4 research outputs found
EVALUASI FUNGSI KERJA PETUGAS ASSEMBLING DI RUMAH SAKIT PUSAT PERTAMINA TAHUN 2020
No full textBased on a preliminary study, the implementation of the medical record assembling at Pertamina CentralHospital was still inappropriate. The return of the medical record file from the inpatient has been delayed,more than 2x24 hours, the medical record file was not 100% complete. The purpose of this study was toevaluate the function of assembling work at Pertamina Central Hospital with 5M management elementsconsisting of man, money, method, machine, material. This type of research was qualitative research withdata collection methods were interview, observation, and documentation. The subject of this research wasthe assembling officer. The results showed that there were problems with man, method, and materialvariables. Man variable, the lack of staff's knowledge about understanding the importance of medicalrecords. Method variables, assembling SOP in Pertamina Central Hospital was not in accordance with thetheory because quantitative analysis of medical record file still not exist. Material variable, medical recordfile wais not 100% complete in the authentication aspect. The solution is to include medical records officersin training activities about medical records, assembling workload evaluation, assembling Standard OperatingProcedures shall be added to control medical records incompleteness (quantitative analysis) and create theKLPCM form to find any deficiency or incomplete medical record file, that will have an impact for improvingthe quality of the medical record.Pada saat survei pendahuluan,pelaksanaan kegiatan assembling rekam medis di Rumah Sakit Pusat Pertamina masih tidak sesuai. Pengembalian berkas rekam dari rawat inap mengalami keterlambatan, yaitu lebih dari 2x24 jam, berkas rekam medis juga masih belum lengkap 100%. Tujuan penelitian ini adalah untuk mengevaluasi fungsi kerja assembling di Rumah Sakit Pusat Pertamina dengan unsur manajemen 5M yang terdiri dari man, money, methode, machine, material. Jenis penelitian ini adalah penelitian kualitatif dengan metode pengumpulan data yaitu wawancara,observasi dan dokumentasi. Subjek penelitian ini adalah petugas assembling. Hasil penelitian didapatkan bahwa terdapat masalah pada variabel man, methode dan material. Variabel man, pengetahuan petugas dianggap kurang paham mengenai pentingnya rekam medis dan kurangnya pelatihan petugas rekam medis. Variabel methode, SOP assembling di Rumah Sakit Pusat Pertamina belum sesuai teori karena analisis secara kuantitatif berkas rekam medis masih belum ada. Variabel material,berkas rekam medis masih belum lengkap 100% pada aspek autentifikasi. Solusinya yaitu mengikut sertakan petugas rekam medis dalam kegiatan pelatihan tentang rekam medis, evaluasi beban kerja assembling, Standar Operasional Prosedure bagian assembling sebaiknya ditambahkan pengendalian ketidaklengkapan rekam medis (analisis kuantitatif) dan membuat form KLPCM
Analisis Berkas Rekam Medis Rawat Inap Pada Kasus Operasi Di Rumah Sakit Pusat Pertamina Jakarta Selatan
No full textBased on the results of observations made at Pertamina Central Hospital, it was found that several inpatient medical record file forms, especially in cases of surgery, were related to filling out forms that were not 100% complete and there was no evaluation of the completeness of inpatient medical record files in surgical cases. The purpose of this study was to analyze the completeness of inpatient medical record files, especially cases of surgery at Pertamina Central Hospital in February 2022. This research method used qualitative descriptive. Sampling using the Slovin formula with a population of 200 and the sample results obtained 67 samples. The results of this study obtained that the completeness of filling out the medical record file operation form in the complete category was 43 medical record files (64%) and 24 medical record files were incomplete (36%). The conclusion of this study is that the completeness of inpatient medical record files in surgical cases, especially related to filling out forms at Pertamina Central Hospital is categorized as incomplete because filling out forms is not 100% complete
Determinan Ketepatan Kode Diagnosis Utama di RS Pusat Pertamina Jakarta Selatan
No full textThe inaccuracy of the main diagnosis code will have an impact on the hospital in terms of financing and the quality of the information produced. This can also be influenced by the accuracy of writing the main diagnosis. The purpose of this study was to determinants of the accuracy of the main diagnosis code in the discharged summary of inpatient in February 2022 at Pertamina Central Hospital by paying attention to several components, namely the clarity of writing the main diagnosis and the accuracy of the main diagnosis code. The method used is descriptive qualitative. The total sample is 130 of inpatient discharged summary sheets from a total of 463 medical record files in February 2022. The results showed that 42% discharge summary sheets were not clear in writing the main diagnosis and 86% the main diagnosis code did not correct. It is suggested that the hospital can improve the evaluation of the accuracy of filling in the code and writing the main diagnosis in the summary of discharge, holding training and seminars related to doctor's compliance with the ICD-10 code, and socializing how to enforce the code and write a diagnosis according to the ICD-10 rules
Analisis Singkatan Dan Simbol Terhadap Formulir Discharge Summary Rawat Inap Untuk Penilaian Akreditasi Snars Mirm (12) Periode Februari Di Rumah Sakit Pusat Pertamina Jakarta Selatan
No full textRecording in SNARS Edition 1 is included in the Hospital Management Standards group on Information and Record Management (MIRM), one of the medical standards in MIRM, namely the standardization of diagnosis codes, procedure/action codes, symbols, abbreviations, and their meanings contained in the MIRM 12 standard. Where in the assessment element, the hospital must have regulations on standardizing diagnosis codes, procedure/action codes, definitions, symbols used and which should not be used, abbreviations used and which should not be used, and monitored their implementation. Pertamina Central Hospital is a referral hospital and accredited B. Where this hospital becomes the Presidential Hospital. Medical Records used in the form of Electronic and Manual Medical Records. On the Medical Record Form in the application there are abbreviations and symbols. In the use of abbreviations and symbols, socialization has been carried out which contains a guideline entitled "The RSPP abbreviation list book" but in its implementation no evaluation has been carried out. And also there are SOPs that state the existence of abbreviations, symbols, actions and diagnostic codes. In the period of February, there were 463 hospitalized patients. And researchers took samples of medical record number 132 medical records from 30% of the number of inpatients using the formula of slovin. This is a qualitative research using direct observation and documentation methods. The results of observation and study documentation show that the abbreviations that are not appropriate are 45%, 67% for symbols and 55% appropriate for summary form releases, The book of abbreviations and symbols belonging to Pertamina Central Hospital has not yet been legalized and socialized legally. And there is no SOP in accordance with SNARS MIRM 12 for abbreviations and symbols at Pertamina Central Hospital. There is also no evaluation in the implementation of the use of abbreviations and symbols as well as the books used, there are still not several symbols and abbreviations listed in the abbreviation and symbol guidelines in the Rspp
