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MEDICORDHIF Jurnal Rekam Medis
Published by Akademi Perekam Medis dan Informasi Kesehatan Bhumi Husada Jakarta
ISSN : 26558955     EISSN : 22529616     DOI : 10.59300/mjrm.v7i0
Core Subject : Health, Education,
Education Health Professions Public Health Other
MEDICORDHIF Jurnal Rekam Medis is a Scientific Electronic Journal of the Medical Recorder and Health Information Academy of Bhumi Husada Jakarta (APIKES BHJ) in order to accommodate the research results of APIKES BHJ lecturers and students as well as other authors outside the APIKES BHJ institutions, as one of the goals of higher education institutions in Indonesia.The Medicordhif e-journal provides the widest opportunity for lecturers, researchers and authors in the scientific fields of medical records, health information, public health, hospital management and also health management to join in as an author in our MEDICORDHIF e-journal.
Arjuna Subject : Profesi Kesehatan - Profesi Kesehatan (Lain-Lain)
Articles 80 Documents
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Tinjauan Ketidaklengkapan Pengisian Resume Medis Pasien Rawat Inap di RS Setia Mitra Tahun 2018 Diaz Maulana; Hudiyati Agustini
MEDICORDHIF Jurnal Rekam Medis Vol 5 (2018): MEDICORDHIF Jurnal Rekam Medis
Publisher : APIKES Bhumi Husada Jakarta

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Abstract

ABSTRAK Based on preliminary observations carried out the medical records of the Setia Mitra Hospital in March 2018 of the 10 medical resumes observed were incomplete results with an average proportion of 14%. The purpose of this study was to find out the description of the incompleteness of filling out medical resumes of hospitalized patients at Setia Mitra Hospital. Specific Objectives, namely (1) identifying Standard Operating Procedures (SOP) filling in medical resumes of hospitalized patients. (2) identify the contents of the inpatient medical resume form. (3) calculate the number of incompleteness in filling out medical resumes of inpatients. The method used is descriptive method. Based on the results of research on 169 medical resume forms conducted at Setia Mitra Hospital, the authors can draw conclusions that the Setia Mitra Hospital has Standard Operating Procedures (SOP). There is a difference in the application of the part of the medical resume form in Setia Mitra Hospital, the application of which differs from the Standard Operating Procedure (SOP) that is established and also according to the provisions of the Komisi Akreditasi Rumah Sakit (KARS). The results of calculations according to quantitative analysis with a sample of 169 medical resumes from 293 medical resumes as a result of completing the medical resume form of incomplete inpatients 100% only reached the completeness value of 12% with an incomplete value of 88%. The author's suggestion is to evaluate the medical resume form so that it is in accordance with the provisions of the Komisi Akreditasi Rumah Sakit (KARS) so that the parts that must be filled are simpler, easier to fill and can be completed. Need to be re-socialized to medical personnel to fill out completely. If there is a section that cannot be completed, it is filled with the phrase "none" or with a sign "-" (stripe). Keyword: Incompleteness in filling out medical resumes of hospitalized patients
Tinjauan Pelepasan Informasi Medis Kepada Pihak Ketiga di Rumah Sakit Setia Mitra Lidia Kanaf; Hudiyati Agustini; Tite Kabul
MEDICORDHIF Jurnal Rekam Medis Vol 4 (2017): MEDICORDHIF Jurnal Rekam Medis
Publisher : APIKES Bhumi Husada Jakarta

