Procedia of Engineering and Life Science

Legal Protection for Medical Recorders and Health Information Personnel in the Management of Electronic Medical Records

2025-01-31T10:29:12+00:00

Medical recorders and health information workers are one type of health workers who have the authority to manage electronic medical record services in health service facilities in accordance with Minister of Health Regulation Number 24 of 2022 concerning medical records. Electronic medical records in their application pose risks in terms of privacy and confidentiality considering that they are vulnerable to changes in data, duplication of data, transfer and buying and selling by irresponsible people. In addition, intentional or unintentional negligence in managing medical record documents makes this profession very vulnerable to lawsuits and legal sanctions in carrying out its authority. Seeing these problems, legal certainty and protection is needed for medical record and health information workers in carrying out their professional principles in managing electronic medical record services. This research was carried out to find out how legal protection is for medical recording and health information workers in managing electronic medical record services. The method in this research is a normative legal method with a statutory approach and a conceptual approach. Based on the results of this research, it is known that medical recording and health information workers have legal certainty and protection, both preventive and repressive, in accordance with the mandate of the state constitution in the 1945 Constitution and confirmed in Law Number 17 of 2023 concerning Health and Minister of Health Regulation Number 55 of 2013 concerning the Implementation of Work Medical. As a profession that exercises its authority, medical recorders and health information have legal implications if they commit a violation. In this way, medical recorders and health information workers have received legal protection and legal implications in maintaining electronic medical records as long as they meet professional standards and health service standards.

Analysis of the Release of Medical Record Information as a Guarantee of Legal Aspects of Patient Data Confidentiality

2025-01-31T10:28:51+00:00

Medical records are certainly very close to maintaining the security and confidentiality of patient data in the means of releasing information by ensuring the legal aspects of the security and confidentiality of patient data. Maintaining the security and confidentiality of patient data during the process of releasing medical record file information is very important in order to facilitate access to information on lawsuits by health services and health practitioners, as well as authorized third parties. This study aims to provide an overview of the release of medical record information in the legal aspect of confidentiality. The things that were studied were the procedures for releasing medical record information, the requirements for releasing medical information, the parties involved in releasing medical information, information on the use of releasing medical information and looking at the security aspects of the process of releasing medical record information, as well as facilities and infrastructure in the information release room. The data collection methods used in this study were interviews and observations. The results of the research on the process of releasing medical information show that two patients are in accordance and two patients are not in accordance with the SOP (Standard Operating Procedure) that applies at JIH Purwokerto Hospital, the human resources involved in the process of releasing information are Medical Recorder and Health Information (PMIK) officers and non PMIK, and inadequate facilities and infrastructure available in the information release room.

Analysis of Verification Aspects Associated with the Return of BPJS Health Claims for Inpatients at RSU Surya Husadha Denpasar

2025-01-31T10:28:30+00:00

Submission of claims by hospitals to the Social Security Agency (BPJS) Health will go through a verification process and requires compliance with verification aspects. However, they often experience refunds or delays in payments due to non-compliance with established regulations. This results in negative impacts such as disruption to hospital cash flow, increased workload, and failure to achieve service quality indicators. It is necessary to have claim data ready before submitting a claim by the hospital. The aim of this research is to determine the relationship between aspects of membership administration, service administration and health services with the return of BPJS Health claims. This type of research uses quantitative descriptive analysis with a cross sectional approach. This research was conducted on 145 pending claims selected using a simple random sampling technique. Based on the results of the discrepancy analysis in the aspects of membership administration, namely 6 files (4.1%), service administration, namely 103 files (71%), and health services, namely 36 files (24.8%). These three aspects of verification are related to the return of BPJS Health claims, resulting in a p-value = 0.000, meaning H₀ is rejected. To increase efficiency and reduce the number of claim returns, it is necessary to carry out internal verification before claims are sent to BPJS Health.

Hospital Cost Containment Efforts on the Differences between Hospital Real Rates and INA CBG's Rates for Inpatients with Pneumonia Complications at Dr. Sardjito Hospital

2025-01-31T10:28:06+00:00

Based on preliminary studies conducted by researchers at the Medical Records and Health Information Installation of Dr. Sadrjito Hospital, it was found that the difference between the hospital’s real rates and INA-CBG’s rates for pneumonia patients from January to May of 2024 had very significant changes in rates and could cause losses to hospital agencies. The purpose of this study was to determine how efforts made by the hospital to the difference in hospital real rates and INA-CBG’s so that hospital costs are efficient. The research method used was a descriptive research method with a quantitative approach. The results of a study of 52 inpatient pneumonia cases analyzed by the researchers found that the real hospital rates were higher than the INA CBG’s rates, causing huge losses for the hospital. The factor that causes the difference in real hospital rates is the lack of JKN claim guarantee costs, while cases of penumonia with complications have a long stay (LOS) of more than 12 days with high action costs, then the hospital must make cost control efforts by implementing standardized services so that hospital costs become more efficient and not the occurrence of higher hospital riil rates than INA-CBG’s.Suggestions for the hospital to reduce losses are to evaluate the calculation of unit costs in each inpatient unit service, monitor and evaluate claims for inpatient service costs through monitoring the coding process, verification and implementing clinical pathways in all services.

