Asesmen

a complete medical record reflects the quality of good documentation, the complete of diagnosis writing reduces incorrect and inaccurate code and appropriate reporting to support decision makers. this study aims to measure the completeness and accuracy of the death code and the basic cause of death of patients. This study uses a quantitative descriptive design using a completeness checklist instrument. researchers used secondary data from the medical records of patients who died in 2021, the total sample was 199 using the slovin formula. secondary data analyzed with STATA, presented with tabulations and descriptive narratives. the basic cause of the basic cause of death was highest in code J80 at 33 (17%), J12.8 at 21 (11%) and the third being E11.9 . Based on the category of completeness of filling out of the 199 medical records analyzed, there were 37% (75) death forms that were not filled in completelyrekam medis yang lengkap mencerminkan kualitas pendokumentasian, kelengkapan penulisan diagnosis meminimalisir kesalah dan kode tidak akurat, dan juga berpengaruh pada kualitas pelaporan guna mendukung pemangku kebijakan. Penelitian ini bertujuan mengukur kelengkapan dan kealuratan kode penyebab pasien meninggal. Penelitian ini menggunakan rancangan deskriptif kualitatif, instrumennya dengan checklist kelengkapan. Peneliti menggunakan data sekunder dari rekam medis pasien meninggal tahun 2021, total samplenya sebesar 199 diukur dengan rumus slovin. Data dianalisis dengan STATA, disajikan dalam bentuk tabulasi dan narasi deskriptif. Hasil asesmen diagnosis tertinggi pada kode J80  sebesar 33 (17%), tertinggi kedua yaitu J96.8 yaitu 21 kasus (11%). Untuk penyebab dasar penyebab dasar pasien meninggal tertinggi pada kode J80 atau Adult respiratory distress syndrome sebesar 33 (17%), J12.8 sebesar 21 (11%) dan ketiga yaitu E11.9 atau diabetes mellitus unspecified. Berdasarkan kategori kelengkapan pengisiannya dari 199 rekam medis yang dianalisis, terdapat 37% (75) formulir kematian yang tidak terisi lengkap. Apabila di asesmen secara rinci, terdapat  terdapat 15% (30 kode) kode terisi lengkap namun akurat tidak akurat, meskipun prosesntase kelengkapan dan keakuratan kode hingga karakter ke 4 mencapai 80% (161 kasus)

IDENTIFIKASI DOKUMEN PEMENUHAN STANDAR MANAJEMEN KOMUNIKASI DAN INFORMASI (MKI) DALAM AKREDITASI KARS 2012 DI RSUP Dr. SARDJITO YOGYAKARTA

Background : Accreditation aims to improve the quality of health care, which is needed by the people of Indonesia are increasingly selective and deserve quality services . As a basic start of construction on the hospital system , which is a regulatory document required in the hospital . Preparation of documents as a key point in the regulation of hospital accreditation , as a reference for the hospital services . With the provision of written policies , guidelines and procedures so that the interests of public health services can be satisfied with the best . The implementation of hospital accreditation survey conducted by the 2012 version KARS will be emphasized on the implementation of the hospital , which was done by interviewing the patient and his or her family , as well as to the Chairman and the hospital or hospital staff , also by means of On-site observations of service activities , as well as to see the physical evidence , either in the form of documents and hospital facilities . In line with the increasing demands of society and the Government of the information and communication needs of the health services provided , the department of the hospital Dr . Sardjito need to perform compliance assessment elements in Management Communication and Information in 2012 KARS accreditation standards to facilitate access to services and access to information on patient care services . Objective : To identify the document Standards Compliance Management Communication and Information in 2012 KARS Accreditation at Dr . Sardjito Hospital. Research methods : The study was a descriptive study with a qualitative approach , and cross-sectional study design . Subjects were examined in this study is Team Management Communication and Information Working Group . While the object of this study of MKI standard is a document , there are form of policies, , guidelines and medical record form. Results : Of the documents that have been identified , Dr . Sardjito Hospital lis able to support working group based standards for accreditation KARS has largely complete the appropriate standards document of Management Communication and Information