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Abstract

ABSTRACT The health ministry`s regulation number 269 2008 on Medical Record, stating that Information about identity, diagnosis, history of disease, history of examination and history of treatment can be opened in accordance with the provisions. Based on the observations made, there is no official who handles the release of medical information and there is no specific responsibility for handling it, so the problem is: how the implementation of the release of medical information to the third party at Setia Mitra Hospital Jakarta ?. The purpose of this research is to know the process of releasing medical information to third party at Setia Mitra Hospital. This research was conducted by using descriptive design. Conclusion, Setia Mitra Hospital already has a policy on the release of medical information in the form of standard operational procedures and general consent form. However, there is no specific regulatory policy regarding the release of medical information. 73.7% of Medical Record Officers understand the importance of SPO (standard operational procedures) made and adhered to. In practice most of them are in accordance with the procedures and theories of health law, while not yet appropriate is the recording and the use of book of expedition and the absence of deadline for the use of written permission from patients. Keywords: the release of medical information
Tinjauan Kelengkapan Pengisian Persetujuan Tindakan Kedokteran Pasien Rawat Inap di Rumah Sakit Setia Mitra Hudiyati Agustini
MEDICORDHIF Jurnal Rekam Medis Vol 4 (2017): MEDICORDHIF Jurnal Rekam Medis
Publisher : APIKES Bhumi Husada Jakarta

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Abstract

ABSTRACT The purpose of this research is general to know completeness of filling in Approval of Medical Action form of inpatient at Setia Mitra Hospital. The specific objective is to identify the Standard Operating Procedures (SPO) on completing the Approval of Medical Action form, calculating the completeness of the completion of the Approval of Medical Action form and knowing the factors causing incomplete filling of the inpatient Approval of Medical Action forms at Setia Mitra Hospital. The research method used is descriptive method and the steps that are done is by collecting data, data classification or analysis, then make conclusions and reporting. Also conducted interview method to the head of medical record at Setia Mitra Hospital. From the results of the study, conclusions were concluded at Setia Mitra Hospital, which already had SPO filling out the Approval of Medical Action and there was an attempt to improve it better. Complete patient identification of 81,23% incomplete equal to 18,77%, complete medical treatment 100%, complete authentication 70% and incomplete 30%, complete recording complete 71,79% and an incomplete amount of 28.20%. Overall, the most complete is the important note that is filled 100% type of medical action, while the most incomplete component is complete 30% complete authentication. Factors that led to incompleteness according to the chief medical record interview were that doctors were busy checking patients so that they did not have time to complete the Approval of Medical Action form. Based on the results of this research, the filling out of Approval of Medical Action forms at Setia Mitra Hospital is still not good and needs to be improved. ABSTRAK Tujuan penelitian ini secara umum untuk mengetahui kelengkapan pengisian formulir persetujuan tindakan kedokteranpasien rawat inap di RS Setia Mitra. Tujuan khusus adalah mengidentifikasi standar prosedur operasional (SPO) tentang pengisian formulir persetujuan tindakan kedokteran, menghitung kelengkapan pengisian formulir persetujuan tindakan kedokteran dan mengetahui faktor- faktor yang menyebabkan ketidaklengkapan pengisian formulir persetujuan tindakan kedokteran pasien rawat inap di RS Setia Mitra. Metode penelitian yang digunakan adalah metode deskriptif dan langkah-langkah yang di lakukan adalah dengan pengumpulan data, klasifikasi pengelohan atau analisis data, kemudian membuat kesimpulan dan pelaporan.Juga dilakukan metode wawancara kepada kepala rekam medis di RSSetia Mitra. Dari hasil penelitian diambil kesimpulan di RS Setia Mitra sudah ada SPO pengisian persetujuan tindakan kedoktean dan sudah ada usaha untuk memperbaiki dengan lebih baik. Pengisian identitas pasien yang lengkap sebesar 81,23% yang tidak lengkap sebesar 18,77%, jenis tindakan kedokteran lengkap 100%, autentifikasi yang lengkap sebesar 70% dan yang tidak lengkap sebesar 30%, pencatatan yang baik yang lengkap sebesar 71,79% dan yang tidak lengkap sebesar 28,20%. Secara keseluruhan maka yang paling lengkap adalah catatan penting yaitu diisi 100%jenis tindakan medis, sedangkan komponen yang paling tidak lengkap adalah autetifikasi sebesar 30% yang diisi lengkap.Faktor- faktor yang menyebabkan ketidaklengkapan menurut wawancara kepala rekam medis adalah karena dokter sibuk untuk memeriksa pasien sehingga tidak punya waktu untuk melengkapi formulir persetujuan tindakan kedokteran. Berdasarkan hasil penelitian ini, pengisian formulir persetujuan tindakan kedokteran di RS Setia Mitra masih kurang baik dan perlu diperbaiki.
Tinjauan Kelengkapan Pengisian Persetujuan Tindakan Kedokteran Pasien Bedah Rawat Inap di Rumah Sakit Umum Pusat Persahabatan Ima Rusdiana
MEDICORDHIF Jurnal Rekam Medis Vol 4 (2017): MEDICORDHIF Jurnal Rekam Medis
Publisher : APIKES Bhumi Husada Jakarta

