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All Journal Jurnal Manajemen Informasi dan Administrasi Kesehatan Journal of Multidisciplinary Academic Nusantara Hasana Journal Indonesian Journal of Health Information Management (IJHIM) Jurnal Ilmiah Kesehatan Masyarakat Sehat Rakyat: Jurnal Kesehatan Masyarakat Jurnal Rumpun Ilmu Kesehatan Jurnal Sosial dan Sains Cerdika: Jurnal Ilmiah Indonesia MEDICORDHIF Jurnal Rekam Medis Journal of Educational Innovation and Public Health Vitamin: Jurnal Ilmu Kesehatan Umum Obat: Jurnal Riset Ilmu Farmasi dan Kesehatan

Widjaja, Lily

Universitas Esa Unggul, Jakarta

Author-ID : 752024

Agriculture, Biological Sciences & Forestry Humanities Astronomy Computer Science & IT Dentistry Economics, Econometrics & Finance Education Engineering Environmental Science Health Professions Law, Crime, Criminology & Criminal Justice Library & Information Science Medicine & Pharmacology Nursing Physics Public Health Social Sciences Veterinary Other

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A Service Quality Review of Medical Record Department In Private Hospital, South Jakarta Eka Widya Rita P.; Ratna Indrawati; Lily Widjaja
Journal of Multidisciplinary Academic Vol 5, No 2 (2021): Science, Engineering and Social Science Series
Publisher : Penerbit Kemala Indonesia

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

The medical record is a document containing the patient's identity, history, physical examination, diagnosis, supporting tests and patient treatment. Here, the excellent medical record system service is one of the standard hospital services that function to help the patient care process. Thus, in this study to obtain empirical evidence and field data regarding the input, process, output, and impact in the medical records department at the outpatient installation of a Class-B Private Hospital at South Jakarta. Here, we used the data observation in June-July 2020 using the Mix Method with retrieval technique of Purposive Sampling sample of 72 medical records and 10 medical record staff respondents. The study results shows that the completeness of medical records reached 93.1% with the accuracy of the data around 87.5% and the distribution reached 58.3% with an average distribution time of 11 minutes / medical record. Also, in the effective category, the reliability value was 92%, responsiveness in was 100%, assurance was 100%, and empathy was 100% while tangibles in the less effective category were 67%. Thus, it means that the medical records service system in the outpatient installation at X Private Hospital Class B, South Jakarta, was in an effective category. Further research should be conducted to obtain more in-depth information.

TINJAUAN TAHAP-TAHAP PELAKSANAAN LAPORAN BULANAN DATA KESAKITAN (LB1) LITERATURE REVIEW Khoirunnisa Sabiladina; Muniroh -; Puteri Fannya; Lily Widjaja
Jurnal Manajemen Informasi dan Administrasi Kesehatan Vol 4, No 2 (2021): JMIAK
Publisher : Program Studi Perekam Medis & Informasi Kesehatan

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.32585/jmiak.v4i2.1786

Laporan Bulanan Data Kesakitan (LB1) adalah laporan bulanan yang berisikan pendistribusi kasus penyakit menurut kelompok umur serta kasus baru ataupun kasus lama di puskesmas. Dengan adanya data dan informasi yang diperoleh dari laporan bulanan data kesakitan, maka dinas kesehatan dapat melakukan perencanaan, pemantauan, dan evaluasi pelaksanaan kegiatan program yang ada di puskesmas. Data dan informasi di dalam laporan tersebut dapat bernilai apabila dilaksanakan secara tepat dan akurat. Selain itu, data dan informasi tersebut harus dapat dipertanggungjawabkan keakuratannya karena keputusan yang tepat waktu tidak akan berguna apabila keputusan tersebut tidak sesuai untuk menangani masalah kesehatan yang sedang terjadi. Penelitian ini bertujuan untuk mengetahui proses pelaksanaan laporan bulanan data kesakitan dengan menggunakan metode literature review. Berdasarkan hasil tinjauan literature review terhadap 4 jurnal terkait pelaksanaan laporan bulanan data kesakitan didapatkan proses pengumpulan LB1 bersumber dari register kunjungan pasien, buku register pelayanan dalam gedung dan luar gedung dan pelayanan puskesmas berupa berkas rekam medis sedangkan pustu berupa lembar nota pembayaran. Proses pengolahan LB1 dibuat secara komputerisasi dengan menggunakan microsoft excel dan masih terdapat pengolahan secara manual, Proses penyajian LB1 disajikan dalam bentuk tabel secara manual, tabel excel dan grafik excel, Proses pengiriman LB1 dalam bentuk soft copy dan hard copy tetapi masih terdapat puskesmas yang mengalami keterlambatan dalam pengiriman.

