Kelengkapan Penulisan Diagnosa Pada Resume Medis Terhadap Ketepatan Pengkodean Klinis Kasus Kebidanan

Pepo, Aurelius Anugerah Harvey; Yulia, Noor

doi:10.33560/.v3i2.88

Cited by 6 publications

(9 citation statements)

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“…This is in line with the research of Nurfadhilah (2017) and Apriyantini (2018) at Fatmawati General Hospital, which found that 2% of incomplete main diagnoses were still found, secondary diagnosis was 39% and main procedures were 5%. Likewise with Pepo and Yulia's (2015) research at Atmajaya Hospital, it was found that 59.1% of writing incomplete diagnoses on medical resumes and 49.9% of writing complete diagnoses on medical resumes. However, it is not in line with Munthe's (2018) research at Dharmais Hospital which found that filling in the primary diagnosis, secondary diagnosis, and action was 100% complete.…”

Section: Analyzing Patient Medical Resume Coding's Completeness and A...mentioning

confidence: 73%

“…3) Human Resource Behavior and Workload: Research conducted by Pepo & Yulia (2015), another factor related to the completeness of filling out a medical resume, namely workload. DPJP always fills out patient resumes after the patient is declared allowed to go home, and some have even started filling in a few points while the patient is still in treatment.…”

Section: ) Human Resource Training: Regarding the Training Dharmais C...mentioning

confidence: 99%

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Analyzing Patient Medical Resume Coding’s Completeness and Accuracy on the Amount of INA-CBG’s Claims

Dorothy

Kadir

Rita

2022

ISS

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The figure for completing medical records of 100% has not yet been achieved which is the standard for completing hospital medical records after completion of service according to the Minister of Health of the Republic of Indonesia No. 129/MENKES/SK/II/2008, and the importance of diagnosis based on ICD-10 as one of the variables for calculating health service costs, this case study of breast cancer patients with operation was conducted to analyze the causes of that problem. The research object was to analyze the completeness and accuracy of the coding of medical resumes for breast cancer patients with surgery on the amount of INA-CBGs claims at Dharmais Cancer Hospital in 2019. This study research is a mix method, with qualitative and quantitative approaches. The qualitative approach was carried out by in-depth interviews, while the quantitative approach was carried out by reviewing the documents to be tested for suitability using the chi square method. The documents were inquired from Dharmais Cancer Hospital. The results showed the incompleteness fulfillment of medical resumes was highest. The secondary diagnosis of 30.23%, supporting examinations 27.91%, physical examinations and procedures/actions 23.26%, and identity of 4.65% of 43 cases were reviewed. Inaccuracy rate of primary diagnosis coding 90,7%, procedure 76,7%, secondary diagnosis 30,2%. Incomplete and inaccurate coding affects the final INA-CBG’s rate grouping results and is the cause of the difference in claims of Rp. 194,089,500.00 than it should be.

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Section: Analyzing Patient Medical Resume Coding's Completeness and A...mentioning

confidence: 73%

Section: ) Human Resource Training: Regarding the Training Dharmais C...mentioning

confidence: 99%

Analyzing Patient Medical Resume Coding’s Completeness and Accuracy on the Amount of INA-CBG’s Claims

Dorothy

Kadir

Rita

2022

ISS

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“…Berdasarkan penelitian Pepo & Yulia yang telah dilakukan tahun 2015 mengenai ketepatan pengkodean klinis kasus kebidanan di Rumah Sakit Atma Jaya thn 2014, diperoleh hasil 22 rekam medis (50%) dengan pengkodean klinis yang tepat dan rekam medis (50%) dengan pengkodean klinis yang tidak tepat, dimana terdapat 26 rekam medis (59,1%) yang penulisan diagnosanya tidak lengkap dan 18 rekam medis (40,9%) yang penulisan diagnosanya lengkap. (Pepo & Yulia, 2015).…”

Section: Pendahuluanunclassified

“…Hal ini tidak sejalan dengan penelitian yang telah dilakukan mengenai ketepatan pengkodean klinis kasus kebidanan pada tahun 2014 di Rumah Sakit Atma Jaya diperoleh hasil dimana terdapat 22 rekam medis (50%) dengan pengkodean klinis yang tepat dan rekam medis (50%) dengan pengkodean klinis yang tidak tepat. Penyebabnya yaitu diagnosa yang tidak lengkap menggambarkan tingkat spesifikasi yang rendah yang sangat berpengaruh terhadap spesifikasi nomor kode yang akan diberikan menggambarkan tingkat spesifikasi yang rendah yang sangat berpengaruh terhadap spesifikasi nomor kode yang akan diberikan (Pepo & Yulia, 2015).…”

