The administration of Medical Records must be supported by qualified, experienced human resources and a workload that is appropriate for the officers who are on hand. The UOBK RSUD Dr. Mohamad Saleh Probolinggo has four filing officers, one of whom has a bachelor's degree in economics and the other three have only completed high school. The purpose of this study is to analyze the workload of filing officers and calculate the need for labor in the filing unit. This type of research is descriptive qualitative with data collection methods through interviews and observations. Calculations made with ABK Kes produced data on the requirement for 12 health human resources, resulting in the demand for 8 more staff in the filing unit.

The registration service is the first service and directly interacts with the patient and the place where they will register at the polyclinic they are going to. Observational data has revealed that a number of issues, including SIMRS and the network, continue to impede patient registration services. Evaluating patient registration service activities is one approach taken to address this issue. The aim of this research is to evaluate activities in patient registration services. The instrument used was an interview sheet. This type of research uses qualitative descriptive analysis to describe the results of evaluation of patient registration services. The study's findings indicate that although RS X Malang's registration service is functioning effectively, a number of issues continue to arise. Patient registration is frequently hampered by sluggish and unreliable internet connections. Delays in the registration procedure are possible, and SIMRS disruptions happen frequently. In addition, the tracer is still manual, which increases the possibility that the registration officer will overlook recording the patient's medical record information. Another issue is that there is currently no bridging between SIMRS and BPJS, which makes BPJS patient registration more time-consuming due to its multiple steps.

In the implementation of coding in the case of accidents at the General Hospital of the University of Muhammadiyah Malang there are still inaccuracies in coding of 79.2% and accuracy of 20.8%. The purpose of this study was to analyze how the completeness of the diagnosis relates to the accuracy of coding injuries and codesexternal cause in case of an accident. The research method used is an analytical survey approachCross Sectional. To determine the relationship between the completeness of writing a diagnosis on the accuracy of coding injuries and codesexternal cause In the case of an accident, a statistical test was carried out with the testWho Squareusing the IBM SPSS application version 25. Using the saturated sampling technique, a total sample of 77 accident cases was obtained in the 2022-2023 period. In this study, the results of the diagnosis accuracy were 20.8% and 79.2% inaccuracy. This inaccuracy is caused because the officer did not do the coding for the codeexternal cause. Based on the SPSS results, it was found that there was a relationship between the completeness of writing a diagnosis and the accuracy of coded injury and external cause codes in accident cases at the General Hospital of the University of Muhammadiyah Malang. These results are due to the writing of the diagnosis which still does not include the chronology of the accident. This can cause coding errors by coding officers at the hospital.

The implementation of coding in labor cases at DKT Sidoarjo Hospital still has inaccuracies of 61.73%, while the accuracy of medical records is 38.27%. The accuracy and inaccuracy of disease diagnosis coding will affect data and information in the health service process and reduce the quality of service in the hospital. The purpose of this study was to analyze the accuracy of the diagnosis code for labor cases in inpatients at DKT Sidoarjo Hospital. This type of research uses quantitative and qualitative methods, with data collection in the form of observation and interviews. The number of samples used was 81 medical records in July–November 2022 cases of childbirth in inpatients, and the number of informants was 1 person who was a key informant. In this study, the accuracy of the results of the maternal complication component was obtained with 55.56% accuracy, the method of delivery with 61.73% accuracy, and the outcome of delivery with 67.90% accuracy. Then the total results were obtained with 38.27% accuracy. The results of the interview found that the accuracy of coding can be influenced by the 5M factors (man, method, material, machine, and money). Conclusion: Most of the diagnosis codes in labor cases are incorrect. So the coding officer should be more careful in coding, both regarding the rules and procedures for coding diagnoses based on ICD-10.

The quarterly report in 2022 shows that the incidence rate is not expected to reach 99 cases. One effort that can be made to prevent patient safety incidents is to implement a patient safety culture. Nurses as health workers who interact most with patients are the main component who are required to carry out their work in accordance with standard operational procedures to avoid patient safety incidents. Perception is very important in the success of communication, when all nurses have the same perception about the importance of implementing patient safety culture then patient safety incidents can also be prevented. The aim of this research was to measure nurses' perceptions of patient safety culture. The research instrument used a questionnaire based on the HSOPSC which was distributed to 55 nurses as research respondents. This type of research uses descriptive analysis to describe 12 dimensions of patient safety culture. The results show that the cooperation dimension within the unit has the highest positive perception, namely 87% in the good category, while the staffing dimension has the lowest positive perception, namely 61% in the medium category. RS X Kota Malang in its commitment to preventing patient safety incidents can focus on staffing dimensions.

