Analisis Hubungan Ketepatan Penulisan Diagnosis dengan Keakuratan Kode Diagnosis pada Kasus Obstetri dan Ginekologi di Rumah Sakit Tk. IV DKT Kediri

Abstract

Activity of determining the disease code and writing the diagnosis must be in accordance with the correct medical terminology and the classification rules that apply in Indonesia, namely ICD-10 in order to get the right and accurate code. This study aims to analyze the relationship between the accuracy of writing a diagnosis and the accuracy of the diagnosis code in obstetrics and gynecology cases at Rumah Sakit Tk. IV DKT Kediri. The method used in this research is analytic research with cross sectional approach. Based on Slovin's formula, the sample used was 100 medical record documents of inpatients. The sampling technique used is simple random sampling. The data collection technique used observation with a checklist instrument. Data on the accuracy of writing the diagnosis and the accuracy of the diagnosis code were analyzed univariately, while the relationship between the accuracy of writing the diagnosis and the accuracy of the diagnosis code was analyzed using SPSS with Chi-Square test. The results showed that the accuracy of writing the diagnosis was 56%, the accuracy of the diagnosis code was 43%, and there was a relationship between the accuracy of writing the diagnosis and the accuracy of the diagnostic code for obstetrics and gynecology cases at Rumah Sakit Tk. IV DKT Kediri (p < 0.025).

Determining Factors For The Accuracy Of Diagnosis Codes Using ICD-10 In Obstetric Cases: Riview Systematics

“…In detail, it was written that the officer did not write down the code because the officer was negligent in re-checking the patient's MRD, so the MRD that was not coded wasn't returned to the authorized health worker. Errors in code selection are caused by 3 things, namely, unclear medical information written in the MRD; the officer did not check the MRD carefully, resulting in coding errors in the third category and sub-category or fourth character in the patient's MRD; officers do not use the ICD in the coding process, officers only use reference books or notes made by themselves which contain the most frequently occurring cases (Alifa Puspaningtyas et al, 2022).…”

“…The RME processing form involves coding, reporting and analyzing (Article 18). The results of inputting the disease classification code will be input into the financing application based on the results of the diagnosis and action written by the health care provider following the medical record to submit a service fee billing application (Peraturan Menteri Kesehatan Republik Indonesia Nomor 24 Tahun 2022 Tentang Rekam Medis, 2022).…”

“…Following the above, the accuracy of the disease diagnosis code is the responsibility and must be carried out accurately by a Medical record coder (Keputusan Menteri Kesehatan Republik Indonesia Nomor: 377/Menkes/SK/III/2007 Tentang Standar Profesi Perekam Medis Dan Informasi Kesehatan, 2007). The World Health Organization or WHO proposed ICD-10 as a language used by healthcare providers worldwide to classify diseases and conditions (Alifa Puspaningtyas et al, 2022).…”

Analisis Hubungan Kelengkapan dan Ketepatan Pencatatan Dokumen Rekam Medis Terhadap Keakuratan Kodefikasi Kasus Obstetri di RS PKU Muhammadiyah Surakarta

“…Penelitian ini relevan dengan penelitian yang dilakukan Linda dan Citra, yang menemukan bahwa ada korelasi yang signifikan antara keakuratan kode pada kasus obstetri dan ketepatan penulisan diagnosis [9] [10]. Petugas koding akan menghadapi kesulitan ketika mereka menentukan kode diagnosis dengan istilah medis yang tidak tepat.…”