Vol 9 No 2 (2022)

Dampak Ketidaklengkapan Komponen Analisis Kuantitatif Pada Rekam Medis Pasien Rawat Inap Terhadap Tertib Administrasi Rekam Medis Di Rumah Sakit Umum Daerah Sanjiwani Kabupaten Gianyar

The Impact of Incomplete Components of Quantitative Analysis on Inpatient Medical Records on the Orderly Administration of Medical Records at sanjiwani regional general hospital, Gianyar regency

Desak Made Ayu Diah Ardiantari1, Dr. dr. Bambang Hadi Kartiko, 2, I Gusti Ngurah Manik Nugraha 3

Program Studi Perekam dan Informasi Kesehatan, Universitas Dhyana Pura1,2,3

Email : ayudiahardiantari26@gmail.com

Abstract

                Based on the observations of patient safety incident reports in 2021, there were 67 incidents and KTD reports, bpjs health cost claims in the first quarter of 2022 were returned totaling 81. The purpose of the study was to determine the impact of the incompleteness of the quantitative analysis component of the medical records of inpatients on the orderly administration of medical records at Sanjiwani Hospital, Gianyar Regency. The research design is descriptive qualitative analytics, with a sample of 8 officers in the Medical Record Installation.The results of the study obtained the impact of incompleteness of the components of the nitatitative analysis of medical records of inpatients, including the impact of incompleteness of identification reviews, namely: delays in the administrative service process for patients, difficulty placing forms on medical record bendels, difficulty distinguishing patients from one another, can result in drug dosage errors, and difficulty determining the ownership of medical records, the impact of incompleteness of important report reviews,  namely: the delay in providing the BPJS claim submission file, and the obstruction of bpjs claim submission, the impact of incomplete review of authentication, namely: medical records do not have legal validity, difficulties of the hospital if there is a lawsuit and there are difficulties if there is an error in the administration of drugs or drug allergies to patients, and the impact of incomplete review documentation, namely: delay in making KLPCM reports, and hampered submission of insurance claims.Based on the results of the study, it was concluded that it was: errors in identifying patients, delays in submitting BPJS claims, medical records could not be used as evidence of defense or legal protection, and the emergence of errors by medical personnel in reading patient medical records.

Keywords: Impact of incompleteness of quantitative components of medical records, orderly administration of medical records.

 

Vol 9 No 2 (2022)

DIAGNOSTIK DAN MANAJEMEN TERKINI GANGGUAN PERNAPASAN SAAT TIDUR Obstructive sleep apnea (OSA) merupakan salah satu jenis gangguan napas saat tidur yang sering terjadi pada 14% pria dan 5% wanita. Penyakit OSA terjadi akibat episode berulang hambatan jalan napas atas, baik secara total (apnea) maupun parsial (hipopnea). OSA berhubungan erat dengan obesitas, hipertensi, gangguan fungsi dan struktur jantung dan vaskular, dan diabetes melitus. Diagnosis dapat ditegakan menggunakan hasil polisomnografi (PSG) yaitu: jika terdapat 5 atau lebih kejadian obstruksi pernapasan (apnea obstruktif dan campuran, hipopnea, atau respiratory effort-related arousals/RERA) per jam tidur pada pasien dengan satu atau lebih gejala: rasa kantuk berlebihan, tidur non-restoratif, kelelahan, atau muncul gejala insomnia; bangun tidur dengan tahanan napas, terengah-engah, atau tersedak; kebiasaan mendengkur, gangguan napas, atau keduanya yang disadari oleh orang lain yang tidur bersama atau orang lain; hipertensi, gangguan mood, gangguan kognitif, penyakit arteri koroner, stroke, gagal jantung kongesti, atrial fibrilasi, atau diabetes melitus tipe 2. Penyakit OSA merupakan penyakit kronik yang membutuhkan manajemen jangka panjang dan melibatkan multidisiplin. Pasien yang terdiagnosis OSA perlu diberikan edukasi komprehensif terkait penyakit, faktor risiko, gejala, dan komplikasi dari OSA. Modifikasi gaya hidup perlu dilakukan untuk mengontrol faktor risiko yang dapat memperberat gejala OSA.

