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Abstrak :
[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 Medical Resume 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 accuracy medical record filling including medical resume., 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 Medical Resume 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 accuracy medical record filling including medical resume]

Abstrak :
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. ...... 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.

Abstrak :
Tujuan: Dalam menilai status gizi usia lanjut (lansia) seringkali ditemukan kesulitan pengukuran tinggi badan (TB) akibat kelainan tulang belakang dan mobilitas. Salah satu alternatifnya menggunakan nilai prediksi dari panjang depa, tinggi lutut, dan tinggi duduk. Beberapa persamaan ketiga prediktor tersebut telah dikembangkan untuk memperkirakan TB lansia Indonesia. Persamaan yang tertuang dalam kartu Penilaian Status Gizi (PSG) lansia ini dan merupakan teknologi pertama di Indonesia, harus diujicobakan lebih dahulu sebelum diterapkan di masyarakat. Tujuan studi adalah untuk melakukan verifikasi model TB prediksi dalam kartu PSG dengan TB sebenarnya. Metode: Disain cross sectional melalui pengukuran antropometri pada 400 lansia sehat di Jakarta telah dilakukan. Studi ini merupakan studi validasi kedua, selain studi pertama yang telah dilakukan di Kota Depok mewakili wilayah semi urban. Hasil: Lansia laki-laki memiliki rata-rata usia, TB, berat badan, panjang depa, tinggi lutut, dan tinggi duduk lebih tinggi dibandingkan lansia perempuan. Korelasi terbesar ditemukan pada prediktor tinggi lutut dengan nilai yang sama pada lansia perempuan (r = 0.80; P < 0.001) dan laki-laki (r = 0.78; P < 0.001), selanjutnya panjang depa, dan tinggi duduk. Tinggi lutut memiliki selisih paling rendah dengan tinggi badan sebenarnya pada laki-laki (3,13 cm) dan perempuan (2,79 cm). Tinggi lutut mempunyai nilai sensitivitas tertinggi (92,2%) dan nilai spesifisitas terbesar pada tinggi duduk (91,2%). Kesimpulan: Persamaan TB prediksi berdasarkan panjang depa, tinggi lutut, dan tinggi duduk dapat digunakan dalam menilai status gizi lansia Indonesia.

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Abstract
Aim: In an anthropometric assessment, elderly are frequently unable to measure their height due to mobility and skeletal deformities. An alternative is to use a surrogate value of stature from arm span, knee height, and sitting height. The equations developed for predicting height in Indonesian elderly using these three predictors. The equations put in the nutritional assessment card (NSA) of older people. Before the card which is the first new technology in Indonesia will be applied in the community, it should be tested. The study aimed was to conduct diagnostic test of predicted height model in the card compared to actual height. Methods: Model validation towards 400 healthy elderly conducted in Jakarta City with cross-sectional design. The study was the second validation test of the model besides Depok City representing semi urban area which was undertaken as the first study. Result: Male elderly had higher mean age, height, weight, arm span, knee height, and sitting height as compared to female elderly. The highest correlation between knee height and standing height was similar in women (r = 0.80; P < 0.001) and men (r = 0.78; P < 0.001), and followed by arm span and sitting height. Knee height had the lowest difference with standing height in men (3.13 cm) and women (2.79 cm). Knee height had the biggest sensitivity (92.2%), and the highest specificity on sitting height (91.2%). Conclusion: Stature prediction equation based on knee-height, arm span, and sitting height are applicable for nutritional status assessment in Indonesian elderly.