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Indonesian of Health Information Management Journal (INOHIM)
Published by Universitas Esa Unggul
ISSN : 23548932     EISSN : 26559129     DOI : -
Core Subject : Health,
Health Professions
Indonesian of Health Information Management Journal (INOHIM) is a scientific publication devoted to disseminate all information contributing to the understanding and development of Health Information management, Health Informatics and Health Information Management System.
Arjuna Subject : -
Articles 153 Documents
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Ketepatan Kode Diagnosis Chronic Kidney Disease Dalam Mendukung Kelancaran Klaim BPJS Di Rumah Sakit Warsi Maryati; Indriyati Oktaviano Rahayuningrum; Hestiana Hestiana
Indonesian of Health Information Management Journal (INOHIM) Vol 11, No 1 (2023): INOHIM
Publisher : Lembaga Penerbitan Universitas Esa Unggul

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.47007/inohim.v11i1.497

Abstract

AbstractAn accurate diagnosis code is crucial to support the smooth submission of health service fee claims. In Indonesia, kidney disease is ranked as the second largest financing from BPJS. The preliminary study results show that of the 30% of claims submitted by patients with chronic kidney disease (CKD) that were not approved, 10% of them were due to inaccurate diagnosis codes. This study aimed to prove the relationship between the accuracy of the CKD diagnosis code and the approval of BPJS claims. This research is a quantitative study with a cross-sectional study design. A sample of 97 CKD patient claim files was taken at a hospital in Surakarta. There are two variables: the accuracy of the diagnosis code and the approval of BPJS claims. Researchers used observation guidelines and ICD-10 to analyze the accuracy of the diagnosis code and observe the reasons for returning BPJS claims. Analysis of the relationship between the two variables using the Fisher Exact test. The results showed 93 (95.9%) valid CKD diagnosis codes and 4 (4.1%) inaccurate codes. Claim files were approved by 79 (81.5%) and not approved by 18 (18.5%). The analysis showed that the accuracy of the CKD diagnosis code had a significant relationship with the approval of BPJS claims (b=6.643; 95% CI=4.099-10.765; p=0.001). An Accurate CKD diagnosis code that is accurate has a 6.643 times greater chance of increasing claim approval than one that is inaccurate. Hospitals should try to improve the accuracy of the diagnosis code through regular training, monitoring and evaluation to minimize the occurrence of claims return.Keyword: code, diagnosis, claim, accuracy, CKD AbstrakKode diagnosis yang akurat sangat penting untuk mendukung kelancaran pengajuan klaim biaya pelayanan kesehatan. Di Indonesia, penyakit ginjal menduduki ranking kedua pembiayaan terbesar dari BPJS. Hasil studi pendahuluan menunjukkan bahwa dari 30% pengajuan klaim pasien dengan chronic kidney disesase (CKD) yang tidak disetujui, 10% diantaranya disebabkan karena ketidakakuratan kode diagnosis. Tujuan penelitian ini untuk membuktikan hubungan antara keakuratan kode diagnosis CKD dengan persetujuan klaim BPJS. Penelitian ini menggunakan desain studi cross sectional dengan sampel sebanyak 97 dokumen klaim pasien CKD. Terdapat dua variabel yaitu keakruratan kode diagnosis dan persetujuan kliam BPJS. Peneliti menggunakan pedoman observasi dan ICD-10 untuk menganalisis keakuratan kode diagnosis serta mengamati penyebab pengembalian klaim BPJS. Analisis hubungan antara variabel bebas dengan variabel terikat dengan menggunakan uji Fisher Exact. Hasil penelitian didapatkan kode diagnosis CKD yang akurat sebanyak 93 (95,9%) dan tidak akurat sebanyak 4 (4,1%). Berkas klaim yang disetujui sebanyak 79 (81,5%) dan tidak disetujui sebanyak 18 (18,5%). Hasil analisis menunjukkan bahwa keakuratan kode diagnosis CKD memiliki hubungan yang signifikan dengan persetujuan klaim BPJS (b=6,643; 95% CI=4,099-10,765; p=0,001). Setiap kode diagnosis CKD yang akurat memiliki peluang sebesar 6,643 kali lebih besar dalam meningkatkan persetujuan klaim dibandingkan yang tidak akurat. Rumah sakit sebaiknya melakukan upaya peningkatan keakuratan kode diagnosis melalui pelatihan, pengawasan dan evaluasi secara berkala sehingga meminimalisir terjadinya pengembalian klaim.Kata Kunci: kode, diagnosis, klaim, kekauratan, CKD 
Analisis Perbedaan Kelengkapan Pengisian Asesmen Medis Gawat Darurat Elektronik dengan Manual pada Diagnosis Skizofrenia Tak Terinci di RSJD Surakarta Ratna Komala Sari; Sri Sugiarsi; Sri Mulyono
Indonesian of Health Information Management Journal (INOHIM) Vol 11, No 1 (2023): INOHIM
Publisher : Lembaga Penerbitan Universitas Esa Unggul