Vol 9 No 2 (2022)

PROFIL KARAKTERISTIK KLINIS PASIEN COVID-19 VARIAN OMICRON PADA RUMAH SAKIT DARURAT COVID-19 WISMA ATLET KEMAYORAN

Background : According to WHO, B.1.1529 or omicron has been found as a variant of SARS-CoV-2 with high num-ber of mutations and is easily transmitted. In a month, 108 countries have reported 151.368 cases. This study aims to determine the clinical characteristics of patients with confirmed Covid-19 Omicron variant being treated at Wisma Atlet Kemayoran Hospital. Methods : This research method is descriptive using retrospective data. Secondary data was taken from medical re-cords of patients with Covid-19 Omicron variant who were hospitalized on December 16 – January 16 2022 at Wisma Atlet Kemayoran Hospital. Inclusion criteria was all patients with confirmed mild to moderate COVID-19 Omicron variant. The data were processed by statistical software and analyzed univariately. Results : We reported a total of 227 patients in this study. Majority of samples were women (53.1%), the age average was 19 – 39 years (56.6%), 96.1% had no comorbidities. The majority are foreign travelers (88.2%), with traveler from Asia as much as 70.6%. A total of 96.1% have never had Covid-19 before. As many as 82% have received 2 doses of the vaccine. 56.6% of patients were asymptomatic with symptomatic patients mostly complaint of cough (31.1%). The lowest Hb value was 5.60, the highest leukocyte was 14.39μL, the highest SGOT was 208 U/L, the highest SGPT was 406 U/L and the highest D-Dimer was 8290 ng/mL. A total of 82.5% did not have lung abnormalities seen on x-ray. Conclusion : Covid-19 Omicron variant patients in this study are mostly female, with transmission from foreign trav-elers, the majority are asymptomatic and without pulmonary abnormalities on x-ray, and mostly do not need antibiotic nor antiviral therapy.
Keyword: Clinical characteristic; Covid-19; Omicron

Vol 9 No 2 (2022)

Penatalaksanaan TB Diseminata dan Pneumonia Pada Pasien Gangguan Hati Kronis : Sebuah Laporan Kasus

Iis Widiayati1, Jesica Supriadi1, Nenny Agustanti2, Pandji Irani Fianza3

1Departemen Penyakit Dalam, Rumah Sakit Umum Hasan Sadikin, Fakultas Kedokteran, Universitas Padjadjaran, Bandung, Indonesia.

2Divisi Gastroenterohepatologi, Departemen Penyakit Dalam, Rumah Sakit Umum Hasan Sadikin, Fakultas Kedokteran, Universitas Padjadjaran, Bandung, Indonesia.

3 Divisi Hematoonkologi Medik, Departemen Penyakit Dalam, Rumah Sakit Umum Hasan Sadikin, Fakultas Kedokteran, Universitas Padjadjaran, Bandung, Indonesia.

 

ABSTRAK

     Frekuensi tuberkulosis meningkat empat belas kali lipat pada pasien dengan penyakit hati kronis dan sirosis hati (SH). Pemilihan obat anti tuberkulosis (OAT) pada pasien SH perlu memperhatikan derajat fibrosis hati. Pneumonia merupakan penyebab kedua tersering yang menyebabkan Acute on Chronic Liver Failure (ACLF) setelah Secondary Bacterial Peritonitis (SBP). CLIF Consortium Organ Failure Score  (CLIF-SOFA) dapat dipakai untuk memprediksi mortalitas SH dengan pneumonia.

     Seorang laki-laki berusia 53 tahun datang ke instalasi gawat darurat (IGD) dengan keluhan buang air besar hitam. Keluhan disertai adanya batuk lama, penurunan berat badan, demam, serta keringat malam. Pasien sudah diketahui menderita hepatitis B dan mendapatkan terapi Tenofovir sejak April 2022. Pasien didiagnosa dengan TB diseminata (TB milier dan peritonitis TB) dan terkonfirmasi dengan ditemukannya Mycobacterium tuberculosis (MTB) pada  hasil Tes Cepat Molekuler (TCM) sputum dan cairan asites. Pasien diterapi dengan regimen RHES. Pada hari perawatan kelima pasien didiagnosa dengan Hospital Acquired Pneumonia dan mendapatkan terapi Ceftazidime dan Levofloxacine. Pasien meninggal pada hari perawatan kesembilan karena repiratory failure.