Analysis of the Accuracy of Diagnosis and Action Codification with Reconfirmation of BPJS Inpatient Patient Claims for the January-April Period of 2024 at SLG Kediri Hospital

2025-01-31T10:27:42+00:00

The accuracy of the coding of diagnoses and procedures is determined based on the completeness of the medical record documents. A dispute case or dispute claim is a claim submitted by a hospital that is declared Dispute by BPJS Health if there is a discrepancy or disagreement between BPJS and the hospital regarding claims involving services or clinical actions that impact payment of patient claims. Accurate disease and procedure coding is very important to support the smooth submission of health service claims health service cost claims. The purpose of this study was to analyze the accuracy of coding diagnoses and actions with reconfirmation of claims for inpatient BPJS patients for the period January-April 2024. The research method used is a case study approach. Techniques data collection techniques in the form of observation, literature study and interviews. The population in this study is the number of BPJS patient claim files returned in January-April 2024. The sample used in this study is the number of BPJS inpatient claim files that are returned with coding inaccuracies in January-April 2024. The research results show that from January to April 2024, reconfirmation of inpatient BPJS patients tends to fluctuate. The highest reconfirmation was in April with a total of 89 documents. Meanwhile, reconfirmation with the highest codification inaccuracy was in January with a total of 26 documents. This reconfirmation is sent in Excel form which must be confirmed by the hospital. From the results of the research conducted, the cause of re-confirmation of inpatient BPJS patients related to coding inaccuracies is still high. Accurate coding can minimize hospital losses and the risk of fraud in health service facilities.

Analysis of the Use of Electronic Medical Records on the Effectiveness of Outpatient Services at the Siulak Mukai Health Center in 2024

2025-01-31T10:27:18+00:00

To improve the quality of health services, health workers are needed who have competencies in accordance with their education and training. Competent health workers are able to provide appropriate services and one of the outpatient health services provided by the government is the Siulak Mukai Health Center. In an effort to modernize and increase the efficiency of the health service system, the government provides a medical record supporting information system, namely the Electronic Medical Record (RME). Siulak Mukai Community Health Center has implemented an electronic medical record system (RME) as an effort to improve the quality and quality of its services. However, there are still some polyclinics that do not fill in complete electronic data due to several obstacles such as network problems at the end of the service and busy nurses and doctors on certain days, as well as the lack of responsibility of health workers in filling in data. on RME. This study aims to determine the impact of using electronic medical records on the effectiveness of outpatient services at the Siulak Mukai Community Health Center. This type of research is quantitative descriptive research. The data analysis method uses quantitative descriptive statistical analysis with the help of SPSS. The research results show that the use of RME has a positive impact on the effectiveness of outpatient services in terms of the aspects of function, program, provisions, objectives and systems at the Siulak Mukai Community Health Center.

Overview of the Accuracy of Inpatient Dyspepsia Diagnosis Codes Based on ICD-10 at Hospital X Bengkulu City

2025-01-31T10:26:51+00:00

Problem of Coding activities for disease diagnosis are very important during medical record services in hospital installations. To get the correct coding, the activities carried out look at the medical resume, admission and discharge summary and supporting sheet where the coding is carried out by the medical record staff, who is responsible for the accuracy of the Dyspepsia code. If coding is not carried out accurately, it will result in errors in disease recording indexes and procedures, inaccurate report information data and inaccurate INA-CBG rates. Objective for Known description of the accuracy of inpatient dysspecia diagnosis codes based on ICD-10 at Rafflesia Hospital, Bengkulu City. Method:This type of research is descriptive observational through direct observation of the population and a sample of 57 medical record files with a diagnosis of dyspepsia cases. The data used in this research is secondary data which was processed univariately. Results of the 57, the majority, namely 36(63,1%) of the dyspepsia diagnosis codes in the medical record files were accurate and 21 (36,9%) of the dyspepsia diagnosis codes in the medical record files were inaccurate. The completeness of the recording files was 36 files (63,1%), the completeness of the incomplete recording files was 31 files (36.9%). Suggestion: Coders should refer to ICD-10 in assigning codes and attend training to deepen their understanding of the implementation of classification and codification.

