skip to main content

Hubungan Ketepatan Penulisan Diagnosis Penyakit dengan Keakuratan Kode Diagnosis pada Pasien Rawat Inap di Rumah Sakit

*Endang Sri Dewi Hastuti Suryandari orcid  -  Program Studi D3 Rekam Medis dan Informasi Kesehatan, Jurusan Rekam Medis dan Informasi Kesehatan, Politeknik Kesehatan Kemenkes Malang, Indonesia
Regina Novi Rahmadhani  -  Jurusan Rekam Medis dan Informasi Kesehatan, Politeknik Kesehatan Kemenkes Malang, Indonesia
Acmad Zani Pitoyo  -  Program Studi D3 Rekam Medis dan Informasi Kesehatan, Jurusan Rekam Medis dan Informasi Kesehatan, Politeknik Kesehatan Kemenkes Malang, Indonesia
Hartaty Sarma Sangkot orcid  -  Program Studi D3 Rekam Medis dan Informasi Kesehatan, Jurusan Rekam Medis dan Informasi Kesehatan, Politeknik Kesehatan Kemenkes Malang, Indonesia
Avid Wijaya orcid  -  Program Studi D3 Rekam Medis dan Informasi Kesehatan, Jurusan Rekam Medis dan Informasi Kesehatan, Politeknik Kesehatan Kemenkes Malang, Indonesia

Citation Format:
Abstract

The accuracy of the disease diagnoses code is determined by the accuracy of writing the diagnoses. The result of observation in 10 inpatient medical record documents at the TNI-AD 05.08.04 Hospital Lawang, 5 documents were found with inaccurate codes (50%) with 3 incorrectly written diagnoses. The purpose of this study was to analyze the effect of the accuracy in writing disease diagnoses to the accuracy of the diagnoses code for inpatients at the TNI-AD 05.08.04 Hospital, Lawang. This methode of research was an analytic observational with a cross-sectional approach. The number of sample analyze were 100 inpatient medical record documents which hospitalitaion from March to August 2022 and using simple random sampling technique by lottery. The accuracy of writing diseases diagnoses of inpatient was an independent variable and the accuracy of the diagnoses code for the inpatient at the TNI-AD 05.08.04 Hospital, Lawang was dependent variable in this study. The results showed the accuracy in writing disease diagnoses was 70% and the accuracy of the disease diagnoses code was 45%. The analytic test with Chi Square showed significantly the effect of accuracy in writing diseases diagnoses to the accuracy of diagnoses code for inpatient at the TNI-AD 05.08.04 Hospital Lawang with a p-value = 0.000 (<0.05). The accuracy in writing diseases diagnoses by doctor that refer to medical terminology of ICD-10 will producted an accurate diagnoses codes.

Note: This article has supplementary file(s).

Fulltext View|Download |  Research Instrument
Hasil Cek Turnitin Manuskrip Jurnal
Subject
Type Research Instrument
  Download (2MB)    Indexing metadata
Keywords: accuracy of diagnoses code; accuracy of writing diagnoses; inpatient medical record

Article Metrics:

