Hubungan Kelengkapan Informasi Medis Dan Keakuratan Kode Diagnosis Diabetes Mellitus

Abstract

Completeness of medical information is very important in supporting the accuracy of the diagnosis code for diabetes mellitus. This study aims to determine the relationship between the completeness of medical information and the accuracy of the diagnosis code for Diabetes mellitus in hospitalization documents. This research is an analytical study with a cross sectional approach. The sample used was 84 documents with simple random sampling technique. Data analysis using Chi-Square. The percentage of completeness of medical information was 54.7% while the incompleteness of medical information was 45.3%. The highest incompleteness is in the 26 discharge summary (31%). Percentage accuracy of diagnosis code Diabetes mellitus is 29.8% while inaccuracy is 70.2%. The most inaccuracies are caused by incorrect in determining the type of Diabetes mellitus as many as 24 documents. Chi square statistical test showed that p = 0.001. The conclusion is that there is a relationship between the completeness of medical information and the accuracy of the diagnosis code for Diabetes mellitus. The author suggests that there should be coordination between medical record officers and other health workers to improve the completeness of medical information, coding officers are more thorough in coding and confirming to physician if the information is incomplete.

The Relationship of Completeness of Medical Information with the Accuracy of Diabetes Mellitus Diagnosis Codes at X Kediri Hospital

“…In accordance with the results of research (Maryati, 2019) that incomplete medical information has an impact on the quality of medical record documents, thereby affecting the accuracy of the code given. [5] In addition, this statement is supported by the results of other studies, namely the completeness of writing medical information plays an important role in determining the accuracy of the code. From Figure 1 it can be seen that the inpatient medical assessment form and supporting examination sheet form are the most incomplete forms.…”

“…Precise and accurate codes are needed because the quality of coding has an important role in providing health care services and billing health services. In this era of national health insurance (JKN), the accuracy of coding greatly affects claims for INA-CBG's rates in the payment of national health insurance which is currently held by BPJS Kesehatan [5].…”

“…From previous research that has been carried out on the analysis of the factors causing the inaccuracy of the diabetes mellitus diagnosis code based on the 5M management element, the factors that influence the inaccuracy of coding are the level of knowledge and training that the coder has attended, the completeness of medical record filling, the availability of SOP as a guideline for coding procedures , and the infrastructure used by coders in coding. According to a research journal regarding the relationship between the completeness of medical information and the accuracy of the diabetes mellitus diagnostic code that has been carried out by Warsi Maryati et al, [5] shows that there is a relationship between the completeness of medical information and the accuracy of the diagnostic code. Medical A information in medical record documents can support proper and accurate coding.…”

“…If the medical information in a medical record document is incomplete, it can affect the accuracy of the resulting diagnosis code. [5] Based on a preliminary study conducted at Tk.IV Hospital DKT Kediri, problems were found in 5 inpatient medical record documents where there were still inaccuracies in giving the diagnosis code.…”

Tinjauan Ketepatan Kodifikasi Penyakit Diabetes Mellitus Tipe Ii Pada Jumlah Pasien Dalam Menunjang Laporan Surveilans Kesehatan Rawat Jalan Di Rs Anna Medika

“…(World Health Organization, 2018) Pada penelitian sebelumnya terkait dengan ketepatan kodifikasi di RS PKU Muhammadiyah Bantul terkait dengan ketepatan kodifikasi diabetes mellitus didapatkan hasil dari 96 sampel ditemukan hanya 89 atau 93% sampel yang ditemukan kodefikasi yang digunakan sudah lengkap (Nikmah, 2018) dan pada penelitian di RS PKU Aisyiyah Boyolali terkait ketepatan kodifikasi didapatkan hasil 59 atau 70.2% dokumen yang tidak tepat klasifikasi dan kodefikasi khususnya pada pasien Diabetes mellitus dari 84 dokumen rekam medis yang di jadikan sampel. (Maryati et al, 2018) Surveilans Kesehatan adalah kegiatan pengamatan yang sistematis dan terus menerus terhadap data dan informasi tentang kejadian penyakit atau masalah kesehatan dan kondisi yang mempengaruhi terjadinya peningkatan dan penularan penyakit atau masalah kesehatan untuk memperoleh dan memberikan informasi guna mengarahkan tindakan pengendalian dan penanggulangan secara efektif dan efisien. (Kemenkes R.I., 2014b) Penelitian terkait dengan Tinjauan Ketepatan Kodifikasi Penyakit Diabetes Mellitus Dalam Laporan Surveilans Rawat Jalan dilakukan di RS Anna Medika dengan alamat jalan Perjuangan No.45, RT.003/RW.003, Harapan Baru, Kec.…”