Abstract:Electronic Medical Records (EMR) are designed to improve service quality, documentation accuracy, and administrative efficiency, including reimbursement through the Indonesian Case-Based Groups (INA-CBGs). However, incomplete…
plete medical assessments remain a challenge, potentially leading to service gaps and reduced hospital claims. This qualitative descriptive study was conducted at Dharma Yadnya General Hospital, Denpasar, which has fully implemented EMR since 2024. Data were obtained through in-depth interviews with five informants: two medical record officers, the head of the emergency nursing unit, the head of the inpatient nursing unit, and the head of the medical record department. Data analysis used the 3M framework: Man, Method, and Material. From the Man aspect, heavy workloads of doctors and the lack of administrative support staff often caused delays and incomplete documentation. From the Method aspect, although Standard Operating Procedures (SOPs) and system reminders existed, monitoring relied mainly on manual follow-ups via WhatsApp groups, limiting effectiveness. From the Material aspect, the EMR system was user-friendly and supported by weekly vendor maintenance, but occasional network disruptions and insufficient administrative staff still hampered real-time documentation. Incomplete medical assessments in EMR directly affect INA-CBGs claims, especially when comorbidities, complications, or procedures are not recorded, resulting in under-coding and reduced reimbursement. Strengthening human resources, enforcing SOPs, and improving system support are essential to ensure documentation completeness, service quality, and financial sustainability
Abstract:Background: Anemia is a condition in which the level of red blood cells or hemoglobin in the body is below normal. In pregnant women, anemia can pose health risks to both the mother and the fetus. One of the non-pharmacological…
logical treatments that can be used is the administration of natural ingredients such as beetroot, which serves as an alternative due to its content of iron, folic acid, and vitamin C that can help increase hemoglobin levels. Objective: To provide an overview of the implementation of beetroot juice to increase hemoglobin levels in pregnant women with anemia. Methods: This study used a case study design involving one pregnant woman with anemia who met the inclusion criteria. The intervention consisted of administering 200 ml of beetroot juice per day for seven consecutive days. Evaluation was carried out by measuring hemoglobin levels before and after the intervention using the Easy Touch GCHb device. Results: The results showed that hemoglobin levels increased from 10.5 g/dL before the intervention to 11.8 g/dL after seven days, with an increase of 1.3 g/dL. Conclusion: Regular administration of beetroot juice is effective in increasing hemoglobin levels in pregnant women with anemia.
Abstract:Background: According to WHO (2022), there are 24 million people suffering from schizophrenia, with 3,980 of them at risk of violent behavior. The risk of violent behavior is an angry response that can manifest physically…
y or verbally. If not addressed promptly, the risk of violent behavior can endanger both the individual and others. This condition poses a serious challenge as it can disrupt the patient’s recovery process and create anxiety in the surrounding environment. Therefore, appropriate nursing interventions are needed—not only to calm the patient but also to enhance the patient’s ability to control their emotions. One of the interventions that can be applied is the deep breathing relaxation technique. Objective: To describe the nursing care from assessment to evaluation for Mrs. A with a risk of violent behavior, focusing on the deep breathing relaxation intervention. Method: This scientific paper uses a descriptive research method in the form of a case study. Results: After three days of nursing interventions for patient with a risk of violent behavior using deep breathing relaxation, the client showed reduced tension and was able to control her emotions well. Conclusion: Deep breathing relaxation for patient was effective in reducing the risk of violent behavior.
Abstract:Background: Visual hallucinations are sensory perception disturbances in which individuals perceive objects or shadows that do not actually exist, even though they appear vivid and real. Therefore, nursing interventions…
are needed to reduce the occurrence of visual hallucinations in patients, one of which is through dzikir (remembrance of Allah). Linguistically, dzikir comes from the word dzakar, which means remembering. Remembering Allah implies maintaining one’s consciousness toward Him by following specific etiquettes prescribed in the Qur’an and Hadith. The purpose of dzikir is to purify the heart and glorify Allah SWT. Purpose: To determine the implementation of nursing care for patients with sensory perception disturbances: visual hallucinations, with a focus on dzikir practice. Method: This study used a descriptive method in the form of a case study. Results: The case study showed that the patient was able to carry out SP 1–3 with a focus on dzikir practice, as indicated by behavioral changes such as feeling calmer, being able to recite dzikir independently, and experiencing reduced hallucinations. This suggests that dzikir is quite effective. Conclusion: Nursing care for patients with sensory perception disturbances, specifically visual hallucinations, with a focus on dzikir intervention over three days, can help control hallucinations
Abstract:Background: Maintaining children's health is a special concern for parents. Changes in children's health conditions are influenced by changes in weather, one of the symptoms that often occurs in children is fever or hyperthermia.…
rthermia. One of the non-pharmacological treatments is by administering Water Tepid Sponge (WTS). Water Tepid Sponge is a combination of warm compress techniques, superficial vascular block compress techniques and wiping techniques. The compression technique is carried out at several points where there are large blood vessels (neck folds, right and left axillary folds, right and left thigh folds) so that vasodilation occurs and then accelerates evaporation and conduction to lower body temperature in children. Objective: To determine the effectiveness of administering Water Tepid Sponge (WTS) to reduce body temperature in toddlers with hyperthermia problems in Panican Village. Method: This study used a descriptive case study with respondents of toddlers with hyperthermia problems. The focus of this case study is the provision of Water Tepid Sponge (WTS) with hyperthermia problems as a nonpharmacological action. This study was conducted in Panican Village for 3 days starting on 23-25 June 2025. Results: After being given Water Tepid Sponge (WTS) for 3 days with 1 meeting within 15-30 minutes using water temperature of 37oC40oC, the child's body temperature decreased, the initial result was 38.7oC and after being given Water Tepid Sponge (WTS) for 3 days, the result was 37.3oC. Conclusion: Providing Water Tepid Sponge (WTS) can reduce body temperature in toddlers with hyperthermia problems in Panican Village.