     Pasien dengan Child-Turcotte-Pugh score  13 sebaiknya pasien diterapi dengan menggunakan obat yang tidak hepatotoksik selama 18-24 bulan. Pasien mengalami pneumonia pada hari perawatan kelima dengan skor CLIF-SOFA 10. Pneumonia mencetuskan terjadinya ACLF pada pasien. Semakin tinggi skor CLIF-SOFA, maka akan meningkatkan mortalitas pasien SH dengan pneumonia.

     Pemilihan OAT pada pasien dengan sirosis hati harus disesuaikan dengan derajat fibrosis hati. Deteksi infeksi pneumonia dan perhitungan CLIF-SOFA pada pasien SH dalam perawatan harus dilakukan sedini mungkin karena pneumonia merupakan penyebab ACLF kedua tersering dan meningkatkan mortalitas pada pasien sirosis hati.

Kata kunci: TB diseminata, pneumonia, sirosis hepatis, obat anti tuberkulosis

ABSTRACT

     Tuberculosis incidence increases fourteenfold in chronic liver disease and cirrhotic patients. The degree of liver fibrosis must be considered when selecting anti-tuberculosis drugs in cirrhotic patients. After Secondary Bacterial Peritonitis (SBP), Pneumonia is the second most common cause of Acute on Chronic Liver Failure (ACLF). CLIF Consortium Organ Failure Score (CLIF-SOFA) can predict mortality in cirrhotic and pneumonia patients.

     A 53-year-old man arrived at the emergency department complaining of black stools, a long cough, weight loss, fever, and night sweats. The patient had been treated for hepatitis B with Tenofovir since April 2022. He was diagnosed with disseminated tuberculosis (miliary and peritonitis tuberculosis). His sputum and ascites fluid contained Mycobacterium tuberculosis (MTB). He received RHES regimen treatment. He was diagnosed with Hospital Acquired Pneumonia on the fifth day and was given Ceftazidime and Levofloxacine. He died on the ninth day due to respiratory failure.

     Patients with a Child-Turcotte-Pugh score of 13 should be treated for 18-24 months with non-hepatotoxic drugs. On the fifth day, the patient developed pneumonia, and his CLIF-SOFA score was 10. In this patient, pneumonia can trigger ACLF. The higher the CLIF-SOFA score, the greater the mortality in a cirrhotic patient with pneumonia.

     We must consider the degree of liver fibrosis when selecting anti-tuberculosis drugs for patients with liver cirrhosis. Early detection of pneumonia is critical and the calculation of CLIF-SOFA score in cirrhotic patients must be performed as early as possible because pneumonia is the second most common cause of ACLF and it might increase mortality risk in cirrhotic patients.

Keywords: Disseminated TB, pneumonia, cirrhosis, anti-tuberculosis drugs

Vol 9 No 2 (2022)