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Abstract

ABSTRACT Medical informed consent is a consent given by the patient. Based on the regulation of Health Minister No 290/MENKES/PER/III/2008 article 1, what it means of Medical informed consent is a consent given by the patient or closest family member after given a thorough information regarding medical/dental procedures that will be done in the hospital. Formulation of the research conducted in Persahabatan Hospital is to review the completeness of filling the surgical informed consent for hospitalized patient in Persahabatan Hospital. The aims of this study are divided in to 2 which are general and specific. General purpose is to know the completeness of filling the surgical informed consent for hospitalized patient in Persahabatan Hospital, while the specific aim is identification of medical informed consent completion in Persahabatan Hospital and analyze the data. The method used in this study is by using descriptive methods. This method is done with main purpose of to give an objective image about the problem. Descriptive study is used to solve or answer the current problem. The result stated that completion of the medical informed consent is complete and running. However, it has not been socialized to the inpatient installation or other unit facilities. Based on the result of this study there are 56 samples of the medical informed consent on Februari 2011 in Persahabatan Hospital. From that samples, there are 68.87% complete filling and 29.94% incomplete filling. ABSTRAK Tujuan penelitian ini dibagi menjadi 2 umum dan khusus yaitu Mengetahui kelengkapan pengisian persetujuan tindakan kedokteran pasien bedah rawat inap di RSUP Persahabatan dan tujuan khususnya yaitu Mengidentifikasi SPO tetang pengisian persetujuan tindakan kedokteran di RSUP Persahabatan. Menganalisis kelengkapan pengisian persetujuan tindakan kedokteran pasien bedah rawat inap di RSUP Persahabatan. Metode yang digunakan untuk penulisan ini adalah menggunakan metode deskriptif yaitu suatu metode penelitian yang dilakukan dengan tujuan utama untuk membuat gambaran atau deskripsi tentang suatu keadaan secara objektif . metode penelitian deskriptif digunakan untuk memecahkan atau menjawab permasalahan yang sedang dihadap pada situasi sekarang. Kesimpulan hasil penelitian di RSUP Persahabatan bahwa SPO Pengisian Persetujuan tindakan kedokteran sudah ada dan lengkap. Tetapi belum di sosialisasikan ke instalasi rawat inap maupun unit-unit terkait lainnya. Berdasarkan hasil penelitian rekam medis tentang kelengkapan pengisian persetujuan tindakan kedokteran pasien bedah sebanyak 56 sampel rekam medis pasien rawat inap di RSUP Persahabatan. Dari hasil kelengkapan pengisian tersebut yang lengkap 69,87 % dan yang tidak lengkap 29,94 %.
Tinjauan Lama Waktu Tunggu Pendaftaran di Tempat Penerimaan Pasien Rumah Sakit Kepolisian Pusat R.S. Sukanto Risky Adiprana; Gama Bagus Kuntoadi
MEDICORDHIF Jurnal Rekam Medis Vol 4 (2017): MEDICORDHIF Jurnal Rekam Medis
Publisher : APIKES Bhumi Husada Jakarta

