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All Journal Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Jurnal Ilmiah Kesehatan Masyarakat Jurnal Sains dan Teknologi Journal of Educational Innovation and Public Health Mutiara: Multidiciplinary Scientifict Journal Jurnal Umum Pengabdian Masyarakat (JUPEMAS) Obat: Jurnal Riset Ilmu Farmasi dan Kesehatan
Dina Sonia
Universitas Esa Unggul
Aerospace Engineering Agriculture, Biological Sciences & Forestry Arts Automotive Engineering Chemical Engineering, Chemistry & Bioengineering Chemistry Computer Science & IT Control & Systems Engineering Dentistry Economics, Econometrics & Finance Education Electrical & Electronics Engineering Energy Engineering Health Professions Industrial & Manufacturing Engineering Materials Science & Nanotechnology Mathematics Mechanical Engineering Medicine & Pharmacology Nursing Public Health Social Sciences Veterinary

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Journal : Jurnal Ilmiah Kesehatan Masyarakat

 1 
Analisis Kualitatif Kelengkapan dan Kekonsistensian Diagnosis di Rumah Sakit Patria IKKT Suciyanti Suciyanti; Lily Widjaja; Puteri Fannya; Dina Sonia
SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat Vol. 2 No. 2 (2023): April 2023
Publisher : Yayasan Literasi Sains Indonesia

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

Abstract

Qualitative analysis is a review of filling in medical records related to the consistency of the contents of medical records. A good medical record must contain complete medical records. This type of research is descriptive with a qualitative approach with observation and interview data collection techniques. This qualitative analysis has 6 components. The purpose of this study was to find out a qualitative analysis of the completeness and consistency of diagnosis in dengue fever patients for the period September-October 2022. This research was conducted using a systematic random sampling method. From 85 medical records, the results of a qualitative analysis on the completeness of the consistency of the diagnosis obtained the percentage of consistency of 63.53%. While the results of the 6 subcomponents include: Completeness of diagnosis at admission: 58.82% incomplete, Consistency of diagnosis at admission: 58.82%, Completeness of diagnosis while being treated: 64.71%, Consistency of diagnosis while being treated amounted to: 64.71%, Completeness of diagnosis when going home amounted to: 67.06%, Consistency of diagnosis when going home amounted to: 67.06%. Of the 6 sub-components the highest proportion of consistency was consistency of completeness and consistency of diagnosis at the time of going home = 67.06%. While the lowest completeness & consistency of diagnosis at admission = 58.82%. The conclusion is that the qualitative analysis of the completeness and consistency of the diagnosis is not 100% in accordance with the Hospital MSS.
Analisis Kualitatif Konsistensi Pencatatan Rekam Medis Rawat Inap Kasus Penyakit Dalam di Rumah Sakit Pelabuhan Jakarta Putri Nurindahsari; Dina Sonia; Lily Widjaja; Daniel Happy Putra
SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat Vol. 2 No. 4 (2023): Oktober 2023
Publisher : Yayasan Literasi Sains Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.55123/sehatmas.v2i4.2352

Abstract

Qualitative analysis is an activity that examines the filling of medical records for inconsistent and incomplete contents, which indicates that the medical records are inaccurate and incomplete. The purpose of this study was to find out a qualitative analysis of the reliability of recording medical records of inpatient cases of internal medicine for the year 2022. This type of research uses a descriptive method with a quantitative approach and data collection by observation and interviews. Of the 99 medical records, the results obtained were 96% consistent and 4% inconsistent. And the results of the 4 subcomponents include: At the time of admission, namely the consistency of the initial assessment of nurses and inpatient doctors, the results were 98% consistent. On the subcomponent during hospitalization, namely the consistency of progress notes between doctors and nurses, obtaining results of 99% consistency, Consistency of Doctor's Instructions with delivery notes the drug gets 93% consistent results, when going home, namely the consistency of the doctor's return summary and the nurse gets 94% consistency results. Of the 4 sub-components that have the highest consistency, the consistency between the doctor's and nurse's developmental records obtains 99% consistent results. While the lowest was the consistency of the Doctor's Instructions with a record of drug administration obtaining 93% consistent results. The conclusion is that the qualitative analysis of medical record recording is not 100% consistent. It is recommended that the Jakarta Harbor Hospital make standard operating procedures and implement related qualitative analysis of medical records.
Tinjauan Kelengkapan Rekam Medis Rawat Inap di Rumah Sakit Umum Daerah Kembangan Nabilah Khairunisa; Dina Sonia; Puteri Fannya; Noor Yulia
SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat Vol. 2 No. 4 (2023): Oktober 2023
Publisher : Yayasan Literasi Sains Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.55123/sehatmas.v2i4.2403

