HUBUNGAN KETEPATAN PENULISAN DIAGNOSIS TERHADAP KEAKURATAN KODE DIAGNOSIS PENYAKIT SISTEM CARDIOVASCULAR DI RS LAVALETTE MALANG

Endang Sri Dewi Hastuti Suryandari; Natalia Nur Susanti

doi:10.14710/jmki.13.1.2025.14-26

DOI: https://doi.org/10.14710/jmki.13.1.2025.14-26

HUBUNGAN KETEPATAN PENULISAN DIAGNOSIS TERHADAP KEAKURATAN KODE DIAGNOSIS PENYAKIT SISTEM CARDIOVASCULAR DI RS LAVALETTE MALANG

Endang Sri Dewi Hastuti Suryandari - Politeknik Kesehatan Kemenkes Malang, Indonesia

*Natalia Nur Susanti - Politeknik Kesehatan Kemenkes Malang, Indonesia

BibTex Citation Data :

@article{JMKI69829,
    author = {Endang Sri Dewi Hastuti Suryandari and Natalia Nur Susanti},
    title = {HUBUNGAN KETEPATAN PENULISAN DIAGNOSIS TERHADAP KEAKURATAN KODE DIAGNOSIS PENYAKIT SISTEM CARDIOVASCULAR DI RS LAVALETTE MALANG},
    journal = {Jurnal Manajemen Kesehatan Indonesia},
  volume = {13},
    number = {1},
    year = {2025},
    keywords = {Medical record; Writing diagnosis; Accuracy diagnosis codes; Cardiovascular system disease},
    abstract = {  Precision of writing diagnosis of cardiovascular system diseases in Lavalette Hospital Malang by 70% with accuracy diagnosis codes by 30%. The purpose of research to determine the relationship between precision in writing diagnosis and accuracy of diagnosis codes of cardiovascular system diseases in Lavalette Hospital Malang. This research used quantitive analysis with cross sectional study approach. The population of this research is 248 medical records of cardiovascular cases. The research sample is 150 medical records with simple random sampling. The independent variable is precision in writing diagnosis of cardiovascular system diseases, while the dependent variable is accuracy of diagnosis codes of cardiovascular system diseases. The univariate test results shows the percentage precision of writing diagnosis cardiovascular system disease by 48% (72 medical records) and accuracy of diagnosis codes of cardiovascular system diseases by 30% (45 medical records). The chi square test results shows there is a relationship between precision in writing diagnosis and accuracy of diagnosis codes of cardiovascular system disease in Lavalette Hospital Malang with p value of 0.019 (<0.05). To increase the level of accuracy diagnosis codes, standarized writing guidebooks for diagnosis should be created and coders should be more careful on reading medical information in medical records.  },
   issn = {2548-7213},   pages = {14--26}  doi = {10.14710/jmki.13.1.2025.14-26},
    url = {https://ejournal.undip.ac.id/index.php/jmki/article/view/69829}
}

Citation Format:

Abstract

Precision of writing diagnosis of cardiovascular system diseases in Lavalette Hospital Malang by 70% with accuracy diagnosis codes by 30%. The purpose of research to determine the relationship between precision in writing diagnosis and accuracy of diagnosis codes of cardiovascular system diseases in Lavalette Hospital Malang. This research used quantitive analysis with cross sectional study approach. The population of this research is 248 medical records of cardiovascular cases. The research sample is 150 medical records with simple random sampling. The independent variable is precision in writing diagnosis of cardiovascular system diseases, while the dependent variable is accuracy of diagnosis codes of cardiovascular system diseases. The univariate test results shows the percentage precision of writing diagnosis cardiovascular system disease by 48% (72 medical records) and accuracy of diagnosis codes of cardiovascular system diseases by 30% (45 medical records). The chi square test results shows there is a relationship between precision in writing diagnosis and accuracy of diagnosis codes of cardiovascular system disease in Lavalette Hospital Malang with p value of 0.019 (<0.05). To increase the level of accuracy diagnosis codes, standarized writing guidebooks for diagnosis should be created and coders should be more careful on reading medical information in medical records.

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Keywords: Medical record; Writing diagnosis; Accuracy diagnosis codes; Cardiovascular system disease

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Section: Articles

Language : EN

In Vol 13, No 1 (2025): April 2025

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Mathar I. Manajemen Informasi Kesehatan Pengelolaan Dokumen Rekam Medis. Sleman: Penerbit Deepublish, 2018
Hatta G. Pedoman Manajemen Informasi Kesehatan di Sarana Pelayanan Kesehatan . 3rd revision. Jakarta: Penerbit Universitas Indonesia, 2014
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Arimbawa IWG, Yunawati NPL, Paramita IAPF. Hubungan Kelengkapan Penulisan Diagnosis terhadap Keakuratan Kode Diagnosis ICD-10 Kasus Obstetri Triwulan III Pasien Rawat Inap di RSU Premagana. J Manaj Inf Kesehat