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.47007/inohim.v11i1.472

Abstract

AbstractBased on the preliminary survey at RSJD Surakarta from 10 electronic emergency medical assessments, the lowest completeness was on the item verification date, 70%. In contrast, the manual item for patient history and psychiatric examination was 80%, and the doctor's name item was 90%. This study aimed to determine the differences in the completeness of filling out electronic emergency medical assessments with manuals on an unspecified diagnosis of schizophrenia at RSJD Surakarta. This type of research is comparative. The research design uses a retrospective approach. The population of all electronic and manual emergency medical assessment forms for the diagnosis of schizophrenia is not detailed in the third quarter of 2021 and 2019. The sample size is 62, taken using a simple random sampling technique. The method of collecting data is by observation and unstructured interviews. The instrument uses an observation sheet and unstructured interview guidelines. Analysis of the data used is Mann Whitney test. The results of the complete identification of electronic and manual emergency medical assessments were 100%. The completeness of the important electronic emergency medical assessment reports was 77.42%, while the manual was 61.29%. The completeness of the electronic emergency medical assessment authentication is 100%, while the manual is 90.32%. Based on the results of the study, it is recommended that medical record officers coordinate with the SIMRS section when the verification date has not been filled in, the server cannot be saved, provide socialization about the importance of writing vital signs to determine the patient's health condition and improve the completeness of the medical record.Keywords: analysis, completeness, electronic emergency medical assessment filling by manualAbstrakBerdasarkan survey pendahuluan di RSJD Surakarta dari 10 asesmen medis gawat darurat elektronik kelengkapan terendah pada tanggal verifikasi 70% sedangkan manual pada riwayat pasien dan pemeriksaan psikiatri 80%, serta nama dokter 90%. Tujuan penelitian ini untuk mengetahui perbedaan kelengkapan pengisian asesmen medis gawat darurat elektronik dengan manual pada diagnosis skizofrenia tak terinci. Jenis penelitian yaitu komparatif. Populasinya adalah seluruh formulir asesmen medis gawat darurat elektronik dan manual pada diagnosis skizofrenia tak terinci triwulan III tahun 2021 dan 2019. Besar sampel adalah 62, diambil dengan teknik simple random sampling. Cara pengumpulan data melalui observasi dan wawancara tidak terstruktur. Uji mann whitney digunakan untuk menganalisis perbedaan kelengkapan formulir elektronik dan manual.  Hasil penelitian menunjukkan bahwa identifikasi asesmen medis gawat darurat elekronik dan manual lengkap 100%. Laporan penting asesmen medis gawat darurat elektronik; lengkap sebanyak 77,42%, sedangkan manual 61,29%. Autentifikasi asesmen medis gawat darurat elektronik lengkap 100%, sedangkan manual 90,32%. Terdapat perbedaan kelengkapan formulir elektronik dengan yang manual pada nilai p=0.033(<0.05).Kata Kunci: analisis, kelengkapan, pengisian asesmen medis gawat darurat elektronik dengan manual
Implementasi Rekam Medis Elektronik di Klinik Kidz Dental Care Sella Yossiant; Hosizah Hosizah
Indonesian of Health Information Management Journal (INOHIM) Vol 11, No 1 (2023): INOHIM
Publisher : Lembaga Penerbitan Universitas Esa Unggul

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.47007/inohim.v11i1.498

Abstract

AbstractThe development of increasingly advanced information technology in various fields has become common in today's digital era. The health sector is no exception. One of the developments in information technology is using information systems in health services in electronic medical records. Electronic medical records are expected to be able to provide benefits in overall health services. However, until now, the application of electronic medical records is still assisted by paper due to limited development costs and users. This study aimed to determine the implementation of electronic medical records in pediatric dental clinics per the five components of electronic medical records: hardware, software, policies, users, and processes. The method used for implementing RME is descriptive, with data collection obtained from observations, interviews, and document review. RME was implemented for one month at the pediatric dental clinic by involving the clinic director, clinic manager, IT officer, dentist, registration officer, and two nurses. The RME application has been integrated with medical support applications. It can be implemented in pediatric dental clinics as patient registration, medical record documentation, patient visit lists, payments, stock of goods and medicines, and clinical reports. However, this system is not entirely electronic, and there are still some manual services such as making drug prescriptions, informed consent, and signing the approval for visits.Keywords: implementation, electronic medical records, electronic medical records, dental clinicsAbstrakPerkembangan teknologi informasi yang semakin maju di berbagai bidang menjadi hal yang biasa terjadi pada era digital saat ini. Tidak terkecuali pada bidang kesehatan, salah satu perkembangan teknologi informasi adalah penggunaan sistem informasi dalam layanan kesehatan yang berbentuk rekam medis elektronik. Rekam medis elektronik diharapkan mampu memberikan manfaat dalam pelayanan kesehatan secara keseluruhan, namun sampai saat ini penerapan rekam medis elektronik masih dibantu dengan kertas karena keterbatasan biaya pengembangan maupun pengguna. Tujuan penelitian ini untuk mengetahui implementasi rekam medis elektronik di klinik gigi anak sesuai dengan kelima komponen dalam rekam medis elektronik yaitu perangkat keras, perangkat lunak, kebijakan, pengguna, dan proses. Metode yang digunakan untuk implementasi RME adalah metode deskriptif dengan pengumpulan data didapatkan dari hasil observasi, wawancara, dan telaah dokumen. Implementasi RME dilakukan selama 1 bulan di klinik gigi anak dengan melibatkan direktur klinik, manajer klinik, 1 orang petugas IT, 1 orang dokter gigi, 1 orang petugas pendaftaran, dan 2 orang perawat. Aplikasi RME sudah terintegrasi dengan aplikasi penunjang medis dan dapat diimplementasikan di klinik gigi anak sebagai pendaftaran pasien, dokumentasi rekam medis, daftar kunjungan pasien, pembayaran, stok barang dan obat-obatan, serta laporan klinik. Namun, sistem ini belum seluruhnya menggunakan elektronik dan masih terdapat beberapa pelayanan yang manual seperti pembuatan resep obat, informed consent, serta tanda tangan persetujuan kunjungan.Kata kunci : implementasi, rekam medis elektronik, rekam medis elektronik, klinik gigi

Page 16 of 16 | Total Record : 153

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