Clarity of Diagnosis Writing and Accuracy of Coding in Heart Failure Based on ICD-10 at Hospital X

2025-01-31T10:26:27+00:00

It is very important to code the diagnosis of Heart Failure correctly and accurately, inaccuracies in codes are often found in medical record files such as unclear writing of the diagnosis or even incomplete supporting documents and the absence of a 4^th character code in the diagnosis of Heart Failure. If coding is not carried out accurately, it will result in errors in disease recording indexes and actions, inaccurate report information data and inaccurate INA-CBG rates. The purpose of this study aims to determine the clarity of writing diagnoses and the accuracy of heart failure coding based on ICD-10 at Rafflesia Hospital, Bengkulu. The type of research is descriptive. The data used are primary data and secondary data which are processed univariately, data collection methods are through interviews and observation. The tool used is a checklist sheet with direct observation of 176 medical record files for the diagnosis of heart disease. Of the 176 medical record files for the diagnosis of Heart Failure, there is clarity in writing the diagnosis on the medical resume, a small number of 56 files (32%) are clear, but the majority of 120 files (68%) are unclear and the accuracy of codes based on ICD-10 is mostly 64 files (36% ) were accurate and as many as 112 files (64%) were inaccurate.

Evaluation of Panti Rapihku Hospital Online Registration Application Based on Android

2025-01-31T10:26:04+00:00

Electronic Government (e-government) utilizes information technology to enhance government performance and public services. Electronic Medical Records (EMR) are mandatory to be implemented in all healthcare facilities in Indonesia to improve services and maintain data confidentiality. Usability is a crucial aspect in the success of applications and websites, including in the healthcare context. Observations of the PantiRapihku application revealed several issues: difficulties in use by patients, absence of a direct payment menu, account limitations, and mismatched doctor schedules. This study aims to evaluate the online registration application of Panti Rapih Hospital using the System Usability Scale (SUS).This descriptive study involved users who tried the PantiRapihku application. The sampling technique used was simple random sampling with a total sample of 30 respondents. Data were collected using the System Usability Scale (SUS) and analyzed descriptively using computer software.The SUS evaluation results showed a score of 83.4, indicating that the PantiRapihku application is in the “Acceptabel” category. The application’s grade scale level is in category B, and the adjective rating is in the “Excellent” category. The PantiRapihku application is well-rated and acceptabel to users. However, it is recommended that the hospital improves the application’s consistency and coherence, such as synchronizing patient registration history with doctor leave schedules and surgery schedules.

The Role of Electronic Medical Records as a Professional Communication Tool for Caregivers at Nyi Ageng Serang Hospital

2025-01-31T10:25:44+00:00

To improve the quality and efficiency of health services in hospitals, there needs to be good communication from care professionals working at the service facility. Communication between care-giving professionals can be done by data communication through Electronic Medical Records (RME). RSUD Nyi Ageng Serang has implemented an outpatient RME to support patient care. However, the existing application has not been optimally utilised. The aim was to determine the role of RME as a communication tool between care professionals at Nyi Ageng Serang Hospital. The type of research used was descriptive qualitative research with a cross sectional design. This study used observation and focused group discussion (FGD) methods for data collection. The subject of this research is professional caregivers in outpatient installations while the object is RME. The data analysis technique used was qualitative data analysis technique starting with data reduction, data presentation, and continued with conclusion drawing. The role of electronic medical records in the implementation of interprofessional communication and collaboration is as a means of communication, especially where every finding and opinion of health professionals by care-giving professionals is poured and put together in electronic medical records, the findings of the medical history and actions given to patients and documented in writing or recorded. However, all of these provide benefits such as more complete RM content, business and communication efficiency, strategic benefits, and easy access to information. The completeness of patient data documentation in the RME at Nyi Ageng Serang Hospital can be improved through strengthening supporting regulations for documentation, training on the completeness of patient data filling for PPAs, adding features to check the completeness of documentation and designing a reward and punishment system for PPAs in terms of completeness of documentation in the RME. The addition of optional features to determine the diagnosis of disease by adding a list of disease diagnoses based on ICD-10 to the RME system database which makes writing a patient's medical diagnosis more concise and standardised and writing the main diagnosis is only written one diagnosis.