Abstract

The completeness of filling in the medical record can be checked using a documentation audit, one of which is quantitative analysis by reviewing certain parts of the contents of the medical record with the intention of finding deficiencies, especially those related to medical record documentation. The purpose of this study was to get an overview of the completeness of filling out inpatient medical records at the Kembangan Regional General Hospital. This research method uses a descriptive method with a quantitative approach. The population in this study were inpatient medical records at the Kembangan Regional General Hospital with a sample of 89 medical records. Based on the results of calculations using quantitative analysis obtained an average completeness of 82%, the highest completeness is the patient identification component of 87% and the lowest completeness is the important reporting component of 76%. Based on the research that has been done, it can be concluded that filling in the medical record at the Kembangan Regional General Hospital is not complete, this is due to the lack of awareness of health workers to complete filling in the medical record so that it has an impact on incomplete filling in medical record files
Tinjauan Penyebab Pengembalian Berkas Klaim Biaya Pelayanan Pasien Rawat Inap BPJS Kesehatan di Rumah Sakit Pelabuhan Jakarta Tahun 2022 Siti Rahmawati Handayani; Lily Widjaja; Daniel Happy Putra; Dina Sonia
SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat Vol. 2 No. 4 (2023): Oktober 2023
Publisher : Yayasan Literasi Sains Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.55123/sehatmas.v2i4.2617

Abstract

In the process of submitting a BPJS Health Claim, some requirements must be completed by the Health Facility. Of these requirements, the BPJS Health party will know that the claim submission can be paid or returned/delayed. This research was conducted to find out the reasons for returning the claim file for BPJS Kesehatan inpatient care at the Jakarta Harbor Hospital in 2022. The method in this study used descriptive research with a quantitative approach. The results of the study were 118 samples (6.7%) of 1,762 files, the highest returned cause was an inaccuracy in the coding of diagnoses/actions of 49 (42%), and the second highest was not fulfilling inpatient administration 18 (15%), other causes - others as much as 51 (43%). 3 factors from 5M are the cause of returning claim files, namely the human factor: casemix officers who are not diligent, lack of coder understanding/knowledge, and lack of accuracy in the filing department so that files are missed/left behind, machine: there is an upgrade to the latest version of the INA-application CBGs and V-Claim are also the Ministry of Health's newest program which requires TB patients to be inputted into the SITB application, Material: incomplete claim requirements files. While the money and method factors are not an obstacle or a cause for returning claim files. It is recommended to evaluate and re-socialize the reasons for returning BPJS Health claims so that the process of submitting BPJS Health claims is carried out properly and is 100% accepted.
Co-Authors Daniel Happy Putra Diva Sabina Eka Rahmasari Emy Wardatunisa Fiqih Nurhidayah Laela Indawati Muniroh Muniroh Nabilah Khairunisa Nanda Aula Rumana Noor Yulia Puteri Fannya Putri Nurindahsari Rizkia Amanda Shafa Aulia Ananda Hermanto Siti Rahmawati Handayani Suciyanti Suciyanti Tazkia Ghalliya Salsabilla Widjaja, Lily