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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
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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Literature Review : Kelengkapan Kode Topography dan Morphology pada Kasus Neoplasma Dian Nur Muslimah; Deasy Rosmala Dewi; Laela Indawati; Lily Widjaja
SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat Vol. 2 No. 1 (2023): Januari 2023
Publisher : Yayasan Literasi Sains Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.55123/sehatmas.v2i1.1000

Abstract

In the Medical Record for determining the cancer diagnosis code (Neoplasm), there are 2 codes, namely the topographic code and the morphology code. These two codes are very important because the topographic code is a code that shows the location of the tumor, while the morphology code is a code that shows the nature of the tumor. If the two codes are not included, it will not determine the level of malignancy of the tumor. The aim of the study was to identify the completeness of the topographic and morphological codes in neoplasm cases. Literature study conducted on 7 journals uploaded online in the span of 2011-2021. Search journals in this study using the keywords "completeness", "Topography and Morphology code" obtained through Google Scholar. The results of the literature review show that the completeness of topographic and morphological codes in neoplasm cases has not yet reached 100%. The highest completeness of topographic codes is 98% at Aisyiyah Hospital Malang in 2018. While the lowest percentage is 0% at MRCCC Siloam Semanggi Hospital in 2020 and Karanganyar District Hospital in 2011. The highest completeness of morphology codes is 82.4% at Santa Elisabeth Hospital Medan while The lowest percentage was 0% at MRCCC Siloam Semanggi Hospital in 2020, Bhayangkara Hospital, Aisyiyah Hospital, Dr Moewardi Hospital, and Karanganyar District Hospital. The incompleteness is due to 2 factors Man: Coder inaccuracy in coding, officers have not implemented coding procedures in neoplasm cases. Method: there is no SOP for coding neoplasms, there is no PA result sheet, and the doctor's writing is not clear and complete. In assigning codes to neoplasm cases, officers should code according to the SOP, so that the resulting code is complete and accurate.
Tinjauan Lama Waktu Pendistribusian Rekam Medis Rawat Jalan di Rumah Sakit Umum Bhakti Asih Adinda Pratiwi; Lily Widjaja; Muniroh Muniroh; Daniel Happy Putra
Cerdika: Jurnal Ilmiah Indonesia Vol. 2 No. 4 (2022): Cerdika: Jurnal Ilmiah Indonesia
Publisher : Publikasi Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (3778.086 KB) | DOI: 10.59141/cerdika.v2i4.362

Abstract

Medical record is written or recorded information regarding identity, history taking, physical determination, laboratory, diagnosis of all medical services and actions provided to patients and treatment, whether inpatient, outpatient or receiving emergency services. Distribution in the health sector, especially medical records, has the meaning of a process of distributing medical records to each polyclinic addressed by the patient according to the medical record number. Minimum Service Standards (SPM) are provisions regarding the type and quality of basic services in the speed of providing medical records, the standard time for providing medical records for outpatient services is 10 minutes. This research was conducted at Bhakti Asih Hospital located at Jalan Raden Saleh No. 10, Karang Tengah, Tangerang City, Banten 15157. The purpose of this study was to determine the length of time for the distribution of outpatient medical records at Bhakti Asih General Hospital. This type of research uses descriptive quantitative methods. Data collection techniques used are observation and interviews. In this study, the population was all outpatient medical records in the period June 2021 with a sample of 96 outpatient medical records, using the Incidental/Convenience sampling technique. The results of this study can be seen that 52 medical records (54.16%) have met the SOP 10 minutes, while 44 medical records (45.83%) have not met the SOP 10 minutes. The time of calculating the distribution of outpatient medical records with 96 samples for 10 days with a total time of 984 minutes obtained an average time of distribution of outpatient medical records of 10.25 minutes.
Tinjauan Kebutuhan Rak Penyimpanan Rekam Medis di RSUD Bangka Selatan Ferina Ferina; Muniroh Muniroh; Daniel Happy Putra; Lily Widjaja
Cerdika: Jurnal Ilmiah Indonesia Vol. 2 No. 4 (2022): Cerdika: Jurnal Ilmiah Indonesia
Publisher : Publikasi Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (3574.344 KB) | DOI: 10.59141/cerdika.v2i4.373