TINJAUAN KEBUTUHAN KODER BERDASARKAN BEBAN KERJA UNIT REKAM MEDIS DI RS IMANUEL BANDAR LAMPUNG Gabriella Eviana Bangun; Muniroh Muniroh; Daniel Happy Putra; Lily Widjaja
Jurnal Manajemen Informasi dan Administrasi Kesehatan Vol 4, No 2 (2021): JMIAK
Publisher : Program Studi Perekam Medis & Informasi Kesehatan

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.32585/jmiak.v4i2.1854

RS Imanuel merupakan salah satu rumah sakit tipe B di kota Bandar Lampung. Rata-rata kunjungan pasien rawat jalan dan rawat inap di RS Imanuel setiap harinya adalah 217 dan 28 pasien. Dalam penyelenggaraan kegiatan koding di RS Imanuel diketahui jumlah koder yang ada adalah 1 (satu) orang. Seiring bertambahnya jumlah pasien setiap tahunnya maka beban kerja pada setiap bagian juga akan terus meningkat yang menyebabkan perlunya penyesuaian antara jumlah tenaga dengan beban kerja yang ada khususnya pada bagian koding di RS Imanuel supaya pelayanan lainnya tidak terhambat. Tujuan penelitian ini adalah mengetahui jumlah kebutuhan tenaga bagian koding berdasarkan beban kerja di RS Imanuel. Jenis penelitian ini adalah deskriptif dengan pendekatan kuantitatif dan menggunakan metode perhitungan Analisis Beban Kerja Kesehatan(ABK-Kes). Teknik pengumpulan data melalui observasi dan wawancara kepada Kepala Instalasi Rekam Medis dan tenaga rekam medis yang melakukan kegiatan koding. Dari hasil penelitian diketahui waktu kerja tersedia (WKT) koder adalah 1.400 jam/tahun atau 84.000 menit/tahun. Rata-rata lama waktu kegiatan koding rawat jalan dan rawat inap adalah 0,84 menit dan 4,69 menit. Standar beban kerja (SBK) koder untuk rawat jalan dan rawat inap adalah 100.000 dan 17.910 rekam medis/tahun. Jumlah kebutuhan koder sebesar 2 (dua) orang sedangkan jumlah yang ada saat ini adalah 1 (satu) orang, maka perlu ditambah 1 (satu) orang.

GAMBARAN PENYEBAB TIDAK DITEMUKAN REKAM MEDIS RAWAT JALAN DIBAGIAN PENYIMPANAN RSUD BUDHI ASIH Mega Puspita Azidah; Muniroh Muniroh; Daniel Happy Putra; Lily Widjaja
Jurnal Manajemen Informasi dan Administrasi Kesehatan Vol 4, No 2 (2021): JMIAK
Publisher : Program Studi Perekam Medis & Informasi Kesehatan