Factors Supporting the Accuracy of External Cause Codes Traffic Accident Injury Cases

2025-01-31T10:22:21+00:00

Injuries due to traffic accidents are one of the third largest causes of death in Indonesia after HIV/AIDS and TB. Based on WHO data (2015), injuries due to traffic accidents are the main cause of death and disability throughout the world, deaths due to traffic accidents worldwide amounted to 1.25 million in 2013. In Indonesia, injuries due to traffic accidents and deaths occurred has become a very serious problem (Djaja et al, 2016). Based on data from the Traffic Accident Unit of the Bengkulu Police Traffic Unit, in 2019 the number of traffic accidents recorded was 33 cases of serious injuries and 173 minor injuries (Munte et al, 2022). Implementation of external cause coding of traffic accident injury cases is very important to be done accurately, because the coding results external cause can be said to be accurate if it has the 4^th and 5^th characters. If coding is not carried out accurately it will have an impact on disease and action recording index errors, inaccurate report information data and inaccurate INA-CBG rates. all officers provide external cause coding and it is hoped that the head of the medical records unit will make a policy for filling in external cause codes.

Virtual Reality Design of Patient Registration for Medical Record Students

2025-01-31T10:23:08+00:00

The use of Virtual Reality (VR) technology in higher education can enhance students’ understanding and practical skills, for patient registration training for Medical Records and Health Information students. This study aims to design and develop Virtual Reality software to improve the efficiency and convenience of the learning process. Using a qualitative research approach with Action Research and purposive sampling techniques, involving 4 students and 1 lecturer, the software development utilized Blender for 3D design and Unity for interactive development, resulting in a realistic and immersive patient registration experience. Integration with Self-Registration Kiosks (APM) and physical facilities such as chairs and air conditioning increased registration efficiency. The results indicate that Virtual Reality is effective in enhancing students’ understanding and skills, although there are challenges such as high costs and significant technical support requirements, necessitating continuous efforts to optimize the use of Virtual Reality in education.

Efficiency of Bed Utilization in Mental Hospitals (Case Study of Regional Mental Hospital Dr. RM. Soedjarwadi Klaten)

2025-01-31T10:23:32+00:00

Hospitalization services for patients with mental disorders have their own standards, especially in the indicator of the length of treatment days. The length of treatment days for patients with mental disorders in accordance with the Minister of Health Indonesia Regulation number 129 of 2008 is ≤6 weeks. Whereas the average ideal length of stay which is one of the indicators of inpatient services that need to be reported on hospital information system, especially for form RL 1.2 is 6 - 9 days. The aim of this report is to present indicators of inpatient services in terms of bed use in mental hospitals, namely the value of Bed Occupancy Rate (BOR), Average Length of Stay (ALOS), Turn Over Interval (TOI), and Bed Turn Over (BTO). Secondary data taken from the hospital information system in the form of a recapitulation of the 2023 inpatient daily census and then analyzed qualitatively. The calculation results obtained are the value of BOR 59.1%, ALOS 11.42 days, TOI 7.89 days, and BTO 18.8 times. Based on the results of the comparison of the four indicators with the standard value of the Ministry of Health, it is still not ideal. The depiction of the four parameters on the Barber Johnson graph also shows a point located outside the efficient area.

Evaluation of the Implementation of the Puskesmas Information System (SIMPUS) Using the HOT-Fit Method at UPT Puskesmas Tirto Pekalongan City

2025-01-31T10:21:56+00:00

Puskesmas is a health service facility that carries out public health efforts and first-level individual health efforts, prioritizing
promotive and preventive efforts in its working area. Puskesmas in carrying out effective and efficient health efforts requires health
information that is organized through a cross-sector health information system. SIMPUS is a regional health information system program that provides information about all public health conditions at the community health center level, starting from personal data on patient, the availability of medicines, to public health education data. UPT Puskesmas Tirto used SIMPUS Indokes. Researchers conducted research using the HOT- Fit method to evaluate SIMPUS. This research uses quantitative methods with questionnaires. The research aims to evaluate the use of SIMPUS Indokes in improving the quality of health services at the UPT Puskesmas Tirto, Pekalongan City. Research on the four parameters of HOT-Fit : Humans, organization, technology and benefits related to the implementation of the SIMPUS Indokes program at the UPT Puskesmas Tirto, shows good results so that it can be continued and developed according to service needs at the puskesmas, but there must still be human resources who continue to be trained when ever the information is always up to date.

Analysis of the Unimplementation of Electronic Medical Records Using the Fishbone Method at the Mojogedang 1 Karanganyare Health Center

2025-01-31T10:24:56+00:00

Mojogedang 1 Community Health Center has not yet implemented electronic medical records because are still obstacles in the process of implementing electronic medical records. The aim of this research is to analyze the factors that cause electronic medical records to not be implemented. This research design was qualitative with a population of all employee components at the Mojogedang 1 Community Health Center of 60 employees. The sample was 38 people determined using a formula Slovin.Data were collected using observation, unstructured interview guides, and questionnaires. Data analysis uses descriptive. The results of the research show that the factors that have not implemented electronic medical records are influenced by factorsman, material, methode, machine, money. The root of the problem of not implementing electronic medical records is influenced by the lack of a budget. The conclusion of this research is that electronic medical records have not been implemented which are influenced by factorsman, material, methode, machine, money with the main root of the problem being that there is no budget to accelerate the implementation of electronic medical records. The suggestion for Mojogedang 1 Community Health Center is to immediately form a special team to accelerate electronic medical records, create service flows and SOPs, add infrastructure, create a special budget and require the highest policy from Mojogedang 1 Community Health Center.