  1. Undang-Undang Republik Indonesia Nomor 44 Tahun 2009. Rumah Sakit. 28 Oktober 2009. Jakarta
  2. Peraturan Pemerintah Nomor 47 Tahun 2021. Penyelenggaraan Bidang Perumahsakitan. 02 Februari 2021. Jakarta
  3. Savitri Citra Budi, M. 2019. Manajemen Unit Kerja Rekam Medis. Yogyakarta: Quantum Sinergis Media
  4. Peraturan Menteri Kesehatan Nomor 24 Tahun 2022. Rekam Medis. 1-20. 31 Agustus 2022. Jakarta
  5. Hatta. 2013. Pedoman Manajemen Informasi Kesehatan Disarana Pelayanan Kesehatan. Jakarta: UI-Press
  6. Peraturan Menteri Kesehatan Nomor 40 Tahun 2012. Pedoman Pelaksanaan Program Jaminan Kesehatan Masyarakat. 1-94. 27 September 2012. Jakarta
  7. Bandiani, N. 2018. Hubungan Ketepatan Penulisan Diagnosis Dengan Keakuratan Kode Diagnosis Pasien Rawat Inap Di Rumah Sakit Bhayangkara Polda DIY. Yogyakarta. Diploma Thesis, Universitas Jenderal Achmad Yani Yogyakarta. 3
  8. Rahasti, M. E. 2016. Hubungan Ketepatan Penulisan Diagnosis Dengan Keakuratan Kode Diagnosis Pasien Rawat Inap di Rumah Sakit UGM Yogyakarta. Doctoral Dissertation, Universitas Gajah Mada. 73
  9. WHO. 2010. International Statistical Classification of Diseases and Related Health Problems, 10th Revision ICD-10: Tabular List. World Health Organization Volume 1. 332-345
  10. Irmawan, I. 2014. Tinjauan Keakuratan Kode Diagnosis Neoplasma Di RSUD Banjarbaru. Jurnal Kesehatan Indonesia. 4(3)
  11. WHO. 2010. International Statistical Classification of Diseases and Related Health Problems, 10th Revision Volume 2. 230(4).314–317
  12. Hanifah, E. G. I. L. N. 2022. Analisis Kemampuan PMIK Terhadap Kelengkapan dan Ketepatan Kode Diagnosis Kasus Persalinan di Rumah Sakit. Indonesian of Health Information Management Journal (INOHIM). 10(2). 112–7
  13. S. Cohen, A. S. Jannot, L. Iserin, D. Bonnet, A. Burgun and JBE. 2019. Accuracy of Claim Data In The Identification and Classification of Adults with Congenital Heart Diseases In Electronic Medical Records. Archives Cardiovascular Diseases. 112(1). 31–43
  14. Setyorini, D., Sugiarsi, S., & Widjokongko, B. 2013. Analisis Kelengkapan Kode Topography dan Kode Morphology Pada Diagnosis Carcinoma Cervix Berdasarkan ICD-10 di RSUD dr. Moewardi Triwulan IV Tahun 2012. Open Journal Systems. 7(2)
  15. Nurhasanah, I., Nurcahyati, S., and Fauzi, A. 2022. Analisis Ketepatan Kode Diagnosis Neoplasma Di Rumah Sakit Tingkat III 03.06.01 Ciremai Cirebon. Jurnal Wiyata Penelitian Sains dan Kesehatan. 9(1). 15
  16. Peraturan Menteri Kesehatan Nomor 27 Tahun 2014. Petunjuk Teknis Sistem Indonesian Case Base Groups (INA-CBGs). 02 Juni 2014. Jakarta
  17. Riyanti, N. 2013. Pengaruh Beban Kerja Coder dan Ketepatan Terminologi Medis Terhadap Keakuratan Kode Diagnosis Penyakit Gigi di RSJ Grhasia DIY Tahun 2012. Journal of the American Chemical Society. 123(10). 2176–2181
  18. Garmelia, E. 2017. Klasifikasi, Kodifikasi Penyakit dan Masalah Terkait I: Anatomi, Fisiologi, Patologi, Terminologi Medis dan Tindakan Pada Sistem Kardiovaskuler, Respirasi dan Muskuloskeletal. 511
  19. Suryandari, E. S. D. H. 2019. Relationship Between Specificity and Precision in Writing the Main Diagnosis and Accuracy of Main Diagnosis Codes with Financing Claims in Cases of DM in Dr Radjiman Wediodiningrat Hospital, Lawang. Modern Health Science. 2(2). 26
  20. Hamid. 2013. Hubungan Ketepatan Penulisan Diagnosis Dengan Keakuratan Kode Diagnosis Kasus Obstetri Gynecology Pasien Rawat Inap Di RSUD. Dr. Saiful Anwar Malang. Skripsi. Program S1 Kesehatan Masyarakat Universitas Muhammadiyah Surakarta. 1-7
  21. Puspaningtyas, C. A., Sangkot, H. S., Akbar, P. S., Suryandari, E. S. D. H., and Wijaya, A. 2022. Analisis Hubungan Ketepatan Penulisan Diagnosis dengan Keakuratan Kode Diagnosis pada Kasus Obstetri dan Ginekologi. Jurnal Rekam Medik dan Manajemen Informasi Kesehatan. 1(2). 94–100
  22. Pepo, A. A. H., and Yulia, N. 2015. Kelengkapan Penulisan Diagnosa Pada Resume Medis Terhadap Ketepatan Pengkodean Klinis Kasus Kebidanan. Jurnal Manajemen Informasi Kesehatan Indonesia. 3(2)
  23. Kresnowati, L. E. 2013. Analisis Faktor-Faktor yang Mempengaruhi Akurasi Koding Diagnosis dan Prosedur Medis pada Dokumen Rekam Medis Rawat Inap di RSUD Kota Semarang Tahun 2013. Penelitian Dosen Pemula. Dikti

Last update:

No citation recorded.

Last update: 2024-11-23 02:38:26

No citation recorded.