Jurnal Rekam Medis dan Informasi Kesehatan最新文献

Analisis Ketepatan Pengkodean Diagnosis Hipertensi Di Rumah Sakit Arjawinangun Arjawinangun 医院高血压诊断编码准确性分析

Jurnal Rekam Medis dan Informasi Kesehatan Pub Date : 2023-10-31 DOI: 10.31983/jrmik.v6i2.10585

Fitria Dewi Rahmawati

{"title":"Analisis Ketepatan Pengkodean Diagnosis Hipertensi Di Rumah Sakit Arjawinangun","authors":"Fitria Dewi Rahmawati","doi":"10.31983/jrmik.v6i2.10585","DOIUrl":"https://doi.org/10.31983/jrmik.v6i2.10585","url":null,"abstract":"Abstrak Salah satu target global penyakit tidak menular adalah menurunkan prevalensi Hipertensi sebesar 33% antara tahun 2010 dan 2030. Hipertensi merupakan salah satu standar pelayanan minimal (SPM) kesehatan di Indonesia. Angka Cakupan pelayanan kesehatan penderita hipertensi di Jawa barat tahun 2020 sebesar 34,7 % berdasarkan hasil pengukuran tekanan darah. Cakupan pelayanan kesehatan penderita hipertensi tertinggi di Jawa Barat terjadi di kota Cirebon. Pelaporan morbiditas kasus hipertensi di Rumah Sakit dibagi menjadi kode I10 dan I11-I15 pada ICD-10. Ketidakakuratan kode diagnosis akan mempengaruhi data dan informasi laporan, ketepatan tarif INA-CBG’s yang pada saat ini digunakan sebagai metode pembayaran untuk pelayanan pasien dengan asuransi atau jaminan. Dampak yang terjadi ketika terdapat ketidaktepatan dalam kode hasil verifikasi dari BPJS akan terjadi kelebihan pembayaran atau kekurangan pembayaran. Tujuan penelitian ini untuk mengetahui pelaksanaan kodifikasi pasien Hipertensi rawat jalan di Rumah Sakit Arjawinangun. Metode penelitian yang digunakan adalah deskriptif kuantitatif dengan desain penelitian analisis univariat. Pengumpulan data dengan menggunakan instrumen ceklist. Sampel penelitian sebanyak 73 pasien dari populasi kunjungan","PeriodicalId":485830,"journal":{"name":"Jurnal Rekam Medis dan Informasi Kesehatan","volume":"1 6","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-10-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135870029","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

Implementation of the Prolanis Online Health Service Management Information System Application (SIMPELPRO) at the Semarang City Public Health Center , Case Study at Padangsari Public Health Center Semarang City 在三宝垄市公共卫生中心实施Prolanis在线卫生服务管理信息系统应用程序(SIMPELPRO)，以三宝垄市巴东沙里公共卫生中心为例

Jurnal Rekam Medis dan Informasi Kesehatan Pub Date : 2023-10-31 DOI: 10.31983/jrmik.v6i2.10664

Setya - Wijayanta, Siti Masrochah, Subinarto Subinarto, Indah Naryanti

{"title":"Implementation of the Prolanis Online Health Service Management Information System Application (SIMPELPRO) at the Semarang City Public Health Center , Case Study at Padangsari Public Health Center Semarang City","authors":"Setya - Wijayanta, Siti Masrochah, Subinarto Subinarto, Indah Naryanti","doi":"10.31983/jrmik.v6i2.10664","DOIUrl":"https://doi.org/10.31983/jrmik.v6i2.10664","url":null,"abstract":"The government is working to reduce the prevalence of chronic diseases and prevent people with chronic diseases from entering the complication stage. One form of effort in this regard is through the chronic disease management program (Prolanis). So that the participants do not know the types of activities and schedules of Prolanis activities so that participants do not take advantage of them. The purpose of this study was to examine the implementation of the online prolanis service management information system application (SIMPELPRO) at the Semarang City Public Health Center, a case study at the Padangsari Public Health Center. This research method is descriptive, with primary data sources from interviews, documentation studies and literature. System design using the prototype method. Prototypes were made and evaluated, and continued to the implementation stage. The result of this study Has been developed using SIMPELPRO web based application for service management of Prolanis activities. The focus of the application in this research is still on the presentation of the health education materials. The development uses the prototype method with UML as a design tool. The application has received positives feedbacks from Prolanis participants, Although some participants have complainedabout limited access to smartphones and the need for assistance for elderly participants.","PeriodicalId":485830,"journal":{"name":"Jurnal Rekam Medis dan Informasi Kesehatan","volume":"54 ","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-10-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135871487","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

Analysis Of The External Cause Code Accuracy Case Of Injury In General Hospital PKU Muhammadiyah Bantul 北京大学综合医院外伤外因码准确性案例分析

Jurnal Rekam Medis dan Informasi Kesehatan Pub Date : 2023-10-31 DOI: 10.31983/jrmik.v6i2.10666