ANALISA PENYEBAB KETERLAMBATAN INPUT KODEFIKASI INDEKS PENYAKIT PASIEN RAWAT JALAN DI RUMAH SAKIT BETHESDA YOGYAKARTA

The Background of Problem: The hospital is a health care facility for all the community, the main purpose of the hospital is to produce a favorable outcome, the outcome obtained depends on the quality of services provided. To take the necessary decisions with accurate information and timely to be a report. Indexing activity is one activity of a series of activities if the data reporting, ie the index is a list of important words or terms that have the same keywords, the indexing activities at the hospital include the index patient, disease index, and the index physician. In the disease index performed using manual coding of ICD-10. Based on the results of the study are documentation-recapitulation recapitulation daily census outpatients who have not been in the code and input into computer for indexing activities and materials reporting morbidity outpatient basis. The Aim of Research: To know the process of implementing the index coding of outpatient illness include charging diagnosis, inputting code outpatient disease, treatment and study data. To determine the factors causing delays in inputting coding of outpatient illness index at Bethesda Hospital and determine the impact of the delay in inputting coding of outpatient illness index at Bethesda Hospital. The Methodology of Research : Type of research used is descriptive research with a qualitative approach to data collection in the study of documentation, interviews, and observations. The study design is case study research. For the validation data using triangulation sumber.penentuan subject and object using purposive sampling. This research was conducted at Bethesda Hospital Yogyakarta. The Result of Research: Based on interviews, the process of filling the diagnosis on the medical record file is done by physicians who care for patients, charging diagnostics on the computer for recapitulation daily census is an outpatient clinic nurse. Inputting a code of disease carried by medical records personnel morbidity outpatient coding part. processing and presentation of data processing that include: coding, indexing, and then processed into outpatient morbidity report, presenting data that has been processed by the results of the interview are reported net patient morbidity (RL4B). Based on interviews the causes of the lack of human resources in terms of man to the census section, in terms of machines already support, there are constraints in terms of material but can be addressed independently by a clinical nurse, method discrepancy between the written standard operating procedures at Bethesda Hospital with officers in the field conditions . Based on interviews the impact of input delay codefication disease index was RL4B delayed delivery report (a report of outpatient morbidity) and incompleteness of data RL4B (outpatient morbidity reports

ANALISIS KUALIFIKASI DAN PENDIDIKAN STAF REKAM MEDIS DALAM MENGHADAPI AKREDITASI RUMAH SAKIT DAN AKREDITASI JCI DI RSUP DR.SARDJITO YOGYAKARTA

Background: The hospital requires quite a lot of people with different skills, and people who are competent to carry out the mission of the hospital and meet the needs of patients. Hospital administrators worked together to determine the number and type of staff needed based on the recommendations of the working unit and the service director. Recruitment, evaluation and assignment of staff to do their best through a process coordinated, efficient and uniform. Also it is important to document the skills, knowledge, education, and previous experience of the applicant. Particularly important to carefully reviewing/ doing the credentials of medical staff and nurses, because they are involved in the clinical care process and work directly with patients. Hospitals should provide opportunities for staff to learn and develop personality and professionalism. Therefore, in-service education and other learning opportunities should be offered to staff. The author has conduct eda preliminary study in Dr.Sardjito Hospital on December 24, 2013. Researchers conducted a preliminary study in the department of Dr.Sardjito because the hospitalis in the processof accreditation. In addition, the department has established long Dr.Sardjito even before the legislation related to medical records and medical recorder existinginstitutions.Therefore, RSUP Dr.Sardjito has medical records staff who have worked and served long over there. That means that there are some medical records staff at DrSardjito who have the educational background of non medical recorder. Based on the background and the preliminary study, the authors are interested in studying and reviewing more about the accreditation standards that the group II chapter 5 Qualifications and Education staff in the department of medical records in particular RSUP Dr.Sardjito Objective: This study aims to determine the fulfillment of qualification and education of medical records staffin the face of hospital accreditation and accreditation in the department RSUP Dr.Sardjito. Research Methods: This type of researchis adescriptive study with a qualitative approach, and cross-sectional study design. Subjects examined in this design is the Chief Medical Record, and medical record sclerk. The object of research his the personnel file, the data kredensialing, document verification and STR diploma from the original source, and document review staff when there is an indication of the findings related to hospital quality improvement efforts. Results: Dr.Sardjito Hospital has implemented a hospital accreditation and JCI accreditation in 2014. The entire staf fof medical records are generally involved in the preparation of hospital accreditation and accreditation JCI, but only 3 teams that go into Standard Team. From a total of 101 medical record staffs, there are 22 staffs with education past high school when registering as RSUP Dr.Sardjito Hospital staf fand 20 staffs who do not have STR and SIK. In addition, the medical records staff credentials already done so in 2012