IMPLEMENTASI KEPERAWATAN POLA NAPAS TIDAK EFEKTIF PADA KASUS ASMA BRONKIAL

Lily Marleni1, Mardiah2, Lia Pitriani3

1,2,3Sekolah Tinggi Ilmu Kesehatan Siti Khadijah Palembang

Email : lilyasheeqa@gmail.com

Abstrack

Asma adalah suatu keadaan dimana saluran napas mengalami penyempitan karena hiperaktivitas terhadap rangsangan tertentu, yang menyebaabkan peradangan/inflamasi, penyempitan ini bersipat sementara. Peradangan pada saluran pernapasan disebabkan oleh allergen, yang tampil dalam bentuk ingesta dimana allergen masuk ke dalam tubuh melalui mulut terutama makanan dan obat-obatan. Selain itu juga bisa dalam bentuk inhalan yaitu allergen yang masuk kedalam tubuh melalui hidung seperti debu atau polusi , bulu binatang, serbuk bunga yang menimbulkan gejala sesak napas, mengi, dada terasa nyeri,batuk. Tujuan penelitian ini adalah untuk memberikan Asuhan keperawatan pola napas tidak efektif pada Tn.R dengan kasus Asma Bronkial. Waktu penelitian dilakukan pada tanggal 28 April 2022 di ruang rawat inap Rumah Sakit Bhayangkara M.Hasan Palembang. Metode penguumpulan data dilakukan dengan metode deskriftif dengan cara wawancara dan observasi. Hasil studi kasus pada Tn.R didapatkan pengkajian yaitu kesadaran conpos mentis, pasien tampak sesak, batuk dan mengi, tekanan darah 130/80 mmHg, nadi 80x/menit, Respiration rate 28x/ menit,dan suhu tubuh 36,5 OC. Diagnosa yang ditegakkan yaitu pola napas tidak efektif berhubungan dengan hambatan upaya napas.Adapun implementasi keperawatan yang dilakukan mengatur posisi semi flowler, memberikan O2,meng observasi tanda-tanda vital, memonitor kemampuan batuk efektif, memonitor pola napas, mengajarkan batuk efektif, mengajarkan relaksasi napas dlam, memberikan minum air hangat, dan menganjurkan pasien istirahat yang cukup..Evaluasi keperawatan dengan metode SOAP dengan masalah pla napas tidak efektif masalah teratasi. Dengan demikian diharapkan kepada pasien olahraga yang tidak berlebihan, hindari asap rokok,yang menyebabkan sesak napas dan batuk menjaga lingkuangan yang nyaman dan bersih

Kata Kunci : Asma Bronkial,  Implementasi Keperawatan, Pola Napas Tidak Efektif

 

Vol 9 No 2 (2022)

COVID-19 Coinfection and Vaccination Profile Amongst People with HIV/AIDS (PWHA) in Indonesia: a Preliminary Study

Sasfia Candrianita1, Rudi Wisaksana1,2, Yovita Hartantri1,2, Uun Sumardi1,2, Susantina Prodjosoewojo1,2, Marita Restie Tiara1, Primal Sudjana1,2, Bachti Alisjahbana1,2

1Internal Medicine Department, Faculty of Medicine Universitas Padjadjaran / Hasan Sadikin General Hospital, Bandung, Indonesia

2Tropical Disease and Infection Division, Internal Medicine Department, Faculty of Medicine Universitas Padjadjaran / Hasan Sadikin General Hospital, Bandung, Indonesia

 

Abstract

Introduction

COVID-19 pandemic that has been occurred for more than two years yields a huge impact for PWHA population. Due to their immunocompromised status, PWHA have greater risk of being coinfected with COVID-19. COVID-19 vaccine as a preventive way of SARS CoV-2 virus transmission has been administered for the PWHA, however the epidemiological studies remain limited.

Method

                This was the first cross-sectional study in Indonesia, analysing COVID-19 coinfection and vaccination coverage in the PWHA population. A total of 307 PWHA who came to the HIV Clinic, Hasan Sadikin General Hospital were included in this study. The data regarding social history, HIV medical history, comorbidity, as well as COVID-19 coinfection and vaccination was obtained from both anamnesis and medical record. The patients` sera were obtained for IgG and IgM SARS CoV-2 rapid test analyses. Analyses were conducted using SPSS version 20, utilising Chi-square test for descriptive analysis.

Results

                Three-hundred and seven PWHA from the total of 1971 patients in the HIV clinic during June 2021 – November 2021 period were included. The median age of the patient was 37 (35 – 38) years. Men dominated the PWHA population (230 people, 75%) with male have sex with male as the key population (100 people, 32.4%). On average, the PWHA were on the stadium I HIV (298 people, 96.4%), with 24.3% (75 people) had pulmonary TB coinfection and 7.1% (22 people) had extrapulmonary TB coinfection. Majority of the patients have CD4 > 200 (20.4%) and undetected viral load (13.9%). The patients consumed antiretroviral therapy daily (305 people, 98.7%). There were 13.6% (48 people) of PWHA with COVID-19 coinfection history. First-dose vaccination has been administered within 78.6% (246 people) PWHA, whereas there were 59.5% (188 people) PWHA who received second-dose vaccination. Rapid tests showed positive IgG SARS CoV-2 in 55% (170 people) PWHA, nevertheless IgM SARS CoV-2 was detected in 1.9% (6 people) PWHA. There was 61.3% seroconversion of the SARS CoV-2 IgG antibody following COVID-19 first-dose vaccination (p-value <0.05).