Kori Puspita Ningsih

{"title":"Analysis Of The External Cause Code Accuracy Case Of Injury In General Hospital PKU Muhammadiyah Bantul","authors":"Kori Puspita Ningsih","doi":"10.31983/jrmik.v6i2.10666","DOIUrl":"https://doi.org/10.31983/jrmik.v6i2.10666","url":null,"abstract":"The assignment of diagnosis codes and procedures must be done correctly to ensure the quality of medical records is met. What is often forgotten when giving a diagnosis code is the secondary code or external cause. This research aims to determine the recording, implementation and level of accuracy of external cause codes. Descriptive research method with a cross sectional design. The research sample was 48 injury medical record files. The research results showed that external cause information was documented on triage forms, emergency department assessments, initial adult inpatient nursing assessments, integrated patient progress notes, and discharge summaries. External cause coding is carried out by a coder with a medical record background in accordance with the SOP for coding implementation using electronic ICD-10 contained in SIMRS. The level of accuracy of the external cause code up to the 5th character (Category A) is 0%, the 4th character (Category B) is 38%, the 3rd character (Category C) is 27%, and the 1st character (chapter) (Category D) of 35%. The reason for the inaccuracy is because SIMRS does not accommodate coding up to the fifth character and the SPO does not yet indicate the officer's activity steps to determine up to the 5th character sub-category. It can be concluded that the accuracy of external cause coding at RSU PKU Muhammadiyah Bantul falls into the Fair criteria with an accuracy range of 20-40%.","PeriodicalId":485830,"journal":{"name":"Jurnal Rekam Medis dan Informasi Kesehatan","volume":"2008 9","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-10-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135813948","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

Analisis Kesesuaian Variabel dan Meta Data Rekam Medis Elektronik: Studi Kasus pada Instalasi Rawat Jalan Rumah Sakit X 变量一致性和电子医疗记录数据分析:X医院路检设施的病例研究

Jurnal Rekam Medis dan Informasi Kesehatan Pub Date : 2023-10-31 DOI: 10.31983/jrmik.v6i2.10640

Arief Azhari Ilyas, Zefan Adiputra Golo, Retnowati Retnowati

引用次数: 0

Analisis dan Perancangan Interoperabilitas Data Pemonitoran SPM (Standar Pelayanan Minimal) Bidang Kesehatan dengan Web Services 现场健康分流的分析和设计

Jurnal Rekam Medis dan Informasi Kesehatan Pub Date : 2023-10-31 DOI: 10.31983/jrmik.v6i2.10511

Farid Mahmudi

{"title":"Analisis dan Perancangan Interoperabilitas Data Pemonitoran SPM (Standar Pelayanan Minimal) Bidang Kesehatan dengan Web Services","authors":"Farid Mahmudi","doi":"10.31983/jrmik.v6i2.10511","DOIUrl":"https://doi.org/10.31983/jrmik.v6i2.10511","url":null,"abstract":"System interoperability is a key factor in the transformation of the minimum service standards (SPM) reporting system in the health sector. This article presents an in-depth analysis to design an Application Programming Interface (API) model that aims to increase the effectiveness of sending and reporting SPM data from primary health facilities under the district health office. Through analytical studies, we identified system interoperability needs at the district health department level, including aspects such as electronic medical record (EMR) data formats, minimum service standards, and patient identification systems. One of the main challenges is the diversity of data formats and sources that must be integrated. Based on this analysis, we designed an API specifically designed to facilitate the exchange of important data related to reporting minimum service standards in the health sector. The resulting API follows the principles of RESTful architecture, prioritizing scalability, flexibility, and security. API specifications include nationally recognized data standards for health reporting as well as stringent authentication and authorization systems to protect sensitive data. Initial implementation and testing results show that the proposed API successfully connects diverse health reporting systems with high effectiveness. Evaluation of API performance through measuring response time and resource usage indicates adequate performance for use in a production environment. Through the design of this API, it is hoped that it can increase interoperability between minimum service standard reporting systems in the health sector, reduce data duplication, and speed up the reporting process. The conclusions of this study underscore the important role of APIs in supporting healthcare quality, data-driven decision-making, and more efficient integration of medical systems.","PeriodicalId":485830,"journal":{"name":"Jurnal Rekam Medis dan Informasi Kesehatan","volume":"2014 18","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-10-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135813407","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

TINJAUAN KEJELASAN KELENGKAPAN PENULISAN DIAGNOSIS DALAM KETEPATAN PENGODEAN BERKAS PENDING KLAIM DI RSUD M.NATSIR SOLOK 2023 这是对在M.NATSIR SOLOK 2023年编写索赔文件的正确编码诊断的清晰审查

Jurnal Rekam Medis dan Informasi Kesehatan Pub Date : 2023-10-31 DOI: 10.31983/jrmik.v6i2.10505