Laporan triwulan di RS X Kota Malang tahun 2022 menunjukkan bahwa angka kejadian tidak diharapkan mencapai 99 kasus. Salah satu upaya yang dapat dilakukan untuk mencegah terjadinya insiden keselamatan pasien adalah dengan penerapan budaya keselamatan pasien. Perawat sebagai tenaga kesehatan yang paling banyak berinteraksi dengan pasien merupakan komponen utama yang dituntut untuk menjalankan pekerjaannya sesuai dengan standar operasional prosedur untuk menghindari terjadinya insiden keselamatan pasien. Persepsi merupakan hal yang sangat penting dalam keberhasilan suatu komunikasi, ketika semua perawat memiliki persepsi yang sama tentang pentingnya penerapan budaya keselamatan pasien maka insiden keselamatan pasien juga dapat dicegah. Tujuan penelitian ini adalah untuk mengukur persepsi perawat tentang budaya keselamatan pasien di RS X Kota Malang. Instrumen penelitian menggunakan kuesioner berdasarkan Hospital Survey On Patient Safety Culture (HSOPSC) yang disebarkan kepada 55 perawat sebagai responden penelitian. Jenis penelitian menggunakan analisis deskriptif untuk menggambarkan 12 dimensi budaya keselamatan pasien. Hasil penelitian menunjukkan bahwa dimensi kerjasama dalam unit memiliki persepsi positif tertinggi yaitu 87% dengan kategori baik, sedangkan dimensi staffing memiliki persepsi positif terendah yaitu 61% dengan kategori sedang. RS X Kota Malang dalam komitmennya mencegah insiden keselamatan pasien dapat berfokus pada dimensi staffing.

Pelayanan pendaftaran merupakan pelayanan pertama dan secara langsung berinteraksi dengan pasien dan tempat dimana akan mendaftar ke poliklinik yang akan dituju. Berdasarkan hasil observasi diketahui bahwa kegiatan pada pelayanan pendaftaran pasien masih terkendala beberapa hal, antara lain jaringan dan pada SIMRS. Salah satu upaya yang dilakukan untuk menyelesaikan permasalahan tersebut yaitu melakukan evaluasi kegiatan pada pelayanan pendaftaran pasien. Tujuan dari penelitian ini adalah untuk melakukan evaluasi kegiatan pada pelayanan pendafataran pasien. Instrumen yang digunakan adalah lembar wawancara. Jenis penelitian  menggunakan analisis deskriptif kualitatif untuk menggambarkan hasil evaluasi pada pelayanan pendafataran pasien. Hasil penelitian menunjukkan bahwa pelayanan pendaftaran di RSI Unisma Malang berjalan dengan baik, namun masih ada beberapa permasalahan yang terjadi. Koneksi internet yang lambat dan tidak stabil sering kali menjadi kendala dalam melakukan pendaftaran pasien. Gangguan pada SIMRS juga kerap terjadi dan beresiko terjadinya perlambatan dalam proses pendaftaran. Selain itu tracer masih manual, sehingga menyebabkan resiko petugas pendaftaran lupa untuk menuliskan data rekam medis pasien. Masalah lainnya yang terjadi adalah SIMRS yang belum bridging dengan BPJS menyebabkan pendaftaran pasien BPJS lebih lama karena melalui banyak tahap.

Pelaksanaan kodefikasi dalam kasus kecelakaan di Rumah Sakit Umum Universitas Muhammadiyah Malang masih terdapat ketidaktepatan dalam mengkode sebesar 79,2% dan ketepatan sebesar 20,8%. Tujuan dari penelitian ini adalah untuk menganalisis bagaimana hubungan kelengkapan diagnosis terhadap ketepatan pemberian kode cedera dan kode external cause pada kasus kecelakaan. Metode penelitian yang digunakan adalah survey analitik dengan pendekatan Cross Sectional. Untuk mengetahui adanya hubungan antara kelengkapan penulisan diagnosis terhadap ketepatan pemberian kode cedera dan kode external cause pada kasus kecelakaan dilakukan uji statistika dengan uji Chi Square dengan menggunakan aplikasi IBM SPSS versi 25. Dengan Teknik sampling jenuh didapatkan jumlah sampel sebanyak 77 sampel kasus kecelakaan pada periode tahun 2022-2023. Pada penelitian ini didapatkan hasil ketepatan diagnosis sebanyak 20,8% dan ketidaktepatan sebanyak 79,2%. Ketidaktepatan ini disebabkan karena petugas tidak melakukan kodefikasi untuk kode external cause. Berdasarkan hasil SPSS didapatkan hasil adanya hubungan kelengkapan penulisan diagnosis terhadap ketepatan pemberian kode cedera dan kode external cause pada kasus kecelakaan di Rumah Sakit Umum Universitas Muhammadiyah Malang. Hasil tersebut disebabkan karena penulisan diagnosis yang masih belum mencakup kronologi kecelakaan. Hal tersebut dapat menyebabkan kesalahan pengkodean oleh petugas koding di rumah sakit.