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Abstract

ABSTRACT This research is based on several problems present, such as queue when the patient register at Patient Admission Center (TPP), the patient complain about the length of time required to wait for the process of activities performed at the time of registering at TPP, and the absence of standard waiting time of registration at TPP which can be used as reference by registration staff at RSKP R.S. Sukanto. The purpose of this descriptive study is to get an idea of ​​the length of waiting time of patients at registration at TPP Outpatient Unit RSKP R.S. Sukanto by observing patient waiting time at registration for new patient and old patient. As well as finding the cause of the long waiting time of registration in TPP Outpatient Unit. The observation is conducted for 9 working days, starting from 28 May to 8 June. From this study found that the average length of waiting time of patients when registering in TPP for new patients is 8 minutes, while for the old patient is 7 minutes. The source of the problem of the length of waiting time is caused by several factors, such as the old patient's inadvertence which often forgot to bring the medication card if will re-treatment, and the absence of standard time in reference in providing services at the time of registration of new and old patients in TPP Outpatient Unit . Another problem that was found was the lack of number of registration staff in TPP Outpatient Unit. Keywords: length of waiting time, patient registration, central police hospital ABSTRAK Penelitian ini dilatar belakangi oleh karena adanya beberapa permasalahan, seperti adanya antrian saat pasien melakukan pendaftaran di Tempat Penerimaan Pasien (TPP), adanya keluhan dari pasien terhadap lamanya waktu yang dibutuhkan untuk menunggu proses kegiatan yang dilakukan pada saat mendaftar di TPP, dan tidak adanya standar waktu tunggu pendaftaran di TPP yang dapat dijadikan acuan oleh staff pendaftaran di Rumah Sakit Kepolisian Pusat R.S. Sukanto. Tujuan dari penelitian deskriptif ini adalah untuk mendapatkan gambaran tentang lama waktu tunggu pasien pada saat pendaftaran di TPP Unit Rawat Jalan R.S.K.P R.S. Sukanto dengan cara mengamati waktu tunggu pasien pada saat pendaftaran untuk pasien baru dan pasien lama. Serta menemukan penyebab terjadinya lamanya waktu tunggu pendaftaran di TPP Unit Rawat Jalan.Pengamatan dilakukan selama 9 hari kerja, terhitung dari tanggal 28 Mei sampai 8 Juni. Dari penelitian ini ditemukan bahwa rata-rata lama waktu tunggu pasien saat mendaftar di TPP untuk pasien baru adalah 8 menit, sedangkan untuk pasien lama adalah 7 menit. Sumber permasalahan lamanya waktu tunggu yang terjadi disebabkan oleh beberapa faktor, seperti ketidakdisiplinnya pasien lama yang sering lupa membawa kartu berobat apabila akan berobat kembali, serta tidak adanya standar waktu yang menjadi acuan didalam memberikan pelayanan pada saat pendaftaran pasien baru dan lama di TPP Unit Rawat Jalan. Permasalahan lainnya yang ditemukan adalah kurangnya jumlah personel/staff bagian pendaftaran di TPP Unit Rawat jalan. Kata kunci: lama waktu tunggu, pendaftaran pasien, rumah sakit kepolisian pusat
Tingkat Produktivitas Petugas Pengambilan Rekam Medis RSUD Pasar Rebo Tite Kabul
MEDICORDHIF Jurnal Rekam Medis Vol 3 (2016): MEDICORDHIF Jurnal Rekam Medis
Publisher : APIKES Bhumi Husada Jakarta