Yulfa Yetno

引用次数: 0

Gambaran Metode HOT-FIT dalam Evaluasi ePuskesmas di UPTD Puskesmas I Denpasar Selatan 登巴萨南部UPTD Puskesmas评估的热配合方法

Jurnal Rekam Medis dan Informasi Kesehatan Pub Date : 2023-10-31 DOI: 10.31983/jrmik.v6i2.10450

Luh Yulia Adiningsih, Putu Erma Pradnyani, Putu Chrisdayanti Suada Putri, Coelestina Astri Bhoko

{"title":"Gambaran Metode HOT-FIT dalam Evaluasi ePuskesmas di UPTD Puskesmas I Denpasar Selatan","authors":"Luh Yulia Adiningsih, Putu Erma Pradnyani, Putu Chrisdayanti Suada Putri, Coelestina Astri Bhoko","doi":"10.31983/jrmik.v6i2.10450","DOIUrl":"https://doi.org/10.31983/jrmik.v6i2.10450","url":null,"abstract":"ePuskesmas merupakan aplikasi multi user dengan teknologi berbasis web yang memungkinkan untuk digunakan oleh lebih dari satu orang pengguna pada saat yang bersamaan. ePuskesmas mempermudah pencatatan dan pendataan pasien karena dilakukan secara elektronik. Puskesmas I Denpasar Selatan menyatakan bahwa masih terdapat permasalahan mengenai penerapan ePuskesmas. Tujuan dari penelitian ini adalah untuk melihat gambaran metode HOT-Fit dalam evaluasi ePuskesmas di UPTD Puskesmas I Denpasar Selatan. Metode penelitian yang digunakan dalam penelitian ini adalah deskriptif kuantitatif. Subjek penelitian dari penelitian ini adalah seluruh petugas yang menggunakan ePuskesmas yang berjumlah 32 responden. Variabel penelitian merupakan komponen HOT-FIT (Human, Organization, Technology, dan Net Benefit). Penelitian ini dilakukan di UPTD Puskesmas I Denpasar Selatan. Hasil penelitian ini didapatkan bahwa pada aspek Human yang menyatakan baik sebesar 62,5%, pada aspek Organisasi yang menyatakan baik 56%, pada Aspek Teknologi yang menyatakan baik dan kurang masing-masing 50%, dan pada aspek Net benefit yang menyatakan baik sebesar 68,8%. Secara keseluruhan gambaran metode HOT-FIT dalam evaluasi ePuskesmas di UPTD Puskesmas I Denpasar Selatan dapat dikatakan sudah berjalan baik, namun dalam aspek teknologi masih perlu ditingkatkan lagi.","PeriodicalId":485830,"journal":{"name":"Jurnal Rekam Medis dan Informasi Kesehatan","volume":"40 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-10-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135871013","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

Determinan Pengembalian Berkas Klaim Berdasarkan Akurasi Kode Diagnosis Pasien Rawat Inap BPJS Kesehatan di RSI Sultan Agung Semarang) 基于苏丹大三宝垄住院医保诊断码的准确性，确定索赔文件的退稿。

Jurnal Rekam Medis dan Informasi Kesehatan Pub Date : 2023-10-31 DOI: 10.31983/jrmik.v6i2.10633

Rizkiyatul Amalia, Sri Lestari, Angga Ferdianto, Prima Soultoni Akbar, Nabila Fardilan

{"title":"Determinan Pengembalian Berkas Klaim Berdasarkan Akurasi Kode Diagnosis Pasien Rawat Inap BPJS Kesehatan di RSI Sultan Agung Semarang)","authors":"Rizkiyatul Amalia, Sri Lestari, Angga Ferdianto, Prima Soultoni Akbar, Nabila Fardilan","doi":"10.31983/jrmik.v6i2.10633","DOIUrl":"https://doi.org/10.31983/jrmik.v6i2.10633","url":null,"abstract":"The Social Security Organizing Agency (BPJS) formed by the government aims to provide Health Insurance for the community through the JKN (National Health Insurance) program. BPJS makes payment to the Hospital, but when there is a discrepancy in the claim process, the file is returned. The primary key grouper results in INA-CBG's coding of diagnosis and action. Of the 111 claim files returned due to code discrepancies, 50 files with a percentage of 45%. The study aims to determine the determinants of claim file returns based on the accuracy of diagnostic codes and actions. The study used a retrospective approach method with an observational descriptive type. The sample used was 53 medical records for returning claim files in October 2022 using a simple random sampling technique. The instruments used are checklist sheets and observation sheets. Determination on the checklist sheet is assisted by expert analysis/expert validation. The results showed that the return of claim files based on the accuracy of the diagnosis code was 19% accurate and 81% inaccurate. The most influential causes of discrepancies in the diagnosis code are the absence of strong supporting examination results and discrepancies in the type of action or description in the operation report/anesthesia report.","PeriodicalId":485830,"journal":{"name":"Jurnal Rekam Medis dan Informasi Kesehatan","volume":"8 ","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-10-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135870888","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0