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JOURNAL OF MEDICAL RECORDS AND HELATH INFORMATION
Published by Sekolah Tinggi Ilmu Administrasi Malang
ISSN : 27159817     EISSN : 27229831     DOI : -
Core Subject : Humanities, Health, Education, Social,
Humanities Education Health Professions Public Health Social Sciences
Puji syukur kita panjatkan kehadirat Allah SWT, atas berkat dan rahmat Nya kamidapat kembali hadir untuk menyajikan artikel-artikel terkini pada JRMIK: Jurnal Rekam Medis & Informasi Kesehatan Volume 03 Nomor 02 Edisi Juni, Tahun 2022. Semua artikel yang dimuat pada Jurnal ini telah diseleksi dan ditelaah oleh Dewan Editor . Hanya artikel-artikel berkualitas baik dan sangat baik yang dapat dimuat pada JRMIK: Jurnal Rekam Medis & Informasi Kesehatan. Topik-topik yang disajikan pada edisi ini meliputi: klasifikasi dan kodefikasi rekam medis, komunikasi rekam medis, dan manajemen rekam medis. Kepada penulis yang telah berkontribusi pada penerbitan jurnal edisi ini, kami menyampaikan terima kasih yang mendalam, selanjutnya kami mengundang rekan sejawat peneliti perekam medis dan informasi kesehatan mengirimkan naskah untuk disajikan pada jurnal ini. Saran dan kritik yang membangun, pembaca dan para pihak lainnya sangat kami harapkan. Selamat membaca.
Arjuna Subject : Profesi Kesehatan - Menejmen Informasi Kesehatan
Articles 47 Documents
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ANALISIS KEAKURATAN KODE EXTERNAL CAUSE KASUS KECELAKAAN LALU LINTAS BERDASARKAN ICD 10 DI RUMAH SAKIT BAPTIS KEDIRI Robiatud Daniyah; Karmelita Ardantik
JRMIK Vol 4 No 2 (2023): JOURNAL OF MEDICAL RECORDS AND HEALTH INFORMATION
Publisher : Malang: Sekolah Tinggi Ilmu Administrasi Malang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.58535/jrmik.v4i2.59

