Garuda - Garba Rujukan Digital

Djasmanto Djasmanto

Rumah Sakit Pusat Pertamina Jakarta Selatan

Author-ID : 5384559

Dentistry Health Professions 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

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.

Analisis Singkatan Dan Simbol Terhadap Formulir Discharge Summary Rawat Inap Untuk Penilaian Akreditasi Snars Mirm (12) Periode Februari Di Rumah Sakit Pusat Pertamina Jakarta Selatan Livia Nuri Syafitri; Demiawan Rachmatta Putro Mudiono; Sustin Farlinda; Djasmanto Djasmanto
Jurnal Rekam Medik & Manajemen Informasi Kesehatan Vol. 1 No. 1 (2022): April
Publisher : Indonesian Journal Publisher

Recording in SNARS Edition 1 is included in the Hospital Management Standards group on Information and Record Management (MIRM), one of the medical standards in MIRM, namely the standardization of diagnosis codes, procedure/action codes, symbols, abbreviations, and their meanings contained in the MIRM 12 standard. Where in the assessment element, the hospital must have regulations on standardizing diagnosis codes, procedure/action codes, definitions, symbols used and which should not be used, abbreviations used and which should not be used, and monitored their implementation. Pertamina Central Hospital is a referral hospital and accredited B. Where this hospital becomes the Presidential Hospital. Medical Records used in the form of Electronic and Manual Medical Records. On the Medical Record Form in the application there are abbreviations and symbols. In the use of abbreviations and symbols, socialization has been carried out which contains a guideline entitled "The RSPP abbreviation list book" but in its implementation no evaluation has been carried out. And also there are SOPs that state the existence of abbreviations, symbols, actions and diagnostic codes. In the period of February, there were 463 hospitalized patients. And researchers took samples of medical record number 132 medical records from 30% of the number of inpatients using the formula of slovin. This is a qualitative research using direct observation and documentation methods. The results of observation and study documentation show that the abbreviations that are not appropriate are 45%, 67% for symbols and 55% appropriate for summary form releases, The book of abbreviations and symbols belonging to Pertamina Central Hospital has not yet been legalized and socialized legally. And there is no SOP in accordance with SNARS MIRM 12 for abbreviations and symbols at Pertamina Central Hospital. There is also no evaluation in the implementation of the use of abbreviations and symbols as well as the books used, there are still not several symbols and abbreviations listed in the abbreviation and symbol guidelines in the Rspp.

Analisis Berkas Rekam Medis Rawat Inap Pada Kasus Operasi Di Rumah Sakit Pusat Pertamina Jakarta Selatan Nungki Annisa Pratiwi; Demiawan Rachmatta Putro Mudiono; Djasmanto Djasmanto
Jurnal Rekam Medik & Manajemen Informasi Kesehatan Vol. 1 No. 1 (2022): April
Publisher : Indonesian Journal Publisher

Based on the results of observations made at Pertamina Central Hospital, it was found that several inpatient medical record file forms, especially in cases of surgery, were related to filling out forms that were not 100% complete and there was no evaluation of the completeness of inpatient medical record files in surgical cases. The purpose of this study was to analyze the completeness of inpatient medical record files, especially cases of surgery at Pertamina Central Hospital in February 2022. This research method used qualitative descriptive. Sampling using the Slovin formula with a population of 200 and the sample results obtained 67 samples. The results of this study obtained that the completeness of filling out the medical record file operation form in the complete category was 43 medical record files (64%) and 24 medical record files were incomplete (36%). The conclusion of this study is that the completeness of inpatient medical record files in surgical cases, especially related to filling out forms at Pertamina Central Hospital is categorized as incomplete because filling out forms is not 100% complete.

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