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Abstract

ABSTRACT Retrieval relates to finding the requested medical records or records and location information. Productivity is the ratio between output and input. The General Objective is To know the productivity level of medical record taker officer of Pasar Rebo General Hospital. The variable in this research is the productivity of the medical record taker. The method of this research is done by descriptive research with survey approach. The results showed that the taking process by all officers has not been able to meet the target productivity of the medical record that should be obtained that is 183 medical records / day (100%). The average length of time to take one medical record is 1.53 minutes. Writer Suggestion is as follows: 1. It should be given understanding for officer of medical record about the importance of tracer recording. 2. It is necessary to review productivity-boosting factors such as giving superior motivation to subordinates, monitoring the discipline of medical records officer, work ethic, and good management. 3.The average time of 1.53 minutes can be applied as a standard of medical record for medical record request can be fulfilled and created maximum work from medical record taker officer of RSUD Pasar Rebo. 4. It is best for the future if the hospital can set the standard service time of each sub-service (registration to medical records to the clinic), in order to create the efficiency of medical records recorder. ABSTRAK Pengambilan atau retrieval berkaitan dengan menemukan catatan atau rekam medis yang diminta dan informasi lokasinya. Produktivitas adalah perbandingan antara output (hasil) dengan input (masukkan). Tujuan Umum Mengetahui tingkat produktivitas petugas pengambilan rekam medis RSUD Pasar Rebo. Variabel dalam penelitian ini adalah produktivitas petugas pengambilan rekam medis.Metode Penelitian yang digunakan ini, dilakukan dengan penelitian deskriptif dengan pendekatan survei. Hasil penelitian menunjukan bahwa pengambilan yang dilakukan oleh seluruh petugas belum dapat memenuhi target produktivitas pengambilan rekam medis yang seharusnya didapatkan yaitu 183 rekam medis/hari (100%). rata-rata lama waktu untuk mengambil satu rekam medis yaitu 1,53 menit. Saran Penulis sebagai berikut: 1. Perlu diberikan pemahaman bagi petugas pengambilan rekam medis tentang pentingnya pencatatan pada tracer. 2. Perlu ditinjau kembali faktor-faktor peningkat produktivitas seperti pemberian motivasi atasan terhadap bawahan, pemantauan disiplin kerja petugas rekam medis, etika kerja, serta manajemen yang baik. 3.Rata-rata waktu 1,53 menit dapat diaplikasikan sebagai standar pengambilan rekam medis agar permintaan rekam medis dapat terpenuhi dan tercipta kerja maksimal dari petugas pengambilan rekam medis RSUD Pasar Rebo. 4.Sebaiknya untuk kedepan rumah sakit harus menetapkan standar waktu pelayanan masing-masing sub bagian pelayanan (pendaftaran s/d rekam medis sampai ke klinik), agar tercipta efisiensi petugas rekam medis.
Perhitungan Kebutuhan Tenaga Berdasarkan Beban Kerja Dalam Pengurusannya Klaim Asuransi Rumah Sakit Asri Jakarta Garis Gemilang
MEDICORDHIF Jurnal Rekam Medis Vol 3 (2016): MEDICORDHIF Jurnal Rekam Medis
Publisher : APIKES Bhumi Husada Jakarta

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Abstract

ABSTRACT A medical record is a collection of facts or evidence of the patient's condition, past and present medical history and treatment written by the health profession that provides services to the patient. Asri Hospital is a specialized hospital for surgery and reproductive services. Based on observations made there is no special officer who handles the claim insurance and there are double jobs or one medical record officers do double jobs so there are jobs that are not resolved on time. The scope of this study regarding the calculation of personnel needs based on workload in the management of insurance claims Asri Hospital. The method used in this research is descriptive research method. Based on the results of the study, the amount of power generated based on WISN calculations required one medical record person to handle insurance claims. In order for the absence of double work, the job description in the Asri Hospital Medical Record Unit is renewed. Special consideration should be given to the addition of medical record officers and the management of insurance claims, as the medical records are confidential. ABSTRAK Rekam medis adalah kumpulan dari fakta-fakta atau bukti keadaan pasien, riwayat penyakit dan pengobatan masa lalu serta saat ini yang ditulis oleh profesi kesehatan yang memberikan pelayanan kepada pasien. Rumah Sakit Asri merupakan rumah sakit khusus bedah dan pelayanan reproduksi. Berdasarkan obervasi yang dilakukan didapat tidak ada petugas khusus yang menangani pengurusan klaim asuransi serta terdapat pekerjaan ganda atau satu orang petugas rekam medis mengerjakan pekerjaan rangkap sehingga terdapat pekerjaan yang tidak terselesaikan pada tepat waktu. Ruang lingkup penelitian ini mengenai perhitungan kebutuhan tenaga berdasarkan beban kerja dalam pengurusan klaim asuransi Rumah Sakit Asri. Metode yang digunakan dalam penelitian ini adalah metode penelitian deskriptif. Berdasarkan hasil penelitian, maka jumlah tenaga yang dihasilkan berdasarkan perhitungan WISN dibutuhkan satu orang tenaga rekam medis untuk pengurusan klaim asuransi. Agar tidak adanya pekerjaan ganda, maka uraian tugas di Unit Rekam Medis Rumah Sakit Asri diperbaharui kembali. Perlu pertimbangan khusus penambahan petugas rekam medis dan pengurusan klaim asuransi, mengingat rekam medis bersifat rahasia.
Implementasi Pengendalian Formulir Rekam Medis Pada SMF Bedah di RSUP Persahabatan Indah Kristina
MEDICORDHIF Jurnal Rekam Medis Vol 3 (2016): MEDICORDHIF Jurnal Rekam Medis
Publisher : APIKES Bhumi Husada Jakarta

