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Recording in SNARS Edition 1 is included in the Hospital Management Standards group on Information and Record Management (MIRM), one of the medical standards in MIRM, namely the standardization of diagnosis codes, procedure/action codes, symbols, abbreviations, and their meanings contained in the MIRM 12 standard. Where in the assessment element, the hospital must have regulations on standardizing diagnosis codes, procedure/action codes, definitions, symbols used and which should not be used, abbreviations used and which should not be used, and monitored their implementation. Pertamina Central Hospital is a referral hospital and accredited B. Where this hospital becomes the Presidential Hospital. Medical Records used in the form of Electronic and Manual Medical Records. On the Medical Record Form in the application there are abbreviations and symbols. In the use of abbreviations and symbols, socialization has been carried out which contains a guideline entitled "The RSPP abbreviation list book" but in its implementation no evaluation has been carried out. And also there are SOPs that state the existence of abbreviations, symbols, actions and diagnostic codes. In the period of February, there were 463 hospitalized patients. And researchers took samples of medical record number 132 medical records from 30% of the number of inpatients using the formula of slovin. This is a qualitative research using direct observation and documentation methods. The results of observation and study documentation show that the abbreviations that are not appropriate are 45%, 67% for symbols and 55% appropriate for summary form releases, The book of abbreviations and symbols belonging to Pertamina Central Hospital has not yet been legalized and socialized legally. And there is no SOP in accordance with SNARS MIRM 12 for abbreviations and symbols at Pertamina Central Hospital. There is also no evaluation in the implementation of the use of abbreviations and symbols as well as the books used, there are still not several symbols and abbreviations listed in the abbreviation and symbol guidelines in the Rspp.
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Nina Rahmadiliyani, et al., "Tinjauan Penggunaan Simbol dan Singkatan pada rekam Medis Rawat Inap dalam Menunjang Akreditasi SNARS Edisi 1.1 di RSD Idaman Kota Banjarbaru, vol. XI, pp. 41-52, November 2022.
Waskito Hendri and Rahmad Saidi, "Tinjauan Ketepatan Penggunaan Simbol dan Singkatan pada Formulir Laporan Operasi RSK Mata Provinsi Sumsel," Cerdika : Jurnal Ilmiah Indonesia, 2021, pp. 1770-1776.
Harjanti and Rizka Khoirul Munawaroh, "Ketepatan Penggunaan Singkatan Dan Simbol Pada Dokumen Rekam Medis Rawat Inap Diagnosis Schizophrenia," Jurnal Rekam Medis dan Informasi Kesehatan, Vol 2, pp. 14-19, 2019.
P. Nurmalinda and Diah Retno Kusumawati, "Evaluasi Tingkat Ketidaktepatan Pemberian Kode Diagnosis dan Faktor Penyebab di Rumah Sakit X Jawa Timur" Jurnal Manajemen Kesehatan Yayasan RS. Dr. Soetomo, vol 3, pp.1-12.
Maryati, Warsi and Aris Octavian Wannay, “Standarize of Simbol and System Using Medical Record Documents of Inpatient in RSJD Dr. Arif Zainudin Surakarta, pp. 64-67.
Pakendek, Gustiani and A.L Rantetampang, “Study Presepsi Kualitas Penyediaan Makanan terhadap Citra Rumah Sakit Umum Jayapura, Jurnal Nasional Ilmu Kesehatan, vol. 1, pp. 1-11, 2018.
Sari, Nila, “Evaluasi Penyelenggaraan Kode Diagnosis MIRM 12 Pada Pasien Rawat Jalan dalam Pemenuhan SNARS Edisi 1.1 Triwulan 1 di Rumah Sakit Umum Madani Tahun 2021, vol. IV, pp. 22-31.
Sudra, Rano Indradi, “Standardisasi Resume Medis Dalam Pelaksanaan PMK 21/ 2020 Terkait Pertukaran Data Dalam Rekam Medis Elektronik,” Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda, vol. 6, pp. 67-72.
Simanjuntak, Esraida and Fajar Insani, “Tinjauan Sistem Penyelenggaraan Rekam Medis Menurut Standart Akreditasi Puskesmas di Puskesmas Pangakalan Berandan Tahun 2020,” Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda, vol. 6, pp. 108-118.
Budiantono, et al., “Tinjauan Ketepatan Penggunaan Simbol dan Singkatan pada Ringkasan Pulang di Rumah sakit Pusri Palembang,” Jurnal Ilmiah Indonesia, pp. 1686-1693.