Improving the Compliance of Electronic Inpatient Daily Census Filling (Seharie) at RSUD Dr. Iskak Tulungagung

2025-01-31T10:25:22+00:00

RSUD dr. Iskak has implemented an electronic medical record so that the recording of the daily inpatient census can be done electronically. Based on data for July 2023 and October 2023 based on 29 categories of inpatient daily census, 84% (16 categories) are suitable, and 16% (3 categories) are not in accordance with the category of inpatient daily census. The inappropriate categories are how to enter for transfer patients, how to exit for deceased patients, and the doctor in charge of the patient. The inaccuracy of filling out the daily census has an effect on the quality of the information produced. This study is descriptive, as the population of the electronic inpatient daily census research for July 2023 -October 2023 is 153 entries. The sample used in this study was a saturated sampling of 153 census entries. Data collected through interviews and observations. The data was analyzed using the fishbon diagram method with a risk assessment approach. The results of the study show that the factors that cause the inconsistency of filling out the electronic daily inpatient census are. Prosedure (there has been no update of procedural operational standards with the latest system in 2022), Policy (lack of warnings related to inconsistencies in filling in census data), Environment (difficulties in filling out the census on time during holidays), Human (weak understanding of filling out the daily census for hospitalization, and not yet knowing the information generated based on census data input), Management (high admin burden), System (many less effective menu options). The hospital’s medical records are expected to be able to make changes to procedural operational standards with the latest conditions, coordinating with the information technology management installation section related to simplifying the filling of the inpatient daily census and the room admin for the accuracy of recording.

Evaluation of Hospital Management Information System Implementation with the Delon and Mclean Method at RSUD dr. Doris Sylvanus Central Kalimantan

2025-01-31T10:22:45+00:00

The Hospital Information System (SIMRS) at RSUD Dr. Doris Sylvanus has been operational since 2021. However, based on a preliminary study, several challenges were identified, including poorly stored data and user formats that do not comply with the standardized SIMRS format. The aim of this research is to evaluate the implementation of SIMRS using the Delone and McLean method at RSUD Dr. Doris Sylvanus. The research design is an analytical observational study with a cross- sectional approach. The population of this study consists of all SIMRS users, totaling 1008 users. The sample size is determined to be 91 users using the Slovin formula. Data collection is conducted through questionnaires, and data analysis is performed using the correlation product-moment test. The research findings indicate a significant influence of system quality, information quality, and service quality on user satisfaction. Furthermore, there is a significant impact of user satisfaction on net benefits, and there is a significant influence of net benefits on user satisfaction. In conclusion, this research reveals the influence of system quality, information quality, and service quality on SIMRS user satisfaction, along with the relationship between user satisfaction and net benefits. The researcher recommends that RSUD Dr. Doris Sylvanus conducts socialization activities to improve user satisfaction with the system.

Challenges, Benefits and Considerations of Transitioning Disease Classification and Codification to ICD-11

2025-01-31T10:21:36+00:00

ICD-11 was developed to address the limitations of ICD-10, adapting to advances in medicine and technology. ICD-11 has not been implemented in Indonesia due to the absence of supporting regulations that enforce the use of ICD-11 as a disease coding guideline to replace ICD-10. This study analyses information related to the benefits, challenges and considerations of implementing ICD-11 in the form of a narrative literature review conducted using the PRISMA framework. The databases used were Google Scholar, Pubmed, ScienceDirect and Scopus. Article search keywords used the SPICE research question framework. Inclusion criteria included articles published within 2019-2024 in English or Indonesian. Article screening was conducted using the Rayyan.ai tool, followed by critical appraisal using the MMAT instrument with a cut-off point of 80%. We obtained 5,813 articles from the database. A total of 5,776 articles were excluded, 4 articles were duplicated, leaving 13 articles selected for extraction and analysis. ICD-11 has many benefits, including a more complete list of diagnoses and health-related problems, from the update of classification data in each organ system/disease group category to the inclusion of new categories. ICD-11 also has a “post- coordination” feature and cluster codes allow for more specific diagnosis codes. One of the barriers to the implementation of ICD-11 is that there are other classification guidelines in some particular diseases that overlap with ICD-11, for example in the classification of mental illness and CHD. The implementation of SNOMED-CT, which is expected to go in parallel with the use of ICD-11, requires a Common Ontology to map the semantics of each system’s terminology. Successful implementation requires policy support, effective training, improved clinical documentation, and promotion so that ICD-11 can be implemented effectively, ensuring relevance and usefulness in various health fields.