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.32585/jmiak.v4i2.1853

Rekam medis adalah berkas yang berisi catatan dan dokumen mengenai identitas pasien, pemeriksaan, pengobatan, tindakan dan pelayanan lain yang telah diberikan kepada pasien. Rekam medis harus disimpan karena berguna untuk perawatan pasien selanjutnya dan berpengaruh dalam kelancaran dan kepuasan pasien terhadap kualitas pelayanan kesehatan. Tujuan umum dari penelitian ini adalah untuk mendeskripsikan penyebab tidak ditemukannya rekam medis untuk mengetahui penyebab tidak ditemukannya rekam medis rawat jalan di bagian penyimpanan RSUD Budhi Asih dengan 5 unsur manajemen yaitu man, money, method, material, machine. Metode penelitian menggunakan metode deskriptif dengan pendekatan kualitatif. Kejadian misfiled yang terjadi sebanyak 0,34%. Ada beberapa faktor yang mempengaruhi rekam medis salah tempat dan tidak ditemukan (misfiled). Dari hasil penelitian penyebab tidak ditemukannya rekam medis dari faktor manusia, terdapat petugas bukan dari D3 RMIK dan tidak mengikuti pelatihan. Faktor uang, anggaran pelatihan yang belum tentu waktunya. Faktor metode sudah memiliki SOP. Faktor bahan, penggunaan map yang tebal namun jika sedikit sobek hanya diperbaiki. kurangnya rak karena keterbatasan ruang, petugas ada yang tidak mengisi buku ekspedisi, Faktor mesin/alat tracer/outguides petugas terkadang lupa/salah penempatannya, masih terdapat map rekam medis lama tidak menggunakan kode warna.

Ketersediaan Rekam Medis di Rumah Sakit Islam Jakarta Sukapura Gina Sonia; Lily Widjaja; Deasy Rosmala Dewi; Puteri Fannya
SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat Vol. 1 No. 2 (2022): April 2022
Publisher : Yayasan Literasi Sains Indonesia

The medical record is an administration system that records all diagnoses and actions followed by the storage of medical records. Medical record retrieval is an important part to support the effectiveness of services in providing medical records for patients who return to the hospital. This research method uses quantitative descriptive and data collection techniques by observation, interviews and literature study. Based on the results of the research, the filing officer of the Islamic Hospital of Jakarta Sukapura often faced problems during retrieval, the results of the study found that 17 (3.4%) medical records were not found and 26 (5.2%) medical records were misplaced. Factors inhibiting the implementation of medical record retrieval include man factors such as the educational background of officers and the habitual factor of officers who do not use tracers when carrying out medical record retrieval that is not in accordance with SPO at the Islamic Hospital of Jakarta Sukapura. The money factor does not affect the implementation of medical record retrieval. The machine factor is the SMART system for medical record data entry that comes off the shelf. The method factor is that the standard operating procedure for retrieval of medical records is not fully appropriate. The material factor is the absence of loan receipts.

Tinjauan Pendokumentasian Yang Baik Pada Rekam Medis Pasien Rawat Inap Di Rumah Sakit Kanker Dharmais Jakarta Bayu Fajar Ilhami; Lily Widjaja; Deasy Rosmala Dewi; Laela Indawati
SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat Vol. 1 No. 2 (2022): April 2022
Publisher : Yayasan Literasi Sains Indonesia

The contents of the Medical Record are not only data on the treatment of sick patients, but also overall health data so that it is more accurately called Health Records. In general, the Health Record is an overview of the patient's health provided by the service provider/doctor to the patient to become the patient's health record. The purpose of this study was to determine the quality of good documentation in inpatients at Dharmais Cancer Hospital. The research design is cross sectional, namely research conducted at a certain time. Data sources: article searches conducted on Google Scholar to use articles that are in accordance with the research.research method Descriptiveis to describe directly the object under study using a quantitative approach. The results of the study obtained the number of completeness of medical records reached 89.13%. The sample obtained 92 medical record files, with the results of the Initial Medical Assessment Form getting a completeness score of 88.77%, CPPT Form 87.68%, Shift Handover 90.58%, and Consultation Sheets 89.49%. Medical Record Documentation still needs to be improved. Dharmais Cancer Hospital, the number of completeness of medical records needs to be increased so that the documentation of medical records is of higher quality.

Tinjauan Kelengkapan Berkas Persyaratan Klaim Pasien Rawat Inap Covid-19 di Rumah Sakit Sumber Waras Bahlani; Lily Widjaja; Deasy Rosmala Dewi; Laela Indawati
SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat Vol. 1 No. 2 (2022): April 2022
Publisher : Yayasan Literasi Sains Indonesia