Abstract

Latar Belakang : Pengkodean pada diagnosa Cedera, Keracunan, dan akibat lain penyebab external(S00-T98) yang tertera pada Bab XIX ICD-10 harus diikuti dengan pengkodean pada Bab XX penyebabpenyebab luar morbiditas dan mortalitas (V01-Y98). Pengkodean dilakukan untuk menggambarkansifat kondisi dan keadaan yang menimbulkannya. Pengkodean eksternal cause dilakukan secaraterpisah pada BAB XX (penyebab luar) morbiditas dan 2 mortalitas (V01-Y98). Kode kasus kecelakaandikatakan lengkap apabila terdapat kode diagnosa cedera dan kode external cause penyebabkecelakaan.Tujuan : Mengetahui keakuratan pemberian kode external cause pada berkas rekam medis pasienkecelakaan lalu lintas pasien rawat inap berdasarkan ICD-10 di Rumah Sakit Baptis Kediri.Metode : Penelitian ini menggunakan metode deskriptif dengan analisis kuantitatif. Tekhnikpengumpulan data dilakukan dengan melakukan observasi dan wawancara.Hasil : Penelitian ini menggunakan 30 sampel berkas rekam medis kasus kecelakaan lalu lintas pasienrawat inap dan mendapatkan hasil 2 dokumen rekam medis dengan kode external cause yang akuratsedangkan 28 dokumen rekam medis lainnya tidak akurat. Ketidakakuratan kode tersebut diantaranyatidak dikode pada karakter ke 5 yang menunjukkan aktivitas korban, salah kode pada karakter ke 4dan, salah kode pada karakter ke 2 sampai karakter ke 4.Kesimpulan : Faktor- faktor yang berkaitan dengan keakuratan dan ketidakakuratan kode externalcause kasus kecelakaan lalu lintas yaitu informasi medis yang tidak lengkap terdapat ketidakjelasandiagnosa yang ditulis oleh dokter. Selain itu faktor yang menyebabkan ketidakakuratan kode externalcause yaitu tidak adanya Standar Operasional Prosedur khusus yang mengatur pengkodean externalcause.Kata Kunci: Kode Penyebab Luar, Pengkodean Diagnosa Kecelakaan Lalu Lintas, Diagnosa Cidera AbstractBackground : Coding for the diagnosis of Injury, Poisoning and other consequences of external causes(S00-T98) listed in Chapter XIX ICD-10 must be followed by coding in Chapter XX for external causesof morbidity and mortality (V01-Y98). Coding is done to describe the nature of the conditions andcircumstances that give rise to them. External cause coding was carried out separately in CHAPTER XX(external causes) morbidity and 2 mortality (V01-Y98). An accident case code is said to be complete ifthere is an injury diagnosis code and an external cause code for the accident.Objective: Observation of healing by assigning an external cause code to the medical record file ofinpatient traffic accident patients based on ICD-10 at the Baptist Hospital of Kediri.Methods: This study uses a descriptive method with quantitative analysis. Data collection techniqueswere carried out by observing and interviewing.Results: This study used 30 samples of medical record files for inpatient traffic accident cases andobtained 2 medical record documents with accurate external cause codes, while the other 28 medicalrecord documents were inaccurate. The inaccuracies of the code include not being coded on the 5thcharacter which indicates the victim's activity, wrong code on the 4th character and, wrong code on the2nd to 4th characters.Conclusion: Factors related to the accuracy and inaccuracy of external cause codes for traffic accidentcases where medical information is incomplete, there is an ambiguity in the diagnosis written by thedoctor. In addition, the factor that causes the inaccuracy of the external cause code is the absence of a special Standard Operating Procedure that regulates the external cause coding.Keywords: External Cause Code, Traffic Accident Diagnostic Coding, Injury Diagnosis
MENGUKUR TINGKAT PERSIAPAN IMPLEMENTASI SISTEM REKAM MEDIS ELEKTRONIK DENGAN PENDEKATAN DOQ-IT DI RSUD DR. RASIDIN PADANG Herman Susilo; Masdalena Masdalena; Sundari Pramulichati; Muhammad Ihksan
JRMIK Vol 5 No 1 (2024): JOURNAL OF MEDICAL RECORDS AND HEALTH INFORMATION
Publisher : Malang: Sekolah Tinggi Ilmu Administrasi Malang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.58535/jrmik.v5i1.62

Abstract

Berdasarkan ketentuan Peraturan Menteri Kesehatan Republik Indonesia nomor 24 tahun 2022 yang mengharuskan fasilitas pelayanan menerapkan Rekam Medis Elektronik (RME) paling lambat pada 31 Desember 2023, penelitian ini bertujuan untuk menganalisis kesiapan pelaksanaan RME dengan menggunakan metode DOQ-IT di RSUD dr. Rasidin Padang. Dalam pendekatan kuantitatif dan deskriptif, sampel terdiri dari 18 petugas rekam medis dengan pengumpulan data menggunakan kuesioner. Penilaian kesiapan dilakukan pada empat komponen utama, yaitu sumber daya manusia, budaya kerja organisasi, tata kelola kepemimpinan, dan infrastruktur, dengan menggunakan skoring EHR Assessment and Readiness oleh Doctor’s Office Quality - Information Technology (DOQ-IT). Hasil penelitian menunjukkan bahwa total skor kesiapan RSUD dr. Rasidin Padang adalah 141,89, berada pada kategori I yang mengindikasikan kesiapan yang sangat tinggi dalam pelaksanaan RME. Secara rinci, skor kesiapan pada masing-masing komponen adalah 4,4 untuk sumber daya manusia, 4,4 untuk budaya kerja organisasi, 4,5 untuk tata kelola kepemimpinan, dan 4,4 untuk infrastruktur. Meskipun secara keseluruhan RSUD dr. Rasidin Padang sangat siap dalam pelaksanaan RME, perlu diperhatikan bahwa tidak adanya Standar Operasional Prosedur (SOP) dalam pelaksanaan RME menjadi catatan penting yang mengindikasikan bahwa secara menyeluruh fasilitas tersebut belum sepenuhnya siap.Langkah-langkah perbaikan dan pengembangan perlu dilakukan terutama dalam pembuatan SOP untuk memastikan pelaksanaan RME dapat berjalan dengan efektif dan sesuai dengan standar yang ditetapkan. Dengan demikian, fasilitas pelayanan kesehatan dapat memenuhi ketentuan peraturan yang berlaku dan meningkatkan kualitas pelayanan kesehatan secara keseluruhan
KELENGKAPAN BERKAS PERSYARATAN KLAIM BPJS PADA PASIEN RAWAT INAP DI RUMAH SAKIT WAVA HUSADA MALANG: PERSYARATAN KLAIM BPJS Miftachul Ulum
JRMIK Vol 5 No 1 (2024): JOURNAL OF MEDICAL RECORDS AND HEALTH INFORMATION
Publisher : Malang: Sekolah Tinggi Ilmu Administrasi Malang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.58535/jrmik.v5i1.63

