STRUKTUR ORGANISASI DAN TATA KERJA RUMAH SAKIT UMUM DAERAH (RSUD) SAWERIGADING KOTA PALOPO DIREKTUR UTAMA DIREKTUR ADMINISTRASI, KEUANGAN DAN BINA PROGRAM DIREKTUR PELAYANAN BAGIAN ADMINISTRASI DAN KEPEGAWAIAN BAGIAN KEUANGAN BAGIAN BINA PROGRAM, HUMAS DAN HUKUM BIDANG PELAYANAN MEDIK BIDANG PENUNJANG PELAYANAN BIDANG KEPERAWATAN SUB BAGIAN ADMINISTRASI UMUM DAN PERLENGKAPAN SUB BAGIAN ANGGARAN DAN PERBENDAHARAAN SUB BAGIAN PENYUSUN PROGRAM DAN KERJASAMA SEKSI PELAYANAN MEDIK RAWAT JALAN DAN KHUSUS SEKSI PENUNJANG MEDIK SEKSI ASUHAN KEPERAWATAN SUB BAGIAN KEPEGAWAIAN, DIKLAT DAN PENGEMBANGAN SDM SUB BAGIAN AKUNTANSI DAN PELAPORAN SUB BAGIAN HUMAS DAN HUKUM SEKSI PELAYANAN MEDIK RAWAT INAP SEKSI PENUNJANG NON MEDIK SEKSI PENGEMBANGAN DAN MUTU KEPERAWATAN INSTALASI PELAYANAN INSTALASI PENUNJANG SATUAN PEMERIKSAAN INTERNAL (SPI) KOMITE
Struktur Organisasi Instalasi Rekam Medik dan SIMRS Ka. Instalasi Rekam Medik dan SIMRS Ka. Ruangan Rekam Medik Ka. Ruangan S I M R S Pendaftaran Pasien RJ (Registrasi) Penyimpanan dan Distribusi RM Assembling dan Analsis Statistik dan Pelaporan Administrator Database Software Tim Pengembangan Sistem Pendaftaran Pasien RI (Admission) Produksi Formulir RM Koding dan Indeksing Korespondensi Rekam Medis Operator / User Hardware dan Maintenance Jaringan
Frequencies [DataSet1] E:\tea print skripsi\spss\1 tidk lancar~tdk tepat~ tdk lengkap.sav Frequency Table Valid Ketepatan Kode Diagnosa Obstetric Frequency Percent Valid Percent Cumulative Percent 17 38.6 38.6 38.6 27 61.4 61.4 100.0 Total 44 100.0 100.0 Valid Kelengkapan Resume Medis Pasien Obstetric Frequency Percent Valid Percent Cumulative Percent 36 81.8 81.8 81.8 8 18.2 18.2 100.0 Total 44 100.0 100.0 Valid Kelancaran Klaim BPJS Frequency Percent Valid Percent Cumulative Percent 23 52.3 52.3 52.3 21 47.7 47.7 100.0 Total 44 100.0 100.0
Crosstabs [DataSet1] E:\tea print skripsi\spss\1 tidk lancar~tdk tepat~ tdk lengkap.sav Ketepatan Kode Diagnosa Obstetric * Kelancaran Klaim BPJS Case Processing Summary Cases Valid Missing Total N Percent N Percent N Percent 44 100.0% 0 0.0% 44 100.0% Ketepatan Kode Diagnosa Obstetric Total Ketepatan Kode Diagnosa Obstetric * Kelancaran Klaim BPJS Crosstabulation Kelancaran Klaim BPJS Total Count 14 3 17 % within Ketepatan Kode Diagnosa Obstetric 82.4% 17.6% 100.0% Count 9 18 27 % within Ketepatan Kode Diagnosa Obstetric 33.3% 66.7% 100.0% Count 23 21 44 % within Ketepatan Kode Diagnosa Obstetric 52.3% 47.7% 100.0%
