abstract

Medical record retention activities that have been carried out at Polyclinic X Jember Regency have encountered obstacles in sorting files that are still manual, starting with the officer checking the month and year of the patient's last visit to the Polyclinic's SIM Clinic, then taking several medical records on the storage rack and recording the medical record number for sorting. There are quite a lot of files on the storage rack, making officers have to sort the files one by one. The type of research used R&D with the Waterfall system development method, namely Requirement Definition, System and Software Design, Implementation and Unit Testing, Integration and System Testing, also Operation and Maintenance. Data collection techniques using interviews and observations with 2 respondents, namely the head of polyclinic and medical records officers. This study aims to design and create a web-based medical record retention information system by minimizing errors in sorting medical record files and facilitating the performance of medical record officers in the filing section. The result of this research is a web-based medical record retention information system created using the PHP programming language.
Co-Authors Demiawan Rachmatta Putro Mudiono Djasmanto Djasmanto Mudafiq Riyan Pratama Muhammad Yunus Sustin Farlinda