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"[Resume medis merupakan ringkasan seluruh masa perawatan dan pengobatan yang dilakukan oleh dokter kepada pasien. Kelengkapan resume medis adalah cerminan mutu rekam medis dan pelayanan yang diberikan oleh rumah sakit. Penulisan diagnosis diisi lengkap dan sesuai arahan pada ICD-10. Penelitian dengan mix method, penelitian kuantitatif desain potong lintang untuk mengetahui hubungan karakteristik dokter dengan kelengkapan resume medis dan kesesuaian penulisan diagnosis berdasarkan ICD-10 sebelum dan sesudah JKN. Penelitian kualitatif untuk menggali informasi kelengkapan resume medis dan kesesuaian penulisan diagnosis berdasarkan ICD-10. Hasil penelitian menunjukkan karakteristik dokter berhubungan dengan kelengkapan dan kesesuaian penulisan diagnosis berdasarkan ICD-10. Rumah sakit harus menerapkan SIMRS guna peningkatan kecepatan dan ketepatan pengisian rekam medis termasuk resume medis.;Medical Resume is summary of the whole treatment and medication that performed by doctor to patient. Resume medical completeness is reflections of the medical record quality and service which given by Hospital. Diagnosis Writing filled complete and according to ICD-10. Research with mix method, Quantitative research design cross-sectional to know relationship doctor characteristic with MedicalResume completeness and diagnosis writing suitability based on ICD-10 before and after JKN. Qualitative Research for dig information medic resume completeness and diagnose writing suitability based on ICD-10. Research Result showing the doctor characteristic correspond with completeness and suitability diagnosis writing based on ICD-10. The hospital must apply SIMRS in order to increase speed and accuracymedical record filling including medical resume., Medical Resume is summary of the whole treatment and medication that performedby doctor to patient. Resume medical completeness is reflections of the medicalrecord quality and service which given by Hospital. Diagnosis Writing filledcomplete and according to ICD-10. Research with mix method, Quantitative researchdesign cross-sectional to know relationship doctor characteristic with MedicalResume completeness and diagnosis writing suitability based on ICD-10 before andafter JKN. Qualitative Research for dig information medic resume completeness anddiagnose writing suitability based on ICD-10. Research Result showing the doctorcharacteristic correspond with completeness and suitability diagnosis writing basedon ICD-10. The hospital must apply SIMRS in order to increase speed and accuracymedical record filling including medical resume]"

"Penelitian ini dilatarbelakangi oleh masih tingginya pengembalian berkas klaim Inacbg’s Rawat Inap di RS Kanker “Dharmais” dimana pengembalian tertinggi disebabkan oleh konfirmasi koding dan resume medis. Hal ini berpotensi menimbulkan kerugan bagi RS akibat pembayaran klaim yang tertunda. Penelitian ini bertujuan untuk melakukan analisis kelengkapan dan ketepatan komponen diagnosis, prosedur dan koding terhadap besaran tarif klaim INA-CBG’s rawat inap di RS Kanker “Dharmais”. Studi kasus ini menggunakan pendekatan kualitatif dengan wawancara mendalam dan telaah resume medis pasien kanker payudara yang mendapatkan kemoterapi selama bulan Maret 2018. Hasil penelitian menunjukkan bahwa ketidaklengkapan pengisian resume medis tertinggi dalam pengisian indikasi masuk rawat 41%, pemeriksaan fisik 20%, dan pemeriksaan penunjang 4% dari total 45 kasus yang ditelaah. Angka ketidaksesuaian penulisan diagnosis sekunder dan prosedur berturut-turut sebesar 40% dan 37.8%. Namun penulisan diagnosis utama sudah sesuai antara rekam medis dan resume medis. Ketidaktepatan koding diagnosis utama masih ditemukan yaitu sebesar 17.8%. Akibat dari ketidaktepatan koding diagnosis utama, ketidaksesuaian diagnosis sekunder dan ketidaksesuaian prosedur/tindakan terdapat selisih negatif sebesar Rp. 142.763.800. Untuk itu komitmen dari manajemen RS Kanker “Dharmais” yaitu tim yang terlibat dalam koding final yang merupakan tim internal rumah sakit perlu diperkuat dalam rangka meningkatkan kualitas berkas klaim dari aspek kelengkapan dan ketepatan diagnosis, prosedur dan koding sehingga didapatkan nilai klaim INA-CBG’s yang tepat.

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The background of this research is the highest return of inpatient Inacbg’s claim in Dharmais Cancer Center because of confirmation of coding and medical resume. This would potentially become hospital loss of payment due to pending claims payments. The study was aiming to analyzing the completeness and accuracy of diagnosis, procedure and coding against amount of INA-CBG’s inpatient claim rate in Dharmais National Cancer Center. This case study research was using a qualitative approach by doing the indeph interview and analyzing the medical resume of breast cancer patients who received chemotherapy during March 2018. The result revealed that the incompleteness of the medical resume written was high in certain component e.a indication of admission (41%), physical examination (20%), supporting investigation(4%) of total 45 cases reviewed. Incorrect written of secondary diagnosis and procedure was 40% and 37.8%. Primary diagnosis is found match between medical record and medical resume. However, inaccuracy of primary diagnosis coding was found in the amount of 17.8%. Due to incompleteness and inaccuracy of claim have potentially effect hospital loss approximately by Rp. 142.763.800. Therefore, hospital should empowered the internal team tahat involve in the process of final coding in order to improve the quality of claim document started from the aspect of completeness and accuracy of diagnosis, procedure and coding to obtain the right claim value of INACBG’s."