Chi-Square Tests Value df Asymp. Sig. (2-sided) Exact Sig. (2-sided) Exact Sig. (1-sided) Pearson Chi-Square 10.047 a 1.002 Continuity Correction b 8.179 1.004 Likelihood Ratio 10.690 1.001 Fisher's Exact Test.002.002 Linear-by-Linear Association 9.819 1.002 N of Valid Cases 44 a. 0 cells (0.0%) have expected count less than 5. The minimum expected count is 8.11. b. Computed only for a 2x2 table Risk Estimate Value 95% Confidence Interval Lower Upper Odds Ratio for Ketepatan Kode Diagnosa Obstetric 9.333 2.121 41.066 ( / ) For cohort Kelancaran Klaim BPJS = 2.471 1.387 4.400 For cohort Kelancaran Klaim BPJS =.265.092.765 N of Valid Cases 44
Crosstabs [DataSet1] E:\tea print skripsi\spss\1 tidk lancar~tdk tepat~ tdk lengkap.sav Kelengkapan Resume Medis Pasien Obstetric * Kelancaran Klaim BPJS Case Processing Summary Cases Valid Missing Total N Percent N Percent N Percent 44 100.0% 0 0.0% 44 100.0% Kelengkapan Resume Medis Pasien Obstetric * Kelancaran Klaim BPJS Crosstabulation Kelengkapan Resume Medis Pasien Obstetric Total Kelancaran Klaim BPJS Total Count 22 14 36 % within Kelengkapan Resume Medis Pasien Obstetric 61.1% 38.9% 100.0% Count 1 7 8 % within Kelengkapan Resume Medis Pasien Obstetric 12.5% 87.5% 100.0% Count 23 21 44 % within Kelengkapan Resume Medis Pasien Obstetric 52.3% 47.7% 100.0%
Chi-Square Tests Value df Asymp. Sig. (2-sided) Exact Sig. (2- sided) Exact Sig. (1- sided) Pearson Chi-Square 6.200 a 1.013 Continuity Correction b 4.404 1.036 Likelihood Ratio 6.764 1.009 Fisher's Exact Test.019.016 Linear-by-Linear Association 6.059 1.014 N of Valid Cases 44 a. 2 cells (50.0%) have expected count less than 5. The minimum expected count is 3.82. b. Computed only for a 2x2 table Risk Estimate Value 95% Confidence Interval Lower Upper Odds Ratio for Kelengkapan Resume Medis Pasien Obstetric 11.000 1.219 99.258 ( / ) For cohort Kelancaran Klaim BPJS = 4.889.767 31.149 For cohort Kelancaran Klaim BPJS =.444.273.723 N of Valid Cases 44
DAFTAR TILIK ANALISIS KUANTITATIF RESUME MEDIS PASIEN OBSTETRI GYNECOLOGY DI RSUD SAWERIGADING KOTA PALOPO-SULAWESI SELATAN Jumlah Resume Medis : 44 Lembar Nama Pelaksana : Andi Tenri Nurrul Izzah Alik Tanggal : 10-24 Mei 2016 No. No. RM Identifikasi Pasien Laporan Penting Autentikasi Catatan Yang Baik 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 1 30 23 27 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 30 40 44 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 3 30 37 34 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 4 30 17 91 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 5 30 32 74 1 1 1 0 1 1 1 1 1 1 1 1 0 1 1 1 1 1 0 1 1 1 0 1 0 1 1 0 6 19 61 91 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 7 30 35 11 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 8 28 38 69 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 9 30 37 65 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 10 12 41 79 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 11 30 21 03 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 12 30 26 64 