Section: Pembahasanunclassified

Ketepatan Kode Penyakit Bronkopneumonia dan Kelengkapan Rekam Medis di Rumah Sakit St. Elisabeth Medan Tahun 2022

Saragih

Ginting

Nainggolan

2022

SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat

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The accuracy of the bronchopneumonia case code is that all diagnoses are filled out correctly based on the completeness of filling out the medical record with code J18.0 as the code in the ICD 10 book. Completeness of filling out the medical record is a medical record that has been completely filled out by a doctor within 1x24 hours, after completing outpatient services. or after an inpatient is decided to go home which includes a patient identity sheet, medical resume, and supporting diagnostic examination sheet. Researchers take specific cases of bronchopneumonia because during the practice service at St. Hospital. Elisabeth in 2021 there are 10 files of bronchopneumonia patients, there are 3 medical record files with incorrect codes. Based on this background, researchers are interested in conducting research with the title of code accuracy and completeness of medical records of bronchopneumonia patients at St. Hospital. Elisabeth Medan 2022. The type of research design used was a descriptive design with a sampling method of 82 respondents in total at St.Elisabeth Hospital Medan 2022. The instrument used in data collection was a checklist study documentation. The results of the study obtain that the correct category code was 70 medical records (85.3%) and the incorrect category are 12 medical records (14.7%) medical record files. While the completeness of the patient identity sheet is 85.3%, the medical resume sheet is 85.3%, and the laboratory support results sheet is 81.7% complete.

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“…Pengkodean klinis dapat diartikan sebagai suatu sistem pengelompokan (categories) penyakit, cedera dan kondisi kesehatan dan prosedur yang disusun sesuai kriteria yang telah ditentukan dan disepakati bersama (Pepo & Yulia, 2015). Dalam melakukan pengkodean diagnosis kode yang dihasilkan harus akurat, complete dan konsisten.…”

Section: Pendahuluanunclassified

Perancangan Instrumen Audit Pengkodean Klinis di Rumah Sakit Umum Pusat Fatmawati

Nasution

Hosizah

2020

JurnalMIKI

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The quality of diagnosis code is very important in the area of clinical data management, billing costs, and other matters relating to health care services. However, still often found inaccurate diagnosis codes resulting from a clinical coder. For this reason, it is necessary to conduct a clinical coding audit to improve the quality of the diagnosis code. In Indonesia some hospitals never conducted clinical coding audits because there are no instruments available for doing that. Fatmawati General Hospital never conducted a clinical coding audit. The purpose of this study is to design a clinical coding audit instrument in Fatmawati General Hospital. This is "Research & Development" study, the Delphi technique used to validate the clinical coding audit instrument design. Subjects of this study were clinical coder experts who had at least 5 years of experience as a clinical coders and the object of this research is clinical coding audit instrument. The results of the first round Delphi technique, the seven coding quality elements of the audit instrument were approved by all clinical coder experts and used in second round questionnaires. The results of second round 2, is known that the encoding quality elements recommended for use are reliability, completeness, timeliness, accuracy, relevance, and legibility. Element definition is not used because 80% of clinical coder experts didn't recommend it. This clinical coding audit instrument needs to be considered for use in conducting clinical coding audits in health care services. However, previously this instrument need to be tested for its implementation.

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Kelengkapan Penulisan Diagnosa Pada Resume Medis Terhadap Ketepatan Pengkodean Klinis Kasus Kebidanan

Cited by 6 publications

References 0 publications

Analyzing Patient Medical Resume Coding’s Completeness and Accuracy on the Amount of INA-CBG’s Claims

Analyzing Patient Medical Resume Coding’s Completeness and Accuracy on the Amount of INA-CBG’s Claims

Ketepatan Kode Penyakit Bronkopneumonia dan Kelengkapan Rekam Medis di Rumah Sakit St. Elisabeth Medan Tahun 2022

Perancangan Instrumen Audit Pengkodean Klinis di Rumah Sakit Umum Pusat Fatmawati

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