Article Per Year (5 Year)
p-Index From 2019 - 2024
2.165
P-Index
This Author published in this journals
All Journal IQRA`: Jurnal Ilmu Perpustakaan dan Informasi Jurnal Penelitian Kesehatan PREPOTIF : Jurnal Kesehatan Masyarakat Jurnal Ners An-Nadaa: Jurnal Kesehatan Masyarakat Science Midwifery Jurnal Kesehatan Tambusai Jurnal Info Sains : Informatika dan Sains Tour Health Journal
Rahmat Alyakin Dachi
Magister Ilmu Kesehatan Masyarakat, Universitas Sari Mutiara Indonesia Medan
Computer Science & IT Dentistry Health Professions Library & Information Science Medicine & Pharmacology Nursing Public Health Veterinary

Published : 14 Documents Claim Missing Document
Claim Missing Document
Check
Articles

Found 2 Documents
Search
Journal : Jurnal Info Sains : Informatika dan Sains

 1 
Analysis of the Causes of Disputes in Medical Record Files for Inpatient BPJS Patients at the Imelda General Hospital for Indonesian Workers in 2022 Geovani Arta Sihite; Rahmat Alyakin Dachi; Evawani M. Silitonga
Jurnal Info Sains : Informatika dan Sains Vol. 13 No. 02 (2023): Jurnal Info Sains : Informatika dan Sains , Edition September  2023
Publisher : SEAN Institute

Show Abstract | Download Original | Original Source | Check in Google Scholar

Abstract

Coded clinical data is needed to retrieve information for the benefit of patient care, research, improving service performance, planning and resource management, and to obtain appropriate reimbursement for health services provided. The purpose of this research is to find out the causes of Dispute in Medical Record Files of BPJS Patients Hospitalization at RSU Imelda Pekerja Indonesia 2022. This type of research is qualitative with a case study approach. The method used is observation and direct interviews to the field. The subjects used in this study were the Medical Record Files of BPJS Inpatient Patients who were in dispute in October - December 2022 as many as 58 claim files. The informants used in this study were 6 BPJS Kesehatan claimants. Based on the results of the study, the causes of dispute claims on hospitalization files that were resubmitted after experiencing pending, were caused by: Administrative Disputes: Incomplete supporting requirements for submitting RITL service claims, such as action reports, procedures or operation reports, as well as supporting examinations of 2 files (4 %) from October-December 2022. Dispute Coding includes, discrepancies in the main diagnostic codes and secondary diagnoses and discrepancies in the main diagnoses and secondary diagnoses with supporting examinations on medical resumes in 28 files (48%) from October-December 2022. Medical Disputes include , medical indications are not attached (initial admission), scan results of supporting examinations are unclear and illegible, scan results of action/surgery reports are unclear and unreadable in the operation/action reports, no schedule for administration of as many drugs is attached, and discrepancies in actions or administration of drugs of the patient's main diagnoses of 28 files (48%) from October to December 2022.
Qualitative Study of Determinants of Medical Record Completeness of Inpatients at Dr. Hadrianus Sinaga Hospital in 2023 Lasrina E. Tambun; Rahmat Alyakin Dachi; Janno Sinaga
Jurnal Info Sains : Informatika dan Sains Vol. 13 No. 02 (2023): Jurnal Info Sains : Informatika dan Sains , Edition September  2023
Publisher : SEAN Institute

Show Abstract | Download Original | Original Source | Check in Google Scholar

Abstract

Medical records are files that contain records and documents about patient identity, examination, treatment, actions and other services that have been provided to patients. Medical records must be kept either electronically or in writing that is clear and concise. Medical record documents that have been completed by the doctor within less then 24 hours after completion of the service or after the inpatient is decided to go home. This research is a qualitative research. The research instrument is the researcher himself who is subjective, so the data obtained is checked for validity using triangulation techniques, namely source triangulation, technical triangulation and time triangulation. Informants are the Doctor in Charge, Nurse, Midwife, Head of Medical Records Installation and hospital management, namely the Head of Nursing and Midwifery Services Section. Interviews were conducted according to Esterberg and literature studies. The results showed that the determinants of the completeness of Medical Record files were influenced by Man, namely the indiscipline in filling out Medical Record files, Machine, namely the absence of a policy from management if human resources was not disciplined in filling out Medical Record files, Method, namely the lack of motivation in filling in accordance with the SOP, Material, namely sometimes slow provision of parts Medical Record dan Money forms, that is there is no reward dan punishment if the Medical Record is complete.
Co-Authors Agnes Febri Roman Putri Mendrofa Chory Vevayosa Br Sembiring Daniel Ginting Dasrina Dasrina Debora Mendrofa Desni Roma Putra Nasution Donal Nababan DONAL NABABAN Donal Nababan Elysa Simanullang Erwin Silitonga Evawani M. Silitonga Evawani Silitonga Evawani Silitonga Fatimah Azhari S Pasaribu Frida Lina Tarigan Geovani Arta Sihite Henny Arwina Bangun Hotman Manurung Isroni Azhari Siregar Ivan Elisabeth Purba Janno Sinaga Janno Sinaga Jasmen Manurung Juang Putra Telaumbanua Lasrina E. Tambun Laura Mariati Siregar Masdalina Pane Mido Ester J. Sitorus Munthe, Seri Asnawati Nelli Purba Otniel Kataren Parlindungan Purba Sinaga, Lia Rosa Veronika Sipayung, Rosetty Sonny Priajaya Warouw Sukardi Kardi Taruli Rohana Wisnu Hidayat