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 13 17 98 23 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 14 30 23 59 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 15 30 28 19 1 1 1 1 1 1 1 1 1 1 0 0 0 0 1 1 1 1 1 1 1 1 0 1 1 1 1 0 16 30 26 51 1 1 1 1 1 1 1 1 1 1 1 1 0 1 1 1 1 1 1 1 1 1 0 1 1 1 1 0 17 30 37 79 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 18 30 15 01 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 19 30 30 04 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 20 24 60 58 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 21 28 85 89 1 1 1 1 1 1 1 1 1 0 1 1 1 1 1 1 0 0 1 1 1 1 0 1 1 1 1 0 22 30 17 76 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 23 30 37 13 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 24 30 28 83 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 25 30 37 45 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 26 30 26 37 1 1 1 1 1 1 1 1 1 0 1 1 0 0 1 1 1 1 1 1 1 1 0 1 1 1 1 0 27 30 32 87 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 28 30 32 89 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 29 29 29 09 1 1 1 1 1 1 1 1 1 1 1 1 0 1 1 1 0 0 1 1 1 1 0 1 1 1 1 0 30 30 21 10 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 31 30 35 19 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 32 30 37 07 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 33 30 19 88 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 34 29 72 11 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 35 27 08 20 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 36 30 32 56 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 37 30 40 10 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 38 30 23 52 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 39 30 17 65 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
40 30 37 82 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 41 30 35 50 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 42 30 28 08 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 0 1 1 1 1 1 1 1 1 1 0 43 28 60 37 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 44 20 21 12 1 1 0 1 1 1 1 1 1 0 1 1 1 1 1 1 0 1 1 1 1 1 0 1 1 1 1 0 Total 50 50 48 49 49 50 50 50 50 46 48 49 45 47 50 50 47 46 48 50 50 50 40 50 48 50 50 39 Keterangan : Identifikasi Pasien : (1) Nama pasien, (2) No.RM, (3) Tgl lahir, (4) Jenis kelamin, (5) Tgl masuk, (6) Tgl keluar, (7) Ruang rawat terakhir Laporan Penting : (8) Penanggungan pembayaran, (9)Keluhan saat masuk RS, (10) Ringkasan riwayat penyakit, (11) Pemeriksaan fisis,...(12) Pemeriksaan penunjang,. (13)Terapi, (14) Hasil konsultasi, (15) Diagnosis utama,.....(16) Diagnosis sekunder,. (17) Tindakan/prosedur, (18) Alergi(reaksi obat), (19) Instruksi pulang,...(20) Edukasi(follow up), (21) Kondisi keluar RS, (22) Terapi pulang Autentikasi Penulisan : (23) Nama dokter, (24) Tanda tangan dokter, (25) Tanggal Catatan Yang Baik : (26) ada coretan, (27) ada tipe-x, (28) kolom yang kosong