Every hospital organizes a health insurance program, the implementation of the national health insurance program is operated by the Health Office, before the hospital collects payments to the Health Office, a complete inpatient claim requirement file is required, if the inpatient claim requirement file is incomplete it will hamper the process. the health office's claim to the hospital, causing a pending claim. The purpose of this study was to get an overview of the completeness of the claim file requirements for Covid-19 inpatients at Sumber Waras Hospital. The research was conducted using a quantitative descriptive method. The sample in this study was taken from the claim requirements file for Covid-19 inpatients at the Sumber Waras Hospital. Sampling using systematic random sampling. Data was collected using a checklist and interview guidelines submitted to Casmiex officers at Sumber Waras Hospital. Based on the results of a study of 87 files for claim requirements for Covid-19 inpatients, 75.90% were obtained. The factors causing the incompleteness of the Covid-19 inpatient claim file requirements are the Covid-19 inpatient claim requirement file provided by the service officer in hardcopy, the service officer does not provide all the files that exist at the patient's discharge date in that month, the occurrence of errors in inputting patient data and medical support officers do not directly enter the results of laboratory tests. Therefore, it is necessary to disseminate information to service personnel so that they can complete the claim requirements for inpatients in a timely manner.

Analisis Kuantitatif Kelengkapan Formulir Pengkajian Medis Awal Dokter Pada RM Pasien Rawat Inap Di RS Vertikal Jakarta Timur Sarah Khonsa; Lily Widjaja; Muniroh Muniroh; Puteri Fannya; Yenni Syafitri
Indonesian Journal of Health Information Management Vol. 2 No. 2 (2022)
Publisher : Sekolah Tinggi Ilmu Kesehatan Mitra Husada Karanganyar

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.54877/ijhim.v2i2.64

Rekam medis wajib dibuat oleh rumah sakit dan diisi lengkap dan jelas baik secara tertulis maupun elektronik. Formulir pengkajian medis awal dokter pasien rawat inap merupakan isi dari bagian rekam medis. Di RS Vertikal Jakarta Timur, pengisian formulir pengkajian medis awal dokter pasien rawat inap masih belum lengkap sehingga nilai gunanya menjadi kurang maksimal. Data yang dianalisis adalah formulir pengkajian medis awal dokter rm pasien rawat inap bulan desember 2020. Tujuan dilakukan penelitian ini adalah untuk mengidentifikasi SPO pengisian pengkajian medis awal dokter pasien rawat inap, menghitung kelengkapan pendokumentasian lembar pengkajian medis awal dokter pasien rawat inap berdasarkan analisis kuantitatif, mengidentifikasi faktor-faktor yang menghambat kelengkapan pengkajian medis awal dokter pasien rawat inap. Analisis kuantitatif merupakan melihat keseluruhan isi dari rekam medis untuk mengidentifikasi terjadinya kekurangan. Penelitian menggunakan metode secara deskriptif kuantitatif dan pengambilan sampel menggunakan simple random sampling. Berdasarkan hasil penelitian SPO pengisian pengkajian medis awal dokter pasien rawat inap sudah ada. Hasil analisis kuantitatif terhadap 90 formulir pengkajian medis awal dokter pasien rawat inap didapat rata-rata kelengkapan sebesar 81%. Faktor penyebab ketidaklengkapan pengisian formulir pengkajian medis awal dokter pasien rawat inap adalah kurangnya tingkat kepatuhan dokter dalam mengisi formulir pengkajian medis awal rawat inap, sehingga banyak formulir tidak terisi secara lengkap. Oleh karena itu, disarankan agar meningkatkan sosialisasi SPO pengisian formulir pengkajian medis awal dokter rawat secara lengkap terutama kepada dokter dan tenaga kesehatan terkait.

Gambaran Ketepatan Waktu Penyediaan Rekam Medis Rawat Jalan Di RSUP Fatmawati Tahun 2021 Arip Budiana; Deasy Rosmala Dewi; Laela Indawati; Lily Widjaja
Sehat Rakyat: Jurnal Kesehatan Masyarakat Vol. 1 No. 1 (2022): Februari 2022
Publisher : Yayasan Pendidikan Penelitian Pengabdian Algero