Discussion

Immunocompromised status of the PWHA renders the population towards vulnerability of having secondary infection. The COVID-19 infection risk in the PWHA population is somewhat similar to the general population. First-dose vaccination coverage in the PWHA impressively surpassed the national coverage target (>70%), though in the beginning of the pandemic there was hesitancy to complete the vaccination. Vaccination was significantly associated with seroconversion towards IgG SARS CoV-2 antibody in the PWHA population.

Conclusion

This was the first epidemiological study regarding COVID-19 coinfection and vaccination in the PWHA population in Indonesia. COVID-19 vaccination is recommended for the PWHA population.

Keywords: Antibody, COVID-19, HIV, PWHA, Vaccine

Vol 9 No 2 (2022)

Fall and Rise Phenomenon pada Tuberkulosis Paru Poliresisten dengan Intoleransi Rifampisin: Sebuah Tantangan dalam Diagnostik dan Terapeutik

Nabila Nauli Asriputri1, Naufal Fauzan Ihsan2, Arto Yuwono Soeroto3

 

1Departemen Ilmu Penyakit Dalam, Fakultas Kedokteran Universitas Padjadjaran / RSUP Dr. Hasan Sadikin, Bandung

2Tuberculosis Working Group, Pusat Riset Pengelolaan dan Pengendalian Penyakit Infeksi (PRP3I) Universitas Padjadjaran

3Divisi Pulmonologi dan Respirasi Kritis, Departemen Ilmu Penyakit Dalam, Fakultas Kedokteran Universitas Padjadjaran / RSUP Dr. Hasan Sadikin, Bandung 

ABSTRAK

Latar Belakang: Penanganan tuberkulosis (TB) yang tidak tepat dapat menyebabkan fall and rise phenomenon, yaitu peningkatan kembali jumlah bakteri Mycobacterium tuberculosis (MTB) karena pengobatan tidak adekuat yang meningkatkan kemungkinan kekambuhan dan kekebalan obat. Penanganan semakin sulit dengan adanya intoleransi terhadap rifampisin.

Laporan Kasus: Seorang wanita 43 tahun dengan riwayat pengobatan TB paru berulang dirujuk ke RSUP Dr. Hasan Sadikin Bandung karena diduga mengalami TB resisten obat (TB-RO). Pasien mempunyai riwayat pengobatan TB sejak tahun 2009 – 2022, namun keluhan terus berulang dan semakin memberat. Pemilihan regimen OAT menjadi semakin sulit karena adanya riwayat intoleransi terhadap rifampisin. Uji kepekaan obat fenotipik dan genotipik menunjukkan adanya resistensi isoniazid, ethambutol, pirazinamid, serta fluorokuinolon. Pengobatan TB diputuskan menggunakan regimen individual karena adanya poliresistensi.

Diskusi: TB poliresisten merupakan kondisi dimana seseorang mengalami resistensi terhadap lebih dari satu OAT lini pertama selain isoniazid dan rifampisin secara bersamaan. Kondisi ini dapat dilatarbelakangi terjadinya fall and rise phenomenon, dimana pengobatan TB yang tidak adekuat dapat menurunkan jumlah kuman MTB di awal, namun organisme yang bertahan dapat berproliferasi dan bermutasi, sehingga meningkatkan risiko kekambuhan dan resistensi. Deteksi TB-RO dilakukan dengan uji kepekaan obat fenotipik dan genotipik. Akan tetapi, akses pemeriksaan ini masih terbatas sehingga diagnosis TB-RO masih menjadi tantangan. Penentuan regimen dipersulit dengan intoleransi rifampisin. Pada kasus ini, tatalaksana dengan regimen individual TB multi drug resistant (TB-MDR) dapat menjadi pilihan

Kesimpulan: Anamnesis dan pemeriksaan fisik mendetail, serta akses pemeriksaan penunjang berperan penting pada diagnosis TB, terutama pada kasus kekambuhan berulang. Pemberian regimen pengobatan yang sesuai dengan panduan dapat mencegah terjadinya kegagalan dan resistensi.