Abstract:Background : Mental disorders are conditions in which individuals experience disturbances in psychological, social, and biological functions. One of the most common symptoms in patients with schizophrenia is visual hallucination,…
cination, which refers to the perception of seeing something that does not actually exist. This condition affects the patient’s ability to function and interact with their social environment. Appropriate nursing interventions are required to help patients manage their hallucinations. One such intervention is the talking technique, a distraction strategy that redirects the patient’s attention from hallucinations to real-life interaction. Objective : This study aims to determine the process of mental nursing care for patients with sensory perception disorders: visual hallucinations with a focus on conversation interventions at Dr. Soedjarwadi Klaten Regional Hospital. Method : The design of this study uses a case study method consisting of stages of assessment, determination of nursing diagnosis, planning, implementation, and evaluation. The subject in this study was Mr. P, a patient at the Dr. RM Soedjarwadi Klaten Regional Mental Hospital. Results : The results of the study showed that consistent implementation of conversational strategies during treatment can reduce the intensity of hallucinations, increase awareness of reality, and rebuild patients' social interaction abilities. Counclusion : Conversation intervention is an effective approach in treating visual hallucinations in mental disorders patients.
Abstract:Background: Gout arthritis is a degenerative disease commonly experienced by the elderly due to elevated uric acid levels in the blood. One safe non-pharmacological treatment alternative is the use of herbal remedies such…
h as soursop leaves (Annona muricata L), which contain active compounds like flavonoids and alkaloids that may reduce uric acid levels. Objective: To describe the effect of boiled soursop leaf water on reducing uric acid levels in elderly patients with gout arthritis in Karangjambu Village, Karangjambu Subdistrict, Purbalingga Regency. Method: This study employed a case study method. Subjects were given an intervention of 200 ml of boiled soursop leaf water daily (100 ml in the morning and 100 ml in the evening) for seven consecutive days. Uric acid levels were measured before and after the intervention. Results: After seven days of soursop leaf water administration, uric acid levels decreased from an average of 8.7–9.0 mg/dl to 5.5–5.8 mg/dl. This suggests that the active compounds in soursop leaves are effective in inhibiting xanthine oxidase and promoting uric acid excretion through urine. Conclusion: Boiled soursop leaf water is effective in lowering uric acid levels in elderly patients with gout arthritis and can serve as a safe and practical complementary non-pharmacological therapy within the community.
Abstract:Urine alcohol testing plays a vital role in detecting alcohol consumption for clinical and forensic purposes, yet its results may be influenced by pre-analytical factors such as the delay between sample collection and laboratory…
boratory analysis. This study aimed to evaluate the effect of delay time before urine examination on alcohol concentration. An experimental One-Shot Case Study design was conducted involving 44 participants in Denpasar who had consumed alcohol. Alcohol concentration was measured immediately, after a 2-hour delay, and after a 4-hour delay using the Alcohol Urine Rapid Test Dipstick Allchek, and the data were analyzed using the Kruskal-Wallis test. The findings showed that average urine alcohol levels increased numerically after a 2- and 4-hour delay compared to immediate testing; however, this change was not statistically significant (p=0.131). These results confirm that delaying urine alcohol examination up to 4 hours does not significantly alter detectable alcohol concentrations, although prompt testing is still recommended to ensure result accuracy and minimize the risk of false positives. This study provides important insights for the development of standard operating procedures regarding urine alcohol analysis in laboratory practice.
Abstract:The accuracy of disease diagnosis coding is an important indicator in the management of medical records and health service claims. This study aims to determine the percentage of accuracy in coding pneumonia diagnoses based…
ed on ICD-10 according to the 2023 National Medical Practice Guidelines (PNPK) at Udayana Hospital II in Denpasar. The research method used was quantitative descriptive with a total sampling approach of 72 medical records of pneumonia patients during the period from October 1, 2024, to December 31, 2024. The research instrument was a checklist for assessing the accuracy of diagnosis codes based on the provisions of ICD-10 and PNPK Pneumonia 2023. The results showed that 51 files (70.8%) were coded accurately, while 21 files (29.2%) were coded inaccurately. The inaccuracy in coding was due to a lack of supporting tests, such as microbiological tests, as well as the excessive workload of the coders. These findings indicate the need for an analysis of coders' workload to measure the effectiveness and efficiency of their tasks, time management, and priorities. This study is expected to serve as evaluation material to improve the quality of service and efficiency of hospital administration.
Abstract:A complete medical record is a crucial part of healthcare delivery, serving as a communication tool between healthcare professionals, legal evidence, and the basis for evaluating and planning hospital services. The completeness…
eteness of medical record documentation, particularly in the emergency department, is an indicator of service quality that requires serious attention. The purpose of this study was to determine the percentage of completeness of identification, authentication, recording, and important reporting in the medical records of emergency patients diagnosed with hypertension at Wangaya Regional Hospital, Denpasar City. This study used a quantitative descriptive method. The population was all 330 medical records of emergency patients diagnosed with hypertension. A sample of 199 files was drawn using a probability sampling technique using a simple random sampling approach. The results showed that completeness of identification reached 100%, authentication reached 176 documents (88.44%), recording reached 174 documents (84.44%), and reporting reached 159 documents (79.90%). It can be concluded that identification had the highest level of completeness, while reporting had the lowest level of completeness. Researchers suggest that hospitals increase outreach and supervision of medical staff, especially in emergency installations, regarding the importance of completeness and timeliness of filling out medical record documents.