REKAPITULASI ANALISIS KUANTITATIF RESUME MEDIS PASIEN OBSTETRIC DI RSUD SAWERIGADING KOTA PALOPO-SULAWESI SELATAN Jumlah Resume Medis : 44 Lembar Tanggal : 10-24 Mei 2016 No. Kriteria Analisis Kelengkapan Jumlah Persentase Identitas Pasien 1 Nama pasien 44 100 2 No.RM 44 100 3 Tgl lahir 43 98 4 Jenis kelamin 43 98 5 Tgl masuk 44 100 6 Tgl keluar 44 100 7 Ruang rawat terakhir 44 100 Average 44 100 Laporan Penting 1 Penanggung pembayaran 44 100 2 Keluhan saat masuk RS 44 100 3 Ringkasan riwayat penyakit 41 93 4 Pemeriksaan fisis 43 98 5 Pemeriksaan penunjang 43 98 6 Terapi 39 89 7 Hasil konsultasi 42 95 8 Diagnosa Utama 44 100 9 Diagnosa Sekunder 44 100 10 Tindakan/prosedur 41 93 11 Alergi (reaksi obat) 41 93 12 Instruksi Pulang 43 98 13 Edukasi (follow up) 44 100 14 Kondisi keluar RS 44 100 15 Terapi pulang 44 100 Average 43 97 Autentikasi Penulisan 1 Nama dokter 37 84 2 Tanda tangan dokter 50 100 3 Tanggal 43 98 Average 41 94 Catatan yang baik 1 ada coretan 44 100 2 ada tipe-x 44 100 3 ada kolom yang kosong 36 82 Average 41 94 AVERAGE 42 96
DAFTAR TILIK KETEPATAN DIAGNOSA PASIEN OBSTETRIC DAN KELANCARAN KLAIM BPJS DI RSUD SAWERIGADING KOTA PALOPO-SULAWESI SELATAN // = 0 / / = 1 Nama Pelaksana : Andi Tenri Nurrul Izzah Alik Tanggal : 10-24 Mei 2016 No. No. RM Catatan Identifikasi Pasien Laporan Penting Autentikasi Yang Baik Diagnosa Kode RS 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 1 30 23 27 KPP PREMITEA, SSTP,LAB 2 30 40 44 PARTUS ATERM LBK, PPN 3 30 37 34 EMERGENCY SC, KPD, RUI, GAWAT JANIN, SC, USG, O2 O82.8, O35.5, 0.59 O80.0, O70.1, Z37.0, 73.59, 75.69 O82.1, O42.1, O70.1, O68.9,, 93.96, 88.78 Reseleksi Kode O82.8, O42.0, Z.37.0, 74.0 50.59 O80.0, Z37.0, 73.59, 75.69 O82.1, O42.1, O70.1, O68.8,, 93.96, 88.78 Ketepatan Kelancaran Kelengkapan 4 30 17 91 PARTUS LAMA, OBSTRUCTIVE LABOUR, SSTP O82.1, O63.1, Z37.0, 4.0 O82.1, O63.1, Z37.0, 4.0 5 30 32 74 EMERGENCY SC, KPD, RUI, GAWAT JANIN, SC O82.1, O42.1, O71.1, O68.8, O82.1, O42.1, O70.1, O68.8, 6 19 61 91 EMERGENCY SC, KPD, SC O82.1, O42.9, O82.1, O42.0, 7 30 35 11 EMERGENCY SC, OLIGOHYDRAMNIOS, SC O82.8, O41.0, O82.1, O41.0, 8 28 38 69 INPARTUM, PPN O80.0, Z37.0 73.6, 73.59 O80.0, Z37.0 73.6, 73.59 9 30 37 65 INPARTUM, PPN O80.0, Z37.0 73.6, 73.59 O80.0, Z37.0 73.6, 73.59 10 12 41 79 ABORTUS IMMINENS, USG O02.0, 88.78 O02.0, 88.78 11 30 21 03 12 30 26 64 MILD HYPEREMISIS GRAVIDA, KONSUL OLIGOHYDRAMNIOS, MEDICAL INDUKSI, PPN Z09.7 O21.0, Z09.7 O80.0, O41.0, O70.1, Z37.0, 73.4, 73.59, 75.69 13 17 98 23 UTERUS KONTRAKTIF O62.9 O62.4 O80.0, O41.0, Z37.0, 73.4, 73.59, 75.69 14 30 23 59 BLIGHTED OVUM O02.0, 69.02 O02.0, 69.02
