Singh, “International Comparisons Of Covid-19 Deaths In The Presence Of Comorbidities Require Uniform Mortality Coding Guidelines,” Int. Bopp, “Cause Of Death Coding In Switzerland : Evaluation Based On A Nationwide Individual Linkage Of Mortality And Hospital In-Patient Records,” Vol. Vilches-Moraga, “Improving The Quality Of Discharge Summaries Through A Direct Feedback System,” Futur. we observe the number of pending claims is 222 due to incomplete of signature and full name of physician items in discharge summary form. the number of classification covid-19 case is probable 25 cases (2,71%), suspected 214(24,15%) and confirmed 648 cases (73,14%). The characteristic of administrative data by gender is man 571 (64,45%), woman 315 (35,35%). The total sampling are 889 of medical records as secondary data was analyze with STATA Version 13. We used the checklist observation to measure the quality of clinical coding for patient covid-19 and interview guideline to explore the factors of pending claims. The research method is mixed-method sequential explanatory. The research aim is to measure the quality of medical records by covid-19 documentation for pending claims and the accuracy of coding Covid-19. In 2021, the number of pending claim for medical record patient’s covid-19 is 41%, as cause the quality of medical record incomplete. Undang-Undang Nomor.A complete of medical record and the accuracy of clinical coding is reflect to the quality of medical record documentation. Undang-Undang Nomor 44 Tahun 2009 tentang Rumah Sakit Undang-Undang Nomor 36 Tahun 2009 tentang Kesehatan Permenkes Nomor 269 Undang-Undang Nomor 29 Tahun 2004 tentang Praktek Kedokteran Permenkes No 269 th 2008 Tentang Rekam Medis Peraturan Pemerintah Nomor 32 Tahun 1996 tentang Tenaga Kesehatan. Kepmenkes Nomor 1333 Tahun 1999 tentang Standar Pelayanan Rumah Sakit Kepmenkes Nomor 034 Tahun 1972 tentang Perencanaan dan Peme liharaan Rumah Sakit Pedoman Manajemen Informasi Kesehatan di Sarana Pelayanan Kesehatan, Jakarta. Dasar-dasar Kependidikan, PT Rineka Cipta, Jakarta. Kiat Mengelola Rumah Sakit, Jakarta.įuad, Ihsan. Direktorat Jenderal Bina Pelayanan Medik, Pedoman Penyelenggaraan dan Prosedur Rekam Medis di Indonesia, Revisi II, Jakarta.ĭjojodibroto, Darmanto. Manajemen Administrasi Rumah Sakit, Jakarta.ĭepartemen Kesehatan RI. Conclusion: The conclusion of this research was the usage of electronic medical record is more savety, accurate and effective in hospitalĪditama, Tjandra. Medical can also record it becomes a tool the evidence in the investigation in a similar way manual medical record. The results showed that has certain excellence that more so than with manual medical. Result: This research gained an electronic medical record. Because of that, needed there is research on how the comparison between medical record manuals by electronic medical record if record of profit and weaknesses and how in terms of safety data storage electronic medical record compared to manual medical record and assess whether electronic medical record can be used as an instrument the evidence in the investigation in the provision of health services related to not repeat this research with methods of juridical normative. The data presented in the form of the patient medical record manually and electronic medical record, and the data it is very important to the hospital. Method:The method used in this research was normative yuridis. Objective:to determine the usage of electronic medical record in hospital. In order to to support these health services then required health information of the members of the data that is neither of the patients medical record. Backgroud: A hospital was a part of a whole system health services which aims to carry out health services, these services through the effort to healing patients.
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