Korelasi antara Ketersediaan Informasi Medis dengan Ketepatan Kode Diagnosis Bronchitis pada Dokumen Rekam Medis Rawat Inap di Rumah Sakit Umum Daerah Kabupaten Karanganyar Tahun 2019

Abstract

One of the factors that affect the accuracy of the diagnosis code was the availability of medical information in the form of filling out the diagnosis. The purpose of the study was to determine the correlation between the availability of medical information and the accuracy of the bronchitis diagnosis code on inpatient medical record documents at the Karanganyar Regency General Hospital in 2019. This type of research was descriptive with a retrospective approach. The method used was observation. The research population was 482 medical record documents and 83 medical record documents were taken as samples. The sampling technique used was simple random sampling. Due to the Covid-19 pandemic, the sample collection became 10 medical record documents. The results of the study were based on a sample of 10 medical record documents with bronchitis cases, there were 3 documents available (30%) of medical information, which was smaller than 7 documents (70%). The accuracy of the code is 2 documents (20%) smaller than the incorrect code, which was 8 documents (80%). From the results of the Chi-Square Test statistical test, the value of (0.016) <0.05, which meant that H0 was rejected and Ha was accepted. The conclusion of this study was that there was a correlation between the availability of medical information and the accuracy of the bronchitis diagnosis code on the medical record document of inpatients at the Karanganyar Regency General Hospital in 2019.

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

“…[13] This study is also in accordance with previous research that there is a relationship between the availability of medical information and the accuracy of the bronchitis diagnosis code on inpatient medical record documents at the Karanganyar Regency General Hospital with the result p (0.016) <0.05, which means H0 is rejected and H1 is accepted. [14].…”

Hubungan Kelengkapan Laporan Operasi Pasien Dengan Keakuratan Kode Kasus Patah Tulang Di Rumah Sakit Panti Waluya Sawahan Malang

“…Selain itu, kelengkapan pengisian berkas rekam medis oleh tenaga kesehatan akan memudahkan tenaga kesehatan yang lainnya dalam menentukan atau memberikan tindakan atau terapi selanjutnya kepada pasien. Berkas rekam medis yang informasinya lengkap akan berguna bagi pihak manajemen dalam menentukan langkah-langkah strategis untuk pengembangan pelayanan kesehatan [11] .…”