Abstract

The completeness of medical record file information is very important for verification of claims. Verification of claims is specially prepared with the aim of being a reference verifier of claims on BPJS. Completeness of medical records also maintains health facilities for service quality and efficiency of health service costs up to the disbursement of claims to health care providers. The purpose of this report is to find out the Completeness of BPJS claim requirements for inpatients at Wava Husada Hospital in 2022 with an observation method in the form of a checklist conducted on March 21-March 26, 2022. This research was conducted at the Health Financing Cooperation Installation and Casemix. Based on the results of the completeness analysis on 120 BPJS claim requirements files conducted by researchers, a completeness percentage of 75 files or 62.5% and a percentage of incompleteness of 45 files or 37.5%. The highest completeness is found in the inpatient cover letter, participant egibility letter (SEP), emergency assessment sheet, and medical support sheet with a completeness rate of 120 files or 100% and the lowest completeness is found on the casemix verification sheet of 102 files or 85%. As for overcoming this, it is recommended to hold a coordination meeting with health service providers regarding the importance of completeness and accuracy of filling out medical record files for BPJS claim requirements, to facilitate the process of submitting hospital claims to BPJS.
OPTIMALISASI PENERAPAN SISTEM APLIKASI E-PUSKESMAS: TINJAUAN TERHADAP PROSES DAN KEEFEKTIFAN DI PUSKESMAS TAJINAN KABUPATEN MALANG Soraya Soraya; Ervita Nindy Oktoriani; Maulidya Adhe S
JRMIK Vol 5 No 1 (2024): JOURNAL OF MEDICAL RECORDS AND HEALTH INFORMATION
Publisher : Malang: Sekolah Tinggi Ilmu Administrasi Malang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.58535/jrmik.v5i1.64

Abstract

The development of digital technology in this modern era has resulted in a digital transformation, including in the realm of health services. This effort is strengthened by the Republic of Indonesia Ministry of Health Regulation Number 24 of 2022, which regulates legal certainty in the management andadministration of Electronic Medical Records (RME). This regulation must be implemented by all health service facilities no later than the end of 2023. This research aims to analyze the implementation of the EPuskesmas Application System at the Tajinan Health Center, Malang Regency. The method used in this research is descriptive qualitative. Data collection was carried out through observations and interviews with health workers using the HOT-Fit information system evaluation model, which includes Human, Organizational, Technology and Benefit aspects. The research results show that the E-Puskesmas application has a variety of menus and features that are considered very profitable and useful, able to help lighten the workload of health workers. Community health center management also supports the implementation of this application by providing adequate hardware. However, there are stillshortcomings, namely the absence of official Standard Operating Procedures (SOP) regarding the implementation of E-Puskesmas, as well as a lack of special training for officers to operate the application. The implications of these findings indicate the importance of preparing official SOPs and appropriatetraining to optimize the implementation of the E-Puskesmas Application System at the Tajinan Health Center, Malang Regency.
HUBUNGAN KELENGKAPAN DOKUMEN REKAM MEDIS DENGAN AKURASI CODING ICD -10 DI RUMAH SAKIT ISLAM MASYITOH BANGIL Robiatud Daniyah; Sri Erna Utami; Moch Ainul Khuluq
JRMIK Vol 5 No 1 (2024): JOURNAL OF MEDICAL RECORDS AND HEALTH INFORMATION
Publisher : Malang: Sekolah Tinggi Ilmu Administrasi Malang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.58535/jrmik.v5i1.65