 

Kata Kunci: tuberkulosis, poliresisten, intoleransi, rifampisin

 

 

ABSTRACT

Introduction: Inadequate treatment of tuberculosis (TB) can result in a rise in the number of Mycobacterium tuberculosis (MTB) bacteria, increasing the risk of recurrence and drug resistance. This phenomenon is known as the fall and rise phenomenon. Rifampicin intolerance makes treatment more challenging.

Case Presentation: A 43-year-old woman with a history of recurrent treatment for TB was referred to Dr. Hasan Sadikin Bandung because of drug-resistant TB (DR-TB) suspected. Despite receiving TB therapy from 2009 to 2022, the patient's problems continue to persist and worsen. A history of rifampicin intolerance makes selecting an OAT regimen more challenging. Phenotypic and genotypic drug sensitivity tests showed resistance to isoniazid, ethambutol, pyrazinamide, and fluoroquinolones. Treatment of TB was decided with individualized regimen due to polyresistance.

Discussion: Polyresistant TB defined as a condition in which a person develops concurrent resistance to more than one first-line medication other than isoniazid and rifampin. This condition may be caused by the fall and rise phenomenon, wherein insufficient TB therapy may initially result in a reduction in the number of MTB germs, but the surviving organisms may then multiply and undergo mutations, raising the chance of recurrence and resistance. Phenotypic and genotypic drug sensitivity testing were used to detect DR-TB. However, since the access to this examination is still limited, the diagnosis of DR-TB is still difficult. Rifampicin intolerance makes choosing a therapy regimen more challenging. In this case, treatment with an individual regimen of multi-drug resistant TB (MDR-TB) may be an option.

Conclusion: Detailed history and physical examination, as well as access to supporting examinations play  important roles in the diagnosis of TB, particularly in cases of repeated recurrence. Providing a treatment regimen that is in accordance with the guidelines can prevent failure and resistance.

 

Keywords: tuberculosis, polyresistant, intolerance, rifampicin

 

 

Vol 9 No 2 (2022)

HUBUNGAN OBSTRUCTIVE SLEEP APNEA DAN COVID-19

 

Telly Kamelia, Jihaan Hafirain

Divisi Pulmonologi dan Medik Kritis, Departemen Ilmu Penyakit Dalam

Fakultas Kedokteran Universitas Indonesia, RSUPN. Dr. Cipto Mangunkusumo, Jakarta

 

 

ABSTRAK

Pandemi Covid-19, infeksi saluran nafas yang disebabkan oleh virus SARS-CoV2, menyebabkan morbiditas dan mortalitas yang tinggi di seluruh dunia. World Health Organization (WHO) melaporkan lebih dari 533 juta kasus terkonfirmasi Covid, dengan 6,3 juta kematian di seluruh dunia.1  Di Indonesia, kasus Covid-19 sempat menurun di awal tahun 2022 namun akhir-akhir ini kembali meningkat. Berdasarkan laporan Kementrian Kesehatan RI, tedapat 6.668 kasus aktif di Indonesia dengan 1.173 kasus terkonfirmasi baru per tanggal 16 Juni 2022.2 Pasien terkonfirmasi Covid-19 memiliki derajat keparahan yang beragam, dari tidak bergejala, bergejala ringan, sedang, berat hingga kritis. Derajat keparahan ini dipengaruhi oleh beberapa faktor, termasuk komorbid yang dimiliki pasien.