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Abstract

ABSTRAK Pengendalian formulir rekam medis harus dilaksanakan di setiap rumah sakit agar terciptanya efisiensi formulir dan biaya pembuatan formulir di rumah sakit. Di RSUP Persahabatan belum dilaksanakan pengendalian formulir rekam medis. Terdapat formulir dengan kode yang berbeda namun dengan judul yang sama, desain formulir yang kurang sesuai dengan pedoman pembuatan formulir yang baik dan benar, serta formulir yang tidak terpakai pada rekam medis pasien tidak dimanfaatkan kembali pada rekam medis untuk pasien baru sehingga terlihat penumpukan formulir rekam medis. Tujuan penelitian ini adalah untuk mengetahui implementasi pengendalian formulir rekam medis pada SMF bedah di RSUP Persahabatan. Ruang lingkup penelitian di bagian rekam medis mengenai pengendalian formulir rekam medis. Metode yang digunakan dalam penelitian ini adalah metode penelitian deskriptif. Dari hasil penelitian yang dilakukan dapat diketahui bahwa formulir yang telah tercantum tanggal revisi ada 4 formulir yaitu formulir yang direvisi pada tahun 2010. Distribusi kelengkapan identitas pasien komponen yang paling tidak lengkap adalah bagian/ unit sebesar 84,61%, pada autentifikasi penulis, ketidaklengkapan nama petugas sebesar 30,76% dan ketidaklengkapan tanda tangan sebesar 38,46%. Desain, batas margin, dan jenis kertas serta huruf yang digunakan dalam formulir masih belum konsisten. Kesimpulan dalam penelitian ini adalah implementasi pengendalian formulir rekam medis di RSUP Persahabatan masih belum maksimal. ABSTRACT Control of the medical record should be performed in each hospital to ensure the efficiency of forms and the efficiensy of cost to make the form in the hospital. RSUP Persahabatan have not conducted control of medical record form. There is a form with a different code but with the same title, the design of the form is not in accordance with the guidelines for making a good and correct form, and the unused form on the patient's medical record is not reused in the medical record for the new patient so there’s a stacking of unused medical record . The purpose of this research is to know the implementation of medical record form control at SMF Surgery in RSUP Persahabatan. The scope of the research is in the medical record form control. The method used in this research is descriptive research method. From the results of the research conducted it can be seen that the form that has been listed, based on revision date there are 4 forms, namely the form that was filled in 2010. The distribution of the completeness of the patient identity of the most incomplete component is the part / unit of 84.61%, the authors authentication, Officers by 30.76% and incomplete signatures by 38.46%. The design, margin, and type of paper and letters used in the form are still not consistent. The conclusion that can be given in this research is the implementation of medical record form control at RSUP Persahabatan is not yet maximal.
Pelaksanaan Kode Penyakit dan Kode Tindakan di Klinik Bedah Rumah Sakit Umum Daerah Pasar Rebo Hudiyati Agustini; Sintiawati Agustina
MEDICORDHIF Jurnal Rekam Medis Vol 3 (2016): MEDICORDHIF Jurnal Rekam Medis
Publisher : APIKES Bhumi Husada Jakarta