Abstract

Medical record is a collection of facts or evidence of the patient's condition, past and current medical history and treatment written by the health professional who provides services to the patient. Medical records require sufficient storage shelves and storage space is needed to maintain confidentiality, avoid damage and make it easier for officers to retrieve and return medical records in the long term. If the medical record storage is adequate and meets the standards to support maximum patient care, it is necessary to adjust the need for medical record storage racks at the South Bangka Hospital. The purpose of this study was to determine the need for medical record storage racks for the next 5 years at RSUD South Bangka. This type of research uses a descriptive method with a quantitative approach. Data collection techniques used are observation and interviews. The results of this study are the number of medical record storage racks in the South Bangka Hospital currently amounts to 17 shelves and the South Bangka Hospital currently has a medical record storage area of 25m². It is recommended that the South Bangka Hospital need to provide 49 storage shelves for the next 5 (five) years so that the shelf needs can be met and can accommodate all medical records and it is hoped that the hospital will add an area of medical record room with an additional area of 11.96m² to adjust the addition of medical record racks.
Tinjauan Ketepatan Pengodean Diagnosis Penyebab Dasar Kematian pada Pasien Diabetes Mellitus di RSU UKI Jakarta Dinda Nurmalasari; Lily Widjaja; Deasy Rosmala Dewi; Laela Indawati
Cerdika: Jurnal Ilmiah Indonesia Vol. 2 No. 4 (2022): Cerdika: Jurnal Ilmiah Indonesia
Publisher : Publikasi Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (3528.296 KB) | DOI: 10.59141/cerdika.v2i4.374

Abstract

Determination is a precaution and the accuracy of disease codes can be easily identified into correct and incorrect codes, Correct codes are adjusted in ICD-10 then incorrect codes are inappropriate codes in ICD-0. The cause of death was hospital reporting. The uncertainty of the diagnostic code consists of 5m (man, money, method, machine, material) based on the interview of the coding officer that the precision of the cause of death in the diabetes mellitus diabetes is not optimum because of poor doctors' writing, the use of abbreviations in the diagnosis, the lack of human resources in rmic education, no charge in coding, The method of conducting a death certificate from the medical certificate form is the cause of death at the point of immediate cause, the cause between and the underlying cause and the absence of a specialized chamber. Hence, the authors conducted a study on the correctness of the causes of death in diabetes patients mellitus according to the icd-10. The purpose of this study was to understand the precision of the diagnosis of the causes of death in the diabetes patient mellitus in Jakarta general hospital. Based on a study of the 72 medical records of patients dying of the precision of the cause of death in diabetes patients mellitus in Jakarta general in 2017-2020.
Tinjauan Kebutuhan Rak Penyimpanan Rekam Medis di Rumah Sakit Annisa Bogor Tahun 2022 Annisa Nur Salsabila; Wiwik Viatiningsih; Lily Widjaja; Laela Indawati
Cerdika: Jurnal Ilmiah Indonesia Vol. 2 No. 7 (2022): Cerdika: Jurnal Ilmiah Indonesia
Publisher : Publikasi Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (757.525 KB) | DOI: 10.59141/cerdika.v2i7.436

Abstract

Hospital is a health service institution by providing outpatient and inpatient services. Each hospital also has an obligation to have a Medical Record Unit. Medical records are files that contain records or documents such as patient identities, results of diagnoses, actions, and treatments as well as services that have been provided to patients. In the context of administering medical records, health service facilities are required to provide the necessary facilities. One of them is a medical record storage rack to store medical records. Based on the results of research at the Medical Record Unit of the Annisa Hospital, Bogor, it was found that the medical record storage rack was inadequate and some medical records were piled on the floor, making it difficult for officers to find medical records when needed and services at the polyclinic became hampered. The purpose of this study was to determine the need for medical record storage racks for the next 5 years at Annisa Hospital Bogor in 2022. The study was conducted using a quantitative descriptive method, using a non-random sampling method with saturated sampling technique. From the results of the study, the Annisa Bogor Hospital still lacks medical record storage rack facilities which currently have 12 wooden shelves and 3 Roll O'packs, an additional rack of 9 Roll O'packs is needed. The storage area at Annisa Hospital Bogor is sufficient because the area needed for the next 5 years is 61.3 m2. Meanwhile, the current room area is 120 m2 combined with the medical record officer's workspace.
Tinjauan Kebutuhan Tenaga Perekam Medis dan Informasi Kesehatan di Puskesmas Leuwiliang Menggunakan Abk Kes Ilham Abdurohman; Puteri Fannya; Lily Widjaja; Deasy Rosmala Dewi
Jurnal Sosial dan Sains Vol. 3 No. 1 (2023): Jurnal Sosial dan Sains
Publisher : Green Publisher Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (1829.528 KB) | DOI: 10.59188/jurnalsosains.v3i1.677