Kata Kunci : Covid-19, SARS-CoV2

Vol 9 No 2 (2022)

 Analysis Of The Effect Of Web-Based Electronic Expedition On The Time Of Availability Of Medical Records At Mangusada Regional Hospital, Badung Regency

Ni Putu Dian Efriliana1, I Wayan Widi Karsana2, Rai Riska Resty Wasita3

Program Studi Perekam dan Informasi Kesehatan, Universitas Dhyana Pura1,2,3

Email : efriliana36@gmail.com

Abstract

Expeditions for borrowing and returning inpatient medical records at the Mangusada Regional Hospital are still carried out manually by writing in the expedition book. The use of manual expedition books has a risk, namely data can be lost, torn and data is difficult to find so that it affects the delay in patient service time and delays in providing medical records. The Standard Operating Procedure for providing medical records at the Mangusada Regional Hospital is adjusted to the Minimum Service Standard, which is 15 minutes. The research design used in this study is Pre-Experimental Design. The system development analysis method used is the System Development Life Cycle (SDLC). Usability test results obtained a percentage value of 80% which can be classified as "Good". The Mann Whitney test results get a significant value of 0.000 <0.05 which indicates the influence of web-based electronic expeditions on the time of providing inpatient medical records at the Mangusada Regional Hospital, Badung Regency. The conclusion obtained in this study is that there is an effect of web-based electronic expeditions on the time of providing inpatient medical records at the Mangusada Regional Hospital, Badung Regency with a significance value of 0.000 and the average time of providing inpatient medical records is 11 minutes.

 

Keywords: Electronic Expedition, Provision of Medical Records, Hospitalization

Vol 9 No 2 (2022)

Analysis Of The Relationship Between Incompleteness Of The Initial Medical Assessment Form Of Inpatients To The Near-Injury Incidence In The Mangusada Regional Hospital

Ni Putu Anggi Riyani1, Bambang Hadi Kartiko2, Dylla Hanggaeni Dyah Puspaningrum3

Program Studi Perekam dan Informasi Kesehatan, Universitas Dhyana Pura1,2,3

Email : ptanggiryn@gmail.com

 

Abstract

Patient safety incidents are events that happen to patients intentionally or not so that the condition can become a potential or result in injury to patients which include Near-Injury Incidence (KNC), Unexpected Incidence (KTD), Unscathed Incidence (KTC), Potential Injury Incidence (KPC) and Sentinel, where this patient safety incident is not allowed to occur in patients and should even be preventable because this has been categorized as a  officer discipline. Based on preliminary observations at Mangusada Hospital, there is an increase in KNC in 2021 compared to other patient safety incidents, namely KTD, KTC, KPC and Sentinel which have decreased every one year. In 2019 there were 41 cases, KNC in 2020 there were 68 cases of KNC and in 2021 it increased to 97 cases of KNC. The purpose of the study was to determine the relationship between the incompleteness of the initial medical assessment form of inpatients to KNC at Mangusada Hospital. The research design used is quantitative analytics. The study sample was an incomplete initial medical assessment form for inpatients as many as 120 in October - December 2021 with sampling using purposive sampling techniques. The instrument of this study is observation and checklist, using univariate and bivariate data analysis. The results of the study from 120 initial medical assessment forms of inpatients obtained incomplete identification reviews totaling 14 (11.7%), incomplete authentication reviews 23 (19.2%), incomplete important reporting reviews 66 (55%) and in incomplete documentation reviews 17 (14.2%). Based on the results of the chi-square test, it was found that the four reviews on the initial medical assessment form of inpatients had a significant relationship with the occurrence of KNC with a p-value of <0.005. The conclusion of this study is that there is a significant association of the incompleteness of the four reviews on the initial medical assessment form (identification review, authentification review, important reporting review and documenting review) to the occurrence of KNC with a p-value = 0.000.