15 30 28 19 INPARTUM INDUKSI O80.0, O41.0, Z37.0, 73.4, 73.59, 75.69 O80.0, O41.0, Z37.0, 73.4, 73.59 16 30 26 51 EMERGENCY SC, OLIGOHYDRAMNIOS, GAWAT JANIN, SC O82.1, O41.0, O68.9, O82.2, O41.0, O68.9, Z37.0, 74.0 17 30 37 79 EMERGENCY SC, KPD, SC O82.0, O68.9, 74.0 O82.0, O68.9, 74.0 18 30 15 01 INPARTUM, PPN O80.0, O70.1, Z37.0, 73.59 O80.0, Z37.0, 73.59 19 30 30 04 MISSED ABORT, KURET O02.1, 69.02 O02.1, 69.02 20 24 60 58 ABORTION, USG, LAB 21 28 85 89 PLASENTA PREVIA, GEMELI, STERILISASI, SC O06.4, 88.78, 90.59 O84.2, O30.0, O44.0, Z30.2, Z37.2, 74.0, 66.39 O04.4, 88.78, 90.59 O84.2, O44.0, Z30.2, Z37.2, 74.0 22 30 17 76 HYPEREMESIS GRAVIDA, GASTRITIS AKUT, LAB O20.0, 91.39 O20.0, K29.1, 91.39 23 30 37 13 INPARTUM, PPN O80.0, O70.1, Z37.0, 73.56, 75.69 O80.0, Z37.0, 73.56 24 30 28 83 INPARTUM, OLIGOHYDRAMNIOS, PPN O80.0, 73.6 O.80.0, O41.0, Z37.0, 73.6 25 30 37 45 26 30 26 37 INPARTUM, KPD, VAKUM EKSTRAKSION, PPN INPARTUM, KPD, OLIGOHYDRAMNIOS, PPN, LAB 27 30 32 87 INPARTUM, PPN 28 30 32 89 INPARTUM, PPN O81.4, O62.0, Z37.0, 72.71 O80.0, O42.0, O70.1, Z37.0, 73.59, 75.69, 90.56 O80.1, Z37.0, 73.56, 75.59 O80.0, Z37.0, 73.56, 75.59 O81.4, O62.0, Z37.0, 72.71 O80.0, O42.0, Z37.0, 73.59, 75.69, 90.56 O80.0, Z37.0, 73.56, 75.59 O80.0, Z37.0, 73.56, 75.59 29 29 29 09 MILD HYPEREMISIS GRAVIDA, AKUT GASTRITIS, KISTA OVARIUM O21.0, K29.1, N38.2 O21.1, K29.1, N38.2 30 30 21 10 KPD, SC, LAB O82.8, O42.0,, 90.59 O82.8, O42.0,, 90.59 31 30 35 19 EMERGENCY SC, KPD, SC, LAB O82.8, O42.1,, 90.59 O82.8, O42.1,, 90.59 32 30 37 07 PLASENTA PREVIA, POST SC O82.0, O44.1, O82.0, O44.1,
33 30 19 88 EMERGENCY SC, GEMELY, KPD, SC, LAB O84.2, O42.1, 74.0, 90.59 O84.2, O42.1, 74.0, 90.59 34 29 72 11 REST PLASENTA, KURET O72.2, 69.02 O72.2, 69.02 35 27 08 20 KJDR, INDUKSI PERSALINAN O36.4, O80.9, 73.01, 73.59, 88.78 O36.4, O80.0, 73.01, 73.59, 88.78 36 30 32 56 INPARTUM, LAHIR SPONTAN BOKONG, PPN, HECTING O80.1, O32.1, O70.1, Z37.0, 73.59, 75.69 O80.1, O32.1, O70.1, Z37.0, 73.59, 75.69 37 30 40 10 EMERGENCY SC, KPD, SC O82.1, O42.9, O82.1, O42.0, 38 30 23 52 INFEKSI PERPERAL, ANEMIA, HEMOLITIK, TRANSFUSI, LAB, O2 O85, D58.9, 99.03, 90.59, 93.95 O85.1, D58.9, 99.03, 90.59, 93.95 39 30 17 65 MISSED ABORTION, KURET, TRANSFUSI O02.1, 69.02, 99.03, 93.96, 90.59 O02.1, 69.02, 99.03, 93.96, 90.59 40 30 37 82 PEB, PERTUMBUHAN JANIN TERHAMBAT, OLIGOHYDRAMNIOUS O82.0, O14.1, O36.5, O41.0, O82.0, O14.1, O36.5, O41.0,Z37.0, 74.0 41 30 35 50 PARTUS LAMA KALA II, UDEM VULVA, VAKUM EKTRACTION O81.4, O71.9, O63.1, 72.71 O81.4, O71.8, O63.1, 72.71 42 30 28 08 PARTUS, EKLAMSIA, STERILISASI, SC O82.1, O15.0, Z37.0, Z30.0, 74.0 O82.1, O15.0, 43 28 60 37 MOLA, KURET O01.0, 69.09 O01.0, 69.09 44 20 21 12 KPD, SC O82.8, O42.9, O82.1, O42.9,