Abstract

Latar Belakang : Puskesmas Leuwiliang, Bogor Jawa Barat yang merupakan puskesmas tipe Utama Rawat Jalan dimana unit rekam medis khususnya hanya memiliki 1 tenaga kerja. Rekam Medis dan 2 Tenaga Pendaftaran di Puskesmas berfungsi untuk Melakukan Pendaftaran pasien , pengambilan , distribusi , coding dan penyimpanan rekam medis . Diketahui kegiatan Rekam Medis dilakukan oleh 1 petugas dengan jumlah rekam medis 61.068 pasien rawat jalan pada tahun 2021. Tujuan : Penelitian ini bertujuan untuk mendapatkan gambaran jumlah kebutuhan tenaga rekam medis yang sesuai dengan beban kerja di Puskesmas Leuwiliang. Metode : Metode yang digunakan adalah penelitian ini bersifat deskriptif kuantitatif, yaitu melakukan penelitian secara langsung untuk mengetahui jumlah kebutuhan tenaga rekam medis berdasakan data dari wawancara dan observasi. Hasil : Hasil penelitian berdasarkan perhitungan Analisis Beban Kerja Kesehatan (ABK Kes) diketahui Standar Beban Kerja (SBK) 5,9 rekam medis/tahun dibagi capaian 1 tahun 61.068 pasien rawat jalan lalu dibagi lagi dengan Standar Tugas Penunjang (STP) didapatkan jumlah tenaga rekam medis yang dibutuhkan sebanyak 8 orang. Kesimpulan: Hasil kesimulam yaitu tinjauan kebutuhan perekam medis yang ada di Puskesmas Cikancung berdasarkan metode analisis beban kerja kesehatan (ABK) membutuhkan 5 orang pegawai, saat ini di Puskesmas Cikancung sudah memiliki 4 orang petugas jadi perlu penambahan 1 orang pegawai baru agar memenuhi kebutuhan.
Tinjauan Kebutuhan Tenaga Assembling Rekam Medis Rawat Inap Berdasarkan Beban Kerja di Rumah Sakit Menggunakan Analisa Beban Kerja Kesehatan Alfi Shiddiq Syafrian; Muniroh Muniroh; Lily Widjaja; Laela Indawati
Jurnal Sosial dan Sains Vol. 3 No. 2 (2023): Jurnal Sosial dan Sains
Publisher : Green Publisher Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.59188/jurnalsosains.v3i2.689

Abstract

Latar Belakang : Rumkital Marinir Cilandak, Kota Jakarta Selatan yang merupakan rumah sakit tipe B dimana unit rekam medis khususnya dibagian assembling rawat inap hanya memiliki 1 tenaga kerja. Assembling di rumah sakit berfungsi untuk melengkapi isi dan merakit dokumen rekam medis yang belum sempurna. Diketahui kegiatan assembling dilakukan oleh 1 petugas dengan jumlah rekam medis 7.597 pasien rawat inap pada tahun 2021. Tujuan : Penelitian ini bertujuan untuk mendapatkan gambaran jumlah kebutuhan tenaga rekam medis assembling rawat inap yang sesuai dengan beban kerja di Rumkital Marinir Cilandak. Metode : Penelitian ini bersifat deskriptif kuantitatif, yaitu melakukan penelitian secara langsung untuk mengetahui jumlah kebutuhan tenaga assembling berdasakan data dari wawancara dan observasi. Hasil : Berdasarkan hasil perhitungan Analisis Beban Kerja Kesehatan (ABK Kes) diketahui Standar Beban Kerja (SBK) 5.891 rekam medis/tahun dibagi capaian 1 tahun 7.597 pasien rawat inap lalu dibagi lagi dengan Standar Tugas Penunjang (STP) didapatkan jumlah tenaga assembling rawat inap yang dibutuhkan sebanyak 2 orang. Kesimpulan: Disimpulkan bahwa Standar Prosedur Operasional (SPO) proses assembling rekam medis di Rumkital Marinir Cilandak diterbitkan pada tanggal 21 Desember 2018, dan belum ada revisi terbaru dari pihak Rumkital.
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.
Pemanfaatan Metode Fishbone Pada Studi Kasus Keterlambatan Pengembalian Rekam Medis di Rumah Sakit Muhammadiyah Taman Puring Choirunisa Choirunisa; Lily Widjaja
MEDICORDHIF Jurnal Rekam Medis Vol 5 (2018): MEDICORDHIF Jurnal Rekam Medis
Publisher : APIKES Bhumi Husada Jakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (11.031 KB)