PEMANFAATAN LAPORAN DARI INSTALASI REKAM MEDIS BAGI PENGAMBILAN KEPUTUSAN MANAJEMEN RSU PKU MUHAMMADIYAH BANTUL

Background: The medical records used in patient care management, quality review, financial reimbusement, legal affairs, education, research, public health planning and marketing. Surely reports from the medical record installation has important uses for the hospital. Based on initial observations, researchers found that in the RSU PKU Muhammadiyah Bantul have made various types of reports regularly. But the benefits of any report made in the medical record installation for RSU PKU Muhammadiyah Bantul not yet known. Therefore, researchers need to know whether the report made by the medical records official utilized by RSU PKU Muhammadiyah Bantul to make management decisions. Goals: To determine the benefits of a report from the Medical Record Installation for decision making management in RSU PKU Muhammadiyah Bantul. Methods: This type of research is a descriptive study using a qualitative approach with a cross-sectional design. The technique of collecting data using interviews, observation and documentation studies. The subjects were reporting officer and the management of RSU PKU Muhammadiyah Bantul. Object of this study is the report of the Installation Medical Record. Results: Reports made by the reporting officer served in a board meeting in three month period and includes an outpatient clinic patient visits per month grouped by the type of patient is new or old, a number of hospitalizations of patients per ward per month, Hospital Efficiency (BOR, LOS , TOI, BTO, GDR, and NDR), Report on surgery, obstetrics care unit report, 10 Major Diseases (Inpatient, Outpatient, ER, cause of death), patient mortality rate (ER and Inpatient), laboratory examination activities, radiology activities, medical rehabilitation services, prescription writing and services, and number of patient visits per sub districts in Bantul. Medical Record Officer assigned to recapitalize the report of each unit of service to be presented to management. Reports are presented in graphical form as a board meeting, and submitted to management in the form of summary reports in tabular form. The report presented by medical records officers have been able to simplify the management to analyze and make decisions. However, there is still a delay in the presentation of a report due to SIRS is not optimal. And not every unit has a summary report made by medical records officers

PERSEPSI PENGGUNA TERHADAP SISTEM INFORMASI MANAJEMEN RUMAH SAKIT (SIMRS) TERKAIT SENSUS HARIAN RAWAT INAP RUMAH SAKIT UMUM DAERAH KOTA YOGYAKARTA

Background: Inpatient daily census in RSUD Yogyakarta done by a nurse in a treatment room manually. Although the menu daily inpatient census was found in SIMRS but not optimally utilized for the implementation constraints are found, that is daily inpatient census mismatch manual with daily inpatient census is in SIMRS. This is possible due to the human factor. Therefore, it is necessary to evaluate the human resources as the user in the implementation of Hospital Management Information System related hospital inpatient daily census in Local Government General Hospital Yogyakarta. Goal: To knowing the user perception in implementing management information system-related hospital inpatient daily census in Local Government General Hospital Yogyakarta. Method: This type of research is descriptive qualitative approach. The study design was cross-sectional. Data collection techniques in this study were interviews, observation, and study documentation. Result: Daily census of inpatient treatment in Yogyakarta in-RSUD first input by the staff in computerized inpatient register through SIMRS, then the nurses make SHRI manually and then submitted to the Installation Medical Record to be processed. Daily census of inpatient treatment not in accordance with the procedures contained in the SOP job or Procedures RSUD Yogyakarta. SIMRS related SHRI in RSUD Yogyakarta useful to users because make work more quickly, useful, enchance effectiveness, improve job performance, and makes job easier. However, for productivity and employment hasn�t increased due to the relatively fixed data quality doesn�t match the quality of real data so it can�t be a reference data. SIMRS related SHRI in RSUD Yogyakarta makes it easy for users because it is easy to learn, easy to use, easy to become skillful, and flexible. However, for the indicator clear and understandable controllable and can�t be fulfilled because of the absence of a policy regarding the return flow inpatients correct. The attitude of the user of the Hospital Management Information System in Yogyakarta City Hospital has been rated good and the users want to use. But the Hospital Management Information System related inpatient daily census has not been enough to satisfy users. Interest in user behavior Hospital Management Information System related daily census of inpatient hospital Yogyakarta that want to follow training on SIMRS