"Resume medis merupakan ringkasan dari seluruh masa perawatan dan pengobatan pasien yang wajib diisi lengkap oleh Dokter Penanggung Jawab Pasien (DPJP) dalam 1x24 jam setelah pasien pulang. Penelitian ini dilakukan untuk menganalisis kelengkapan dan ketepatan waktu pengisian resume medis menggunakan pendekatan sistem. Jenis penelitian kualitatif digunakan untuk mendapatkan gambaran input dan transformasi melalui wawancara mendalam serta telaah dokumen, yang kemudian diperkuat dengan penelitian kuantitatif untuk mendapatkan gambaran output, melalui observasi dan telaah formulir. Terdapat 61 sampel formulir resume medis dengan menggunakan perhitungan total sampling. Hasil penelitian menunjukkan bahwa persentase resume medis yang termasuk ke dalam kategori terpenuhi lengkap hanya 16,4%, sedangkan dari segi ketepatan waktu ditemukan hanya 45,9% pengisian resume medis yang termasuk ke dalam kategori tepat waktu. Rata-rata waktu pengisian resume medis yaitu 32,3 jam. Kelompok item identitas pasien dan data perawatan memiliki distribusi keterisian terendah, sedangkan distribusi keterisian tertinggi terdapat pada kelompok item data medis dan data autentikasi. Masih terdapat perbedaan pengetahuan dalam pengisian resume medis, kurangnya motivasi dokter, evaluasi format formulir yang belum rutin dilaksanakan, adanya inkonsistensi kebijakan rumah sakit, belum ada sistem reward dan punishment untuk dokter, belum ada diklat khusus resume medis, terdapat perbedaan persepsi mengenai alur pengisian resume medis, serta konflik dalam komunikasi interpersonal.

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.Discharge summary is a resume of all patient care and treatment periods that must be filled in completely by the doctor in charge within 1x24 hours after the patient was declared discharged. This study discuss about the completeness and the timeliness of filling in discharge summary by using the system approach. This research is a qualitative study to obtain input and transformation through in-depth interviews and review of hospital documents, then reinforced with quantitative research to get an overview of the output, through observation and study of discharge summary forms. Obtained 61 discharge summary forms used as research samples by using the calculation of total sampling. The results showed that the percentage of discharge summary included in the category fulfilled was only 16.4%, while in terms of timeliness it was found that only 45.9% of filling discharge summary were included in the appropriate time accuracy category. The average time needed for a doctor to get a discharge summary is 32.3 hours. The patient identity and the nursing data items group had the lowest filling distribution, while the highest filling distribution was in the medical data and data authentication group. There are still differences in knowledge in filling out discharge summary, lack of motivation of the doctors, form formats evaluation that have not been carried out routinely, there is no reward system, punishment system and special training for discharge summary, differences in perceptions regarding the flow of the discharge summary filling process, and the discovery of conflicts related to communication."

"Latar Belakang : Salah satu dampak sistemik dari penyakit paru obstruktif kronik (PPOK) yaitu modifikasi tipe otot skeletal. Tujuan penelitian ini adalah untuk menilai tingkat kelelahan kaki dengan menilai skala Borg lelah dan asam laktat perifer sebagai penanda kelelahan kakiMetode : Desain penelitian ini adalah studi potong lintang, terdiri dari 34 subjek PPOK dan 25 subjek kontrol sehat yang seusia dengan usia subjek PPOK. Subjek dinilai skala Borg kelelahan kaki lelah dan asam laktat perifer sebelum dan sesudah uji jalan 6 menit (UJ6M).Hasil : Terdapat peningkatan lebih tinggi median asam laktat yang tidak bermakna (p > 0,05) secara statistik antara subjek PPOK (0,5) dibandingkan kontrol (0,45). Terdapat peningkatan median skala Borg lelah yang bermakna (p < 0,001) antara subjek PPOK (5,0) dibandingkan subjek kontrol (1,0). Terdapat jarak tempuh yang lebih besar secara bermakna pada subjek kontrol dibandingkan subjek PPOK (p < 0,05).Kesimpulan : Kelompok PPOK memiliki peningkatan asam laktat yang tidak bermakna dibandingkan kelompok kontrol. Kelompok PPOK memiliki peningkatan skala Borg kaki lelah yang lebih besar dan berbeda bermakna dibandingkan dengan kontrol.

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Background : One of systemic effects of COPD is a modification of skeletal muscle fiber types. The objective of this study is to determine the increase of leg fatigue by using Borg scale leg fatigue and lactic acid level.

Methods : This is a cross-sectional study design. The samples were 34 COPD patients and 25 healthy adults with the same age as COPD patients as the control. The lactic acid level and Borg leg fatigue scale were measured before and after six minute walking test (6MWT).

Results : There was an unsignificantly difference change of median of lactic acid level (p > 0,05) between COPD (0,5 mMol) compared to control (0,45 mMol). There was a statistically significant difference (p < 0,001) change of leg fatigue Borg scale between COPD (5,0) compared to control (1,0). There was a significantly (p < 0,05) higher mean of distance of 6MWT in control subjects (411,62 meters) compared to COPD (364 meters).

Conclusion : COPD patients had an unsignificantly increase of lactic acid level after the 6MWT compared to control subjects. COPD patients had a significantly higher leg fatigue Borg scale compared to control after the 6MWT."