Keywords: Incomplete of Initial Medical Assessment Form, Near-Injury Incidence

Vol 9 No 2 (2022)

ANALISIS PENGARUH PELATIHAN TERMINOLOGI DAN KODE PENYEBAB CEDERA KECELAKAAN TRANSPORTASI DARAT TERHADAP PELAPORAN MORBIDITAS PENYEBAB CEDERA PASIEN RAWAT INAP DI RUMAH SAKIT   DAERAH MANGUSADA

THE ANALYSIS OF EFFECT OF TERMINOLOGY TRAINING AND THE CODE FOR THE CAUSE OF INJURY TO LAND TRANSPORTATION ACCIDENT ON INJURY MORBIDITY REPORTS OF INPATIENTS AT THE MANGUSADA REGIONAL HOSPITAL

Ni Putu Anggun Meilia Kusuma Dewi1, Rai Riska Resty Wasita2, Made Nyandra3

Program Studi Perekam dan Informasi Kesehatan, Universitas Dhyana Pura1,2

Program Studi Kesehatan Masyarakat, Universitas Dhyana Pura3

Email: putuanggun2505@gmail.com

 

Abstract

In the accuracy of reporting the morbidity that causes injury to patients in land transportation accidents, the process processing data in the patient's medical record is important. The results of a preliminary study on 50 medical records, the right terminology is 14, the right code is 14, the right morbidity report data is 14. The study aims to determine the effect of the terminology training and the code for the cause of injury to land transportation accident patients on the accuracy of the terminology, code, and data on morbidity reports. The research design was pre-experimental designs with one group pre-post test design. Data analysis using the Wilcoxon test. The research sample was 3 admins of inpatient installations and 50 medical records of inpatients in injuries cases of land transportation accident before and after the intervention. The results showed an increase after the intervention of terminology and code of causes of injury to patients in land transportation accidents. The accuracy of the previous terminology is 14 (28%) to 50 (100%) Wilcoxon test results ρ=0.000, the previous code accuracy is 14 (28%) to 50 (100%) Wilcoxon test results ρ=0.000, the accuracy of the previous morbidity report data is 14 (28 %) to 50 (100%) Wilcoxon test results ρ=0.000. Based on the results, it can be concluded that there was a significant effect after the intervention in the form of training in terminology and codes of causes of injury to patients in land transportation accidents on the accuracy of terminology, codes, and data on morbidity reports that cause land transportation accidents in inpatients at the Mangusada Regional Hospital.

Keywords: Injury Case Terminology and Codes, Morbidity Reporting, Land Transport Accidents, Training

Abstrak

Dalam ketepatan pelaporan morbiditas penyebab cedera pasien kecelakaan transportasi darat proses pengolahan data dalam rekam medis pasien penting diperhatikan. Hasil studi pendahuluan pada 50 rekam medis, terminologi yang tepat 14, kode yang tepat 14, data laporan morbiditas yang tepat 14. Penelitian bertujuan mengetahui pengaruh pelatihan terminologi dan kode penyebab cedera pasien kecelakaan transportasi darat terhadap ketepatan terminologi, kode, dan data laporan morbiditas. Rancangan penelitian adalah pre experimental designs dengan one group pre-post test design. Analisis data penelitian menggunakan uji wilcoxon. Sampel penelitian adalah 3 orang admin instalasi rawat inap dan 50 rekam medis pasien rawat inap kasus cedera kecelakaan transportasi darat sebelum dan setelah intervensi. Hasil penelitian menunjukkan peningkatan setelah intervensi pelatihan terminologi dan kode penyebab cedera pasien kecelakaan transportasi darat. Ketepatan terminologi sebelumnya 14 (28%) menjadi 50 (100%) hasil uji wilcoxon ρ=0.000, ketepatan kode sebelumnya 14 (28%) menjadi 50 (100%) hasil uji wilcoxon ρ=0.000, ketepatan data laporan morbiditas sebelumnya 14 (28%) menjadi 50 (100%) hasil uji wilcoxon ρ=0.000. Berdasarkan hasil penelitian diperoleh kesimpulan terdapat pengaruh signifikan setelah intervensi berupa pelatihan terminologi dan kode penyebab cedera pasien kecelakaan transportasi darat terhadap ketepatan terminologi, kode, data laporan morbiditas penyebab cedera.

 

Kata Kunci: Terminologi dan Kode Kasus Cedera, Pelaporan Morbiditas, Kecelakaan Transportasi Darat, Pelatihan