The hospital as a public health service institution is an important part that provides complete individual health services and provides inpatient, outpatient, and emergency services. Provision of medical records is a process of providing medical records starting from searching for medical records to sending medical records to the intended polyclinic for health services in accordance with health service standards. The purpose of this study was to get an overview of the timeliness of providing outpatient medical records at Fatmawati Hospital. In this study the authors decided to use a qualitative descriptive method which aims to describe the situation or field conditions regarding the occurrence of inaccuracies in the provision of outpatient medical records at Fatmawati Hospital. Based on Standard Operating Procedures, the provision of outpatient medical records at Fatmawati Hospital is <30 minutes (maximum 30 minutes), in this study it was found that the timely provision was 75.55%. With an average delivery time of 27,96 minutes. From this it is known that there is a gap related to the time delay in the process of providing medical records. Delays in the process of providing outpatient medical records are caused by factors including factors in the 5M management element which include man, machine, material, money, method. The staff's knowledge factor needs to be improved, the discipline of the supply officer is good but not optimal, the officer has not attended training on the timeliness of providing good medical records. The machine factor is the lack of number of outpatient medical record storage racks, and the lack of a trolley for the provision of medical records. The method factor is the need for periodic socialization of SOPs to remind officers' performance. The matherial factor requires trolly rejuvenation and good maintenance in order to function as it should. The money factor is that the budget should always be a priority that can be a support for the creation of good health services.

Tinjauan Faktor Penyebab Pengembalian Klaim BPJS Pasien Rawat Inap di RSKD Duren Sawit Jakarta Timur Tahun 2021 Alex Sander; Laela Indawati; Lily Widjaja; Nanda Aula Rumana
Sehat Rakyat: Jurnal Kesehatan Masyarakat Vol. 1 No. 4 (2022): November 2022
Publisher : Yayasan Pendidikan Penelitian Pengabdian Algero

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.54259/sehatrakyat.v1i4.1180

BPJS claim returns have 2 types of returns, the first is a purification failure or a return that occurs due to incompatibility and incompleteness of patient administration, such as patient eligibility letter number (SEP), class of care, and way of returning the patient. The second is pending, this return occurs due to discrepancies and incomplete diagnoses, diagnosis codes and service files received by inpatient BPJS patients submitted to BPJS. Therefore, officers must have thoroughness and understanding when carrying out their duties. This study was conducted to determine the factors causing the return of BPJS claims for inpatients at the Duren Sawit Hospital, East Jakarta in 2021 using a descriptive quantitative approach, by providing an overview and results regarding the factors causing the return of BPJS claims for inpatients. The results of the study used 227 samples of claim files that were returned by the BPJS verifier and obtained 2 (two) types of claim returns. 54 (23.8%) failed to be purified and 173 (76.2%) pending claim files. The most reason for returning claims is that the diagnosis is not supported by treatment and supporting results. There are 2 factors hindering the identification of 5M. Man factor: human error, competence of officers, and the absence of a casemix team. Material: inaccuracy of diagnosis in electronic medical resume so that there is inaccuracy when coding patient diagnosis. There are no barriers to the Money, Method, Machine factors. To get maximum results when submitting BPJS claims for inpatients, hospitals should pay attention to the competence of officers and socialize policies that are in accordance with the system run by the hospital.

Co-Authors Adinda Pratiwi Alex Sander Alfi Shiddiq Syafrian Aliyani Aliyani Angelina Angelina Annisa Nur Salsabila Arip Budiana Bahlani Bayu Fajar Ilhami Choirunisa Choirunisa Dani Sagitha Daniel Happy Putra Deasy Rosmala Dewi Deasy Rosmala Dewi Dian Nur Muslimah Dina Sonia Dinda Nurmalasari Eka Widya Rita P. Fauziah Irfany Ferina Ferina Gabriella Eviana Bangun Gina Sonia Ilham Abdurohman Intan Rusdiana Dewi Khoirunnisa Sabiladina Laela Indawati Laela Indawati Mega Puspita Azidah Muniroh - Muniroh Muniroh Muniroh Muniroh Muniroh Muniroh Muniroh Muniroh Nanda Aula Rumana Natsir Nugroho Noor Yulia Octa Rina Sari Puteri Fannya Putri Nurindahsari Ratna Indrawati Sarah Khonsa Siti Rahmawati Handayani Suciyanti Suciyanti Vania Rachma Putri Wiwik Viatiningsih Yenni Syafitri

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