Analysis of the Accuracy of ICD-10 Codes in Outpatient Diagnoses at the Kijang Health Center

2025-01-31T10:24:32+00:00

Coding accuracy is very important in medical records. This is related to the use of medical records seen from the administrative aspect, medical aspect, legal aspect, financial aspect, research aspect and documentation aspect. Code accuracy produces good medical records that can be used as a source of decision making. The diagnosis code is considered appropriate and accurate if it matches the patient’s condition. The aim of this study was to find out the causal factors and percentage of ICD- 10 code occurrence in the diagnosis of outpatients at the Kijang Public Health Center. The research method used is quantitative descriptif by using independent cross-sectiational bonding. The analysis of the accuracy of codes diagnosed in correct patients was 66.7% or 66 cases and the inaccurate diagnoses were 33.3% or 33 cases. The influencing factors are man, method and material.

The Relationship between Completeness of Inpatient Claims and BPJS Health Claim Approval at UPT RSUD Massenrempulu Enrekang

2025-01-31T10:24:06+00:00

The Massenrempulu Enrekang Regional Hospital technical Implementation Unit is a class C hospital where the hospital has outpatient and inpatient services as well as an emergency room. Based on the preliminary survey, it was found that there were incomplete medical records and incomplete claims administration requirements. this will affect the BPJS Health claim approval process. the aim of the research is to determine the relationship between the completeness of inpatient claims and the approval of BPJS Health claims. this research uses the Observational Analytical method with a cross sectional approach. the sample for this study was 80 medical records and BPJS Health inpatient claim files. The research instrument uses observation and interview guidelines. The research results show that there is a relationship between claim completeness (medical records and claim administration requirements) with BPJS Health claim approval. this is shown by the results of the Fisher Exactt test where the p value is: 0.002 (<0.05). the conclusion of this research is that there is a relationship between claim completeness and BPJS Health claim approval.

Risk Assessment in the Life Cycle of Electronic Medical Record System Development

2025-01-31T10:21:15+00:00

The Indonesian government mandated PMK 24 of 2022 concerning Medical Records as a challenge for health service facilities in Indonesia to develop Electronic Medical Records (EMR). Risk management plays an important role in every stage of the system development life cycle (SDLC). Risk assessment is the first stage in the risk management method. This research aims to explore risks in RME development in an effort to determine risk mitigation for RME development in the SDLC framework. The results of this research show the identification of risks based on hardware, software, vulnerability to technological change, vulnerability to instability in technology supply, project failure,regulatory and compliance impact. These categories of risks are outlined in the SDLC framework including the initiation, development, implementation, maintenance and disposal phases. Next, probability and impact measurements are carried out, to analyze the level of risk with low, medium and high determinants. The existence of this risk level makes it easier for stakeholders to identify appropriate controls to reduce or eliminate risks during the risk mitigation process. The output of this research is presented in the form of a risk register. The conclusion of this research shows that risks in high determinants require mitigation efforts from the aspects of regulations, infrastructure and human resources.

Geographic Information Systen (GIS) Mapping of Toddler Cases Stunting Cases in Bantul Regency in 2022

2025-01-31T10:20:54+00:00

Geographic information system GIS is technology based on computers to collect, analyze, and serve data and information from an object that is connected and located on the ground. A toddler with stunted is shorter than his or her age, less than the -2 standard of the World Health Organization’s WHO growth curve. A condition caused by lack of nutritional intake in a toddler during the first 1000 days of life. This study aimed to map the cases of a stunted toddler in the Bantul district with Quantum of GIS and analyze the influencing factors based on specific nutritional interventions. Varieties of qualitative research with planned case studies. The subjects sample were nutrition officers of the Bantul Public Health Office while the subjects sample were three stunted toddlers in the Kapanewon district of Bantul. Data collection for toddlers with stunted was using ePPBGM electronic Nutrition Report Based on Sleep Record. In 2022, there were 3,001 cases of developmental delay in toddlers. The three higher-ranked cases in Kapanewon are Kapanewon Imogiri 492, Dlingo 258, and Piyungan 228. Risk factors of stunting in toddlers through specific nutritional interventions. The conclusion: 1. We can see that the higher toddler case mappings of the three Kapanewons have clearer visuals compared with the other Kapanewons. 2. The analysis of incidents Stunted a toddler from the higher three kapanewons through specific nutritional interventions where available in Imogiri Kapanewon, the mom does not want to do IMD, give exclusive breastfeeding, pregnant with KeK anemia, Pregnant women with anemia and parenting patterns are still high compared with Dlingo and Piyungan Kapanewon. Suggestion: Stunting is a complex problem as of specific nutritional interventions and sensitive nutritional interventions are needed.