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Abstract

ABSTRACT In RSUD Pasar Rebo, medical record procedure is as follows, registration is done by Cashier Section, Medical Record Installation has a function as storage place of medical record, assembling, quantitative analysis, qualitative analysis, and hospitalization coding. Data processing is done by SIM Section (Management Information System ), Whole coding The outpatient installation includes a surgical clinic performed by nursing staff. The number of patient visits per day at the surgical clinic is 56 patients, as long as the coding done by the Nurse there are many incomplete coding actions. The formulation of this research problem is how the implementation of disease code and code of operations in Surgical Clinic of Pasar Rebo Regional General Hospital. General purpose of the research to find out the implementation of disease code and surgical procedure of surgical patient's clinic at Pasar Rebo Regional General Hospital. Methods using descriptive analytics. The observed aspect is to determine the number of medical records with the inaccuracy of disease coding and operations codes and to analyze whether the code of action chosen by the coder is in accordance with ICD 9 CM. ABSTRAK Di RSUD Pasar Rebo, prosedur rekam medis sebagai berikut, pendaftaran dikerjakan oleh Bagian Kasir, Instalasi Rekam Medis mempunyai fungsi sebagai tempat penyimpanan rekam medis, assembling, analisis kuantitatif, analisis kualitatitif, koding rawat inap, Pengolahan data dikerjakan oleh Bagian SIM (Sistem Informasi Manajemen), Koding seluruh Instalasi rawat jalan termasuk klinik bedah dilakukan oleh tenaga keperawatan. Jumlah kunjungan pasien perhari di klinik bedah adalah 56 pasien, selama koding dikerjakan oleh Perawat terdapat banyak ketidaklengkapan pengkodean tindakan. Rumusan masalah penelitian ini adalah bagaimana pelaksanaan kode penyakit dan kode tindakan di Klinik Bedah Rumah Sakit Umum Daerah Pasar Rebo. Tujuan Umum penelitian untuk mengetahui pelaksanaan kode penyakit dan kode tindakan pasien klinik bedah di Rumah Sakit Umum Daerah Pasar Rebo. Metode menggunakan deskriptif analitik. Aspek yang diamati adalah menentukan jumlah rekam medis dengan ketidaktepatan pengkodean penyakit dan kode tindakan serta menganalisa untuk melihat apakah kode tindakan yang dipilih oleh pengkode sesuai dengan ICD 9 CM.
Kelengkapan dan Keakuratan Sertifikat Medis Penyebab Kematian di Rumah Sakit Umum Pusat Fatmawati Yuni Marugun; Gama Bagus Kuntoadi
MEDICORDHIF Jurnal Rekam Medis Vol 2 (2015): MEDICORDHIF Jurnal Rekam Medis
Publisher : APIKES Bhumi Husada Jakarta

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Abstract

Abstract Fatmawati Central General Hospital (RSUP) is a government’s hospital of type A which has the purpose of providing a full service. To achieve its objectives, the RSUP Fatmawati will always strive to improve the quality of service, including providing complete and accurate medical information. To achieve the full service, RSUP Fatmawati has work units that have their duties and obligations. One of them is Medical Record Installation and Health Information (IRMIK) which one of its duty is to make monthly report of mortality. In order to create a good and complete mortality report, IRMIK requires a complete and accurate data source in the form of Medical Cause of Death Certificate (SMPK) from Forensic Installation (IFPJ). From the initial research found the existence of some SMPK columns that are not filled completely by the doctor in charge. The incompleteness of filling the SMPK in Fatmawati Central General Hospital is the reason behind this followed research. The research was conducted in May 2013 located in RSUP Fatmawati, South Jakarta, Indonesia. The research was conducted using qualitative descriptive approach by focusing on completeness and accuracy of SMPK form filling. From the result of the research, it was found that most of the incompleteness of the contents occurred in the Population Identity Number column as much as 100%, then in the cause of death collum also found not fully filled, so it can be concluded the average completeness of filling of Medical Cause of Death Certificate in RSUP Fatmawati in May 2013 is 84%. Keyword : medical record, medical cause of death certificate, incompleteness, inaccuracies

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