Abstract

ABSTRACT The delay in returning inpatient medical records can show the quality of health services that are less than optimal. To achieve service goals optimally, it is necessary to have a good and supportive system in RM services in accordance with the procedures set out in the hospital. Delay in returning inpatient RM patients will affect and result in the processing and presentation of data starting from assembling activities, analysis, coding, indexing to reporting RM (RM). The purpose of this study was to find out the factors that influence the delay in returning the hospitalization RM to the RM unit at the Muhammadiyah Hospital in Taman Puring using the fishbone method. This type of research is descriptive, population of 253 RM in July 2018 obtained a sample of 155 RM. The technique of collecting data by observation and interviews, the instruments are in the form of interview guidelines, checklists, calculators and return expedition books. Analysis of the data with the percentage of the accuracy of the RM return time and with the Fishbone method get the factors that affect the delay in returning the RM. The results of the study and the discussion that the RM return from the appropriate treatment room was 65.16% and the late ones were 34.83%. The main factor in delaying the return of a patient's RM is a resume that has not been filled in, there is no special officer who returns the hospitalized RM to the RM unit. Keyword: Delay, Return Medical Record, Fishbone.
Tinjauan Kinerja Pegawai dalam Menggunakan E-Puskesmas di Puskesmas Kecamatan Kepulauan Seribu Utara Aliyani Aliyani; Daniel Happy Putra; Puteri Fannya; Lily Widjaja
Jurnal Sosial dan Sains Vol. 3 No. 5 (2023): Jurnal Sosial dan Sains
Publisher : Green Publisher Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.59188/jurnalsosains.v3i5.760

Abstract

Latar Belakang : Dalam meningkatkan manajemen penyelenggaraan Puskesmas perlu dukungan sistem informasi Puskesmas yang mampu menjamin ketersediaan data dan informasi secara cepat, akurat, terkini, berkelanjutan dan dapat dipertanggungjawabkan. Sebuah metode yang digunakan untuk mengukur sumber daya manusia terhadap kinerja petugas adalah HRSC (Human Resources Scorecard). Tujuan : Tujuan penelitian ini mengetahui kinerja pegawai dalam menggunakan ePuskesmas di Puskesmas Kecamatan Kepulauan Seribu Utara. Metode : Metode penelitian yang dilakukan adalah deskriftif dengan pendekatan kuantitatif. Penelitain ini lakukan di Puskesmas Kecamatan Kepulauan Seribu Utara denga jumlah 30 responden yang mengisi kuesioner penelitian. Hasil : Hasil penelitian menunjukan terdapat pada indikator kualitas 29 petugas (96.7%) menyatakan baik, pada indikator kuantitas 27 petugas (90.0%) menyatakan baik, pada indikator kehadiran 30 petugasa (100,0%) menyatakan baik, pada indikator supervisi 13 petugas (43.3%) menyatakan baik, pada indikator konservasi 25 petugas (83.3%) menyatakan baik. Hasil dari lima indikator didapatkan kinerja petugas yang menggunakan ePuskesmas di Puskesmas Kecamatan Kepulauan Seribu Utara dengan 18 petugas (60.0%) menyatakan baik menggunakan ePuskesma dan 12 petugas (40.0%) menyatakan tidak baik menggunakan ePuskesmas. Kesimpulan: Penelitian diatas dapat disimpulkan bahwa karakteristik petugas berdasarkan umur di Puskesmas Kecamatan Kepulauan Seribu Utara yang menggunakan ePuskesmas yaitu rata-rata usia 32 tahun, median 30.50 tahun, standar deviasi 6.425 tahun, umur termudah 23 tahun umur tertua 48 tahun dan 95%Confidence Interval adalah 29.63 – 34.43 tahun, berdasarkan jenis kelamin, jenis kelamin pada petugas perempuan sebanyak 56.7% (17 petugas) sedangkan pada petugas laki-laki sebanyak 43.3% (13 petugas) dilihat pendidikan terakhir terbanyak yaitu pada pendidikan D3 sebanyak 56.7% (17 petugas) sedangkan pendidikan terbanyak kedua yaitu S1 sebanyak 23.3% (7 petugas) dan pendidikan terendah yaitu SMA sebanyak 20.0% (6 petugas), dan dilihat dari lama bekerja di Puskesmas Kecamatan Kepulauan Seribu Utara yang menggunakan ePuskesmas yaitu rata-rata 6.80 tahun, median 6 tahun, standar deviasi 3.517 tahun, lama bekerja termudah yaitu 1 tahun, lama bekerja tertua yaitu 15 tahun dan 95% Confidence Interval adalah 5.49 – 8.11 tahun.
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