The Relationship between Perceived Benefits and Perceived Ease of Use with Actual Use of the E-Link Health Center Management Information System at the Slawe Health Center, Trenggalek Regency

2025-01-31T10:20:28+00:00

SIMPUS e-Link is a form of support for the Community Health Center Information System which is able to guarantee data and information that is fast, accurate, up-to-date, sustainable and accountable. The aim of the research is to analyze the relationship between perceived usefulness and perceived ease of use with the actual use of the Community Health Center Information System at the Slawe. Community Health Center, Trenggalek Regency. This research is a quantitative research using a cross sectional approach. The sample size for this study was 51 community health center staff users. The independent variable is perceived usefulness and convenience, while the dependent variable is actual use. The instrument of this research is a questionnaire whose validity and reliability have been tested. The research results showed that respondents had a good category of perceived benefits as much as 94.1%, perceived ease of use was in a good category (90.2%) and the actual usage variable was in a good category (72.5%). The results of statistical analysis show that the perceived usefulness variable is related to the actual use of SIMPUS with a value of p = 0.0001 (< 0.05), and a value of r = 0.84, which means there is a positive and strong relationship between perceived usefulness and actual use of SIMPUS e-Link. The variable perceived ease of use and actual use of SIMPUS has a significant relationship with a value of p = 0.0001, and a value of r = 0.78, which means there is a positive and strong relationship between perceived ease of use and actual use of SIMPUS e-Link. The conclusion of this research is Perceptions of the benefits of SIMPUS e-Link and ease of use of SIMPUS e-Link are related to actual use.

Factors Affecting User Behavior of Hospital Management Information Systems in the Emergency Department of Rsud Dr. Moewardi

2025-01-31T10:20:03+00:00

Redesigning Mobile Application Interface Design Bethesda Hospital with Design Thinking Method

2025-01-31T10:19:39+00:00

The ease of patient registration process and access to information in hospitals through technology is increasingly in demand. Bethesda Yogyakarta Hospital launched their mobile application in 2017, avaiable on Google Play Store and App Store. User responses varied from positive to negative. Some users gave negative responses, namely less user-friendly, limited features, and simple design compared to its competitors. To overcome this, this study aims to redesign the interface design of the Bethesda Hospital Mobile Application by prioritizing user needs through a design thinking approach. This research is categorized as Research and Development (R&D) and involves various data collection methods, including interviews, documentation studies, competitive analysis, and survey distribution. Data validity used source triangulation by involving the IT department of Bethesda Hospital Yogyakarta. At the empathize stage, researchers identified problems and user needs related to information and features that need to be improved. At the define stage, core problems were formulated, including adding application functions, features, information, and interface design. At the ideate stage, researchers generated creative ideas for application development solutions. At the prototype stage, a visualization design was created based on the the design development ideas. In the testing stage, the test results showed that users completed the scenario tasks, but there were still tasks that required more time to complete. This research resulted in a redesign of the Bethesda Hospital Mobile Application interface that can be used as a development reference. The application of each stage of the design thinking method can be used to design other information technology applications.

Analysis of Completeness of Informed Consent Forms for Inpatients with Surgical Cases at the General Hospital Pku Muhammadiyah Bantul

2025-01-31T10:19:17+00:00

A hospital is a provider of health service facilities consisting of treatment and recovery as well as a health service facility consisting of outpatient services, inpatient services, emergency services and referral services. A medical record is a file that contains notes regarding the patient’s identity, examination, treatment, medical procedures and other services that have been provided to the patient. Medical recorders have the authority to carry out clinical classification systems and codefication of health-related diseases and medical procedures according to correct medical terminology. Medical terminology is a system used to organize a list of medical terms for diseases, symptoms and procedures. Disease terms or health conditions must be in accordance with the terms used in a disease classification system. Coding activities are assigning codes using letters and numbers or a combination of letters and numbers that represent data components. Activities carried out in coding include coding disease diagnosis and coding medical procedures. Incompleteness of informed consent forms or medical procedures includes a lack of understanding from doctors regarding the importance of filling out informed consent, resulting in negligence which creates obstacles in filling out informed consent which has a negative impact on doctors and the medical procedures given to patients. With this incompleteness, apart from having an impact on reducing the quality of medical records, it also has an impact on ensuring legal certainty for patients. The aim of the research is to determine the percentage of completeness, incompleteness, factors causing incompleteness, efforts to overcome incomplete informed consent for inpatient surgical cases at the PKU Muhammadiyah Bantul Hospital,Yogyakarta . Research method: using a qualitative descriptive method, with case studies, sampling using a purposive sampling method. Research results and conclusions with the percentage of complete informed consent 32.1%, incomplete doctor authentication 33.8%, incomplete patient witnesses 34.1%. The influencing factors are methods and man. Efforts to overcome incompleteness are through regularly scheduled outreach to nurses, doctors, medical records officers regarding the importance of completing the informed consent form. Check the list of informed consent data in the medical record file, whether it is complete or not.

