Perancangan Instrumen Audit Pengkodean Klinis di Rumah Sakit Umum Pusat Fatmawati

Abstract

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.

Audit Informasi Klinis dengan Aturan Morbiditas di Puskesmas Kota Yogyakarta

“…Audit informasi klinis merupakan kegiatan yang seharusnya dilakukan secara regular oleh divisi atau bagian yang melakukan penjaminan mutu dan disebut juga audit pengkodean klinis yaitu proses pemeriksaan pendokumentasian rekam medis untuk memastikan bahwa proses dan hasil pengkodean diagnosis dan tindakan yang dihasilkan adalah akurat, presisi dan tepat waktu sesuai dengan aturan ketentuan kebijakan dan perundang-undangan yang berlaku (Nasution and Hosizah, 2020 Hasil analisis kode diagnosis yang dilakukan pada penelitian ini membedakan tingkat ketepatan kode diagnosis utama menjadi 5 kategori yaitu Kategori A, B, C, D, dan E sesuai dengan tingkatan ketepatan kode menurut Nasution and Hosizah, 2020 dan Sa'adah, 2020 yang telah dimodifikasi oleh peneliti. Kategori A pada berkas rekam medis mempunyai angka ketepatan sebesar 28%, SIMPuS 52%, dan P-Care 49%.…”