Abstract

One of the authorities of medical recorders is to carry out a system of clinical classification and codification of diseases and must refer to regulations that have been issued by WHO. The purpose of this study was to analyze the factors that affect the accuracy of coding outpatient medical record documents at RSI Masyitoh Bangil. The independent variable in this study is the completeness of medical record documents consisting of patient identity, history, diagnosis, physical examination, treatment and action, supporting examinations, service plans. The type of research used is quantitative research, using bivariate analysis. The results and conclusions obtained there is a clearly proven relationship between the accuracy of ICD 10 outpatient document codification with physical examination at p value = 0.302. And there is a relationship between the accuracy of ICD 10 codefication of outpatient documents with supporting examinations with results with p value = 0.002. And there is a real relationship between the accuracy of ICD 10 codefication of outpatient documents with treatment and action with a p value = 0.006. The results of statistical tests with a Sig (P-Value) value of <0.25 in bivariate chi square analysis can enter the multivariate analysis stage.
FAKTOR YANG BERPENGARUH DARI PERANCANGAN SISTEM PENDAFTARAN ONLINE PASIEN UMUM DI RUMAH SAKIT KHUSUS BEDAH HASTA HUSADA KEPANJEN femy anggryani; Mashuri Dika Adi Saputro; Adi Santosa
JRMIK Vol 5 No 1 (2024): JOURNAL OF MEDICAL RECORDS AND HEALTH INFORMATION
Publisher : Malang: Sekolah Tinggi Ilmu Administrasi Malang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.58535/jrmik.v5i1.66

Abstract

The development of information and communication technology in the health sector is currently growing rapidly, as evidenced by the existence of an online registration system. The patient registration system at the Hasta Husada Special Surgical Hospital is still done manually, which requires patients to come to the hospital to register and have their data recorded by officers, then the patient waits to be called to be examined based on the queue number, this will take longer and can result in backlogs. patients in four patient registries. The aim of this research was to determine the influencing factors in designing an online general patient registration system basedm on WhatsApp API-gateway using the Wablas Website and WA Queue at the Hasta Husada Special Surgical Hospital. This research uses descriptive analytical research with a qualitative and quantitative approach. The data collection technique used is a questionnaire, then for problem solving using a fishbone diagram, from the problem the author has the idea to solve the problem by creating a WhatsApp-based online registration program with the Wablas Website and WA Queue, using the F test to determine the factors that influence the design of the registration system on line. The subjects in this study were 8 medical records officers in the registration section. The results of research using the Wablas Website and Queue WA applications show that the average scale for respondents is 2.60, where a scale of 2.60 is included in the agree category, so it is stated that respondents showed the highest score of 3.40, the criteria for agreeing in the ease of the patient registration process.It was concluded that the manual registration process for general patients at the Hasta Husada Special Surgical Hospital required the addition of a new registration system that could make things easier for staff and patients. As a consideration for the IT team and medical records officers to design a WhatsApp API-gateway based online registration system using the Wablas Website and WA Queue.
ANALISIS KEPUASAN PASIEN TERHADAP APLIKASI HARYOTO ONLINE DENGAN MENGGUNAKAN METODE EUCS Mohammad Arief Rachman; Febriannisa Fitroh Lisya Farasi
JRMIK Vol 5 No 1 (2024): JOURNAL OF MEDICAL RECORDS AND HEALTH INFORMATION
Publisher : Malang: Sekolah Tinggi Ilmu Administrasi Malang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.58535/jrmik.v5i1.67

Abstract

User satisfaction refers to the satisfaction felt by a user with a particular product, service, or experience. A person's satisfaction is simply formed by two components, namely the user's expectations of a product compared to the value the product has provided to the user. The purpose of this study was to determine patient satisfaction in using the Haryoto Online application using the End User Computing Satisfaction (EUCS) model. This study uses a descriptivemethod with a quantitative approach with a questionnaire instrument. Data collection was carried out by distributing questionnaires to 45 respondents using the Haryoto online application who use and utilize the application. The results show that in the ease of use dimension the patient is very satisfied, in the format, content and accuracy dimension the patient is satisfied and in the timeliness dimension the patient is neutral.

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