Medical Record Service Management: Interface Design Integrated Application and Registration System Research Unit

2025-01-31T10:18:57+00:00

Applications for scheduling research in the Diklit section are still manual, resulting in the process of arranging researchers having to go back and forth between officers which takes a long time. When the payment process has been carried out, the researcher returns to the Medical Records Installation and meets the research officer for registration and determining the date the research will be carried out. Researchers still have to come back to the research section of the Medical Records Installation one day before the research is carried out to write down the data on borrowing medical record files by filling in the tracers manually one by one so that the officers can prepare them on the day the research is carried out by the researchers. The aim is to create an interface design for an integrated application and registration system for research units. The result is an interface design for the research scheduling application process by researchers who can anticipate queues (online registration). Interface design for the application validation process by officers. The interface design of the researcher’s email confirmation of the application is validated. The interface design of the registration process by researchers after validation shows that the research records include medical records that will be used by researchers whether using eMR, BRM or both. When using BRM, the researcher writes down the number of BRM and then a tracer template will appear according to the amount that must be filled in and later printed by the officer for taking the BRM from the storage shelf. The interface design of the researcher’s email confirmation of successful registration contains the day, date and time the research can be carried out to make it easier for the researcher to come at the available time. The interface design for registration data sent to officers displays data on the number of applications, validated applications, number of daily visitors, and print reports. Conclusion: the interface design that has been designed can be taken into consideration in developing an information system in the research field involving the medical records work unit

A Simple Information System Using Spreadsheets For Inpatient Daily Census (Si-Sehari) Of Klungkung District General Hospital

2025-01-31T10:18:35+00:00

Daily census reporting is something carried out by hospitals to describe the achievements of inpatient service quality indicators. Based on Minister of Health Regulation Number 1171 of 2011 concerning Hospital Information Systems, it is stated that the daily inpatient census is included in the Recapitulation Report 3 reporting regarding inpatient service activity data. Based on a preliminary study conducted at the Klungkung Regional General Hospital, it is known that the implementation of the daily census uses a manual system, causing several problems, namely late reporting of daily records, frequent recording errors, loss of daily census forms and lack of flexibility in filling them out. Therefore, a simple Spreadsheet-based information system innovation (Si-Sehari) is needed to overcome problems that arise during the implementation of the daily census. This research was carried out to determine the stages and process of implementing a simple Spreadsheet-based information system design (Si- Sehari) for the daily inpatient census at Klungkung Regency Regional Hospital. The method used is quasi-experimental with the development method being the waterfall method. With the development of Si-Sehari, there are good implications for the implementation of inpatient service reporting. All users stated that using this information system provides convenience in its implementation including easy access, flexible filling and changing of data, easy search for data, cost efficient and effective in use. Thus, the use of the Si-Sehari Spreadsheet system improves the quality of hospital services, especially reporting to hospital management in real time.

Analysis Of Pending Claims For Inpatients Social Security Organizing Body (Bpjs) Health Hospital Mitra Siaga Tegal

2025-01-31T10:18:16+00:00

The Hospital understands and realizes the importance of the claim process as a reimbursement for insurance patients who have been treated. pending claims, namely the return of claims where there is no agreement between BpJS Health and FKRTL regarding coding and medical rules (dispute claims), but settlements are carried out in accordance with statutory provisions. Mitra Siaga Tegal Hospital in September 2022 obtained data that there were 94 pending BPJS claim files for inpatients out of 1427 files that had been submitted for claims to BPJS. This is due to coding errors, incorrect data entry, incomplete supporting examinations such as the absence of therapy and laboratory results. The method used in this research is qualitative with in-depth interviews with the Assistant Manager of Insurance Control and the officer in charge of Inpatient Claims at Mitra Siaga Tegal Hospital. The purpose of this study was to find out the causes of pending claims for hospitalization in September 2022 at Tegal Mitra Siaga Hospital. The results of the study show that pending cases of inpatient BPJS claims at Mitra Siaga Hospital in Tegal can occur due to several factors, which consist of administrative, medical, and coder aspects. The most common factor causing pending hospitalization claims was the coder aspect in 76 cases