Jurnal Rekam Medik & Manajemen Informasi Kesehatan
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Penerapan Hukum Benford Dalam Mendeteksi Potensi Fraud Pada Data Klaim JKN Rawat Inap Di RS X
Full text linkFraud in healthcare services is any form of deception carried out by various parties in healthcare services to gain personal benefits beyond the profits obtained from normal practices. At RS X, there is a team called the National Health Insurance (JKN) Fraud Prevention Team, which functions to ensure that the quality of healthcare services provided meets the applicable standards. One of the methods to analyze the distribution of abnormal data in a dataset is by using the concept of Benford's Law. The purpose of this research is to detect potential fraud in inpatient JKN claim data at RS X using Benford's Law. The type of research used is descriptive quantitative research. The population in this study is the JKN inpatient claim data for the period from August 2024 to October 2024, consisting of 11,789 rows of data. The use of Benford's Law to examine the differences in the "Hospital Rate" values shows that there is no difference in the pattern between the actual frequency and the expected frequency according to Benford's Law. The hypothesis test using chi-squared where the null hypothesis of the study is accepted, namely that the first digit numbers in the "Hospital Rates" column from August to October 2024 are distributed according to Benford's law
TINJAUAN PELAYANAN LAMA WAKTU PASIEN JKN BAGIAN TPPRJ DI RS PANTIWILASA DR. CIPTO SEMARANG TAHUN 2024
Full text linkWaktu tunggu merupakan faktor yang berpotensi menyebabkan ketidakpuasan terhadap pelayanan pasien JKN di Rumah Sakit. Waktu tunggu pelayanan Unit pendaftaran RS Pantiwilasa dr. Cipto Semarang cenderung lama. Penelitian bertujuan untuk mengetahui waktu tunggu pelayanan sistem BPJS pendaftaran rawat jalan di RS Pantiwilasa dr. Cipto Semarang. Jenis penelitian yang digunakan adalah deskriptif kuantitatif melalui wawancara dan observasi. Subjek penelitian ini adalah tiga petugas pendaftaran rawat jalan. Hasil penelitian menunjukkan petugas pelayanan pendaftaran pasien rawat jalan berusia produktif, lulusan SMA, dan mengikuti pelatihan setahun sekali. Kendala pada sarana di Unit Pendaftaran Pasien Rawat Jalan adalah komputer lambat dan fingerprint tidak terbaca. Waktu tunggu pelayanan pendaftaran rawat jalan pasien BPJS yang terlama adalah 63 menit, waktu tersebut lebih dari standar pelayanan minimal kurang dari 60 menit
PERANCANGAN SISTEM INFORMASI REKAM MEDIS ELEKTRONIK DALAM PELAPORAN 10 BESAR PENYAKIT RAWAT JALAN DI RSIA YASMIN PALANGKARAYA
Full text linkThis study aims to design an electronic medical record information system to support the reporting of the top ten outpatient diseases at RSIA Yasmin Palangkaraya. The previous reporting process was still manual using Microsoft Excel, resulting in delays and inefficiencies. This research used a qualitative method with a waterfall system development approach. Data were collected through observation, interviews, and literature study. The result is an electronic-based information system design that includes flowmap, context diagram, level 0 DFD, and ERD, which aims to improve the effectiveness, efficiency, and accuracy of medical data reporting. This system is expected to help hospitals comply with digital reporting obligations in accordance with existing regulations
Gambaran Penyebab Pending Claim BPJS Kesehatan Akibat Ketidaktepatan Kode Diagnosis di Rumah Sakit Universitas Sebelas Maret (UNS)
Full text linkIn the process of submitting a BPJS Health claim, not all files submitted can be claimed. Claim status is declared ineligible or pending. A pending claim occurs if the claim file submitted by the hospital is incomplete or does not comply with the requirements set by BPJS Health. Delayed claims can disrupt hospital cash flow and cause losses for the hospital and BPJS Health participants. This research aims to describe the causes of pending claims at UNS Hospital. This research is a quantitative descriptive study with a population of 182 inpatients pending claim files at UNS Hospital for the period August-October 2023. The sample for this research is 78 pending claim files based on diagnosis code verification. The sampling technique is total sampling. Based on the data obtained, the number of files with coding confirmation is 78 pending claim files or 11.3% of the total pending claims in the period August – October 2023. This data shows that the majority of pending claim files are due to inaccurate diagnosis. The factor causing pending claims from BPJS Health inpatients at UNS Hospital occurs due to differences in perception between hospital staff and BPJS Health and is not purely due to coder error, but due to a lack of supporting data as a diagnosis enforcer which affects the accuracy of the code
Keamanan Sistem Informasi Rekam Medis Elektronik Di Rumah Sakit Islam Jakarta Sukapura
Full text linkThe implementation of Electronic Medical Records (EMR) in all health service facilities is outlined in Minister of Health Regulation Number 24 of 2022, with a deadline of 31 December 2023. Ensuring the security of EMR is vital to protect patient data privacy, prevent unauthorized data access, and avoid breaches. This study evaluates the security practices of EMR systems at the Islamic Hospital Jakarta Sukapura using a descriptive qualitative research method with seven informants. The study focuses on six key aspects of EMR security: privacy, integrity, authentication, availability, access control, and non-repudiation. The results show that the hospital has established security procedures, such as using usernames and passwords, but there are significant areas for improvement. The study notes the need for automatic logout features to prevent unauthorized access when computer screens are left unattended and emphasizes the importance of regularly updating passwords to improve security, as well as hospitals using encryption and firewall technologies to protect data during transmission and storage. Apart from this, research shows that some staff members still use default passwords, posing a security risk. Overall, this study provides recommendations for strengthening RME security frameworks in hospitals
ANALISIS ASPEK KEAMANAN DATA PASIEN DALAM IMPLEMENTASI REKAM MEDIS ELEKTRONIK DI RUMAH SAKIT X
Full text linkRekam kesehatan berbasis komputer merupakan rekaman pasien secara elektronik untuk mendukung pengguna mengakses secara lengkap & akurat. Manfaat rekam medis elektronik (RME) sangat penting tetapi terdapat beberapa ancaman yg menjadi perhatian khusus dpt berdampak merugikan. Pencurian data kesehatan mengalami peningkatan menjadi permasalahan serius. Berdasarkan observasi & wawancara ditemukan permasalahan dari aspek keamanan di Rumah Sakit X. Tujuan penelitian untuk menganalisis aspek keamanan data pasien dlm penerapan RME berdasarkan aspek kerahasiaan, integritas, autentikasi, ketersediaan, akses kontrol, nir-sangkal. Penelitian menggunakan pendekatan kualitatif, pengumpulan data melalui wawancara, observasi, dokumentasi dgn subjek penelitian 7 responden. Data dianalisis dg reduksi data, penyajian data & kesimpulan. hasil menunjukkan bahwa keamanan dari aspek kerahasiaan yaitu login menggunakan username & password namun belum melakukan penggantian secara berkala serta belum adanya SOP. Dari aspek integritas terdapat fitur edit data untuk pengguna sesuai tupoksi, edit data dlm jumlah besar tidak dapat dilakukan secara langsung namun harus sesuai SOP. Aspek Autentikasi sudah menerapakan tanda tangan elektronik bersertifikat menjamin keabsahan. aspek ketersediaan RME hanya ddt diakses dilingkungan rumah sakit dengan VPN sehingga mudah diakses. Aspek kontrol akses untuk membatasi hak akses pengguna diterapkan username & password. Aspek Nir-sangkal terdapat riwayat bagi pengguna yg mengakses data pasien
Gambaran Penerapan PERMENKES Nomor 55 Tahun 2013 tentang Penyelenggaraan Pekerjaan Perekam medis dalam Pengkodean Diagnosis Medis dan Tindakan di Puskesmas Surabaya Timur
Full text linkPerekam medis dan Informasi Kesehatan merupakan tenaga kesehatan yang wajib ada dalam penyelenggaraan pelayanan kesehatan dan sesuai dengan PERMENKES RI No. 55 tahun 2013. Penelitian ini dilakukan pada lima Puskesmas yang berada di wilayah Surabaya Timur dengan tujuan untuk mengetahui penerapan PERMENKES RI No. 55 tahun 2013 Pasal 13 ayat 3 tentang penyelenggaraan pekerjaan Perekam medis dalam melaksanakan sistem klasifikasi klinis dan kodefikasi penyakit yang berkaitan dengan kesehatan dan tindakan medis seusai dengan ICD-10 dan ICD-9. Jenis penelitian ini adalah penelitian deksriptif dengan pendekatan kualitatif. Pengumpulan data dilakukan melalui wawancara dan observasi pada petugas Perekam medis yang melakukan klasifikasi klinis dan kodefikasi penyakit. Hasil penelitian menyatakan bahwa Perekam medis dalam melakukan pengkodingan di Puskesmas wilayah Surabaya Timur tidak melakukan pengkodingan diagnosa medis dan tindakan tetapi hanya sebatas pengecekan ulang koding yang sudah diisi oleh dokter, perawat atau unit terkait yang memberikan pelayanan, dalam hal ini masih belum sesuai dengan PERMENKES No. 55 Tahun 2013 Pasal 13 Ayat 3 tentang penyelenggaraan pekerjaan Perekam medis, yang harusnya Perekam medis melakukan pengkodingan. Sosialisasi tentang pelaksanaan pekerjaan Perekam medis untuk mempunyai kewenangan dalam melaksanakan sistem klasifikasi klinis dan kodefikasi penyakit yang berkaitan dengan kesehatan dan tindakan medis sesuai terminologi medis yang benar sangat diperluka
Analisis Kelengkapan Pengisian Ringkasan Pulang Terhadap Kelancaran Klaim Badan Penyelenggaraan Jaminan Sosial Kesehatan di Rumah Sakit PTPN VIII Subang
Full text linkOne of the existing forms of one of the medical records is a discharge..sumaary containing the patient's clinical data. The purpose of this study is to identify the completeness of filling out the discharge summary sheet of the medical record of the patient of the BPJS hospital in the PTPN VIII Subang hospital in 2021. This type of study is a descriptive quantitative study. Randomized Sampling Technique The population of this study is a summary extract from the medical record of patient. The sample in this study is 84 discharge forms of a patient, the results showed the completeness of filling in the patient's identification by date of birth by 95% and by gender equal to 78%. The completeness of completion of the important report for the obsolete element is 79%, and for the input of the diagnostic element - 67%. The completeness of authentication for the item Date of completion is 72%, and for the item "Doctor's..name" - 87%. Correct documentation of bug fixes is 99%, and records are clear and readable at 82%. The effect of the completeness of the repayment summary on BPJS claims is current 39% and not smooth 61%
Strategi Pencegahan Missfile Pada Rekam Medis Dilihat Dari Unsur 5M di RSAU dr. Sukirman Lanud Roesmin Nurjadin Tahun 2021
Full text linkoai:ojs2.rammik.pubmedia.id:article/2In the medical record filling section of RSAU dr. Sukirman Air Base Roesmin Nurjadin in the last few days found 5 missfile events. Missfile is an error in placing medical records, incorrectly storing medical records, or not finding medical records in the storage section. The purpose of this study was to determine the missfile prevention strategy based on the 5M element at RSAU dr. Sukirman Air Force Base Roesmin Nurjadin. This type of research is descriptive with a qualitative approach. Methods of data collection using interviews and observation. Informants in this study amounted to 3 people, namely the head and staff of medical records. From the research conducted in the filling section, it was found that two medical record officers with a D III education level in Medical Records and Health Information who had worked for a long time ranged from 4-5 years. But have never received training from a hospital. There is no use of tracers, color codes, and expedition books, only outpatient register books. There is a budget for facilities and infrastructure as well as shelves. SOP for storing and retrieving medical records has been going well. An open medical record shelf made of wood and a medical record folder that is quite thick and has bones in it. We recommend that the hospital filling section use tracers and expedition books in order to minimize missfile events, conduct training for officers and increase the number of existing shelves so that medical records do not pile up and missfile events do not occur again
Analisis Prioritas Penyebab Masalah dalam Pemenuhan Standar Akreditasi 8.4 di Puskesmas Kraksaan
Full text linkKraksaan Public Health Center got basic accreditation in 2017. The results of the accreditation standard 8.4 regarding MIRM have not been reached and must be improved for the next accreditation assessment. The purpose of this study is to analyze the priority causes of problems in the 8.4 accreditation standards at the Kraksaan Public Health Center. The method used is the MCUA (Multiple Criteria Utility Assessment). The results of identification of the organization of medical records in fulfillment of the 8.4 accreditation standard were 53.85% (partially fulfilled) with the lowest results in criterion 8.4.4 related to the completeness and confidentiality of medical records (16.67%) while based on the results of priority analysis of the causes of the problem related to the implementation of medical records in compliance with accreditation standards shows that there is no SOP on the implementation of assessments of the completeness and accuracy of the contents of medical records to be a top priority. The results of the study are efforts to improve the organization of medical records in fulfillment of the 8.4 accreditation standards in the form of making SOP assessing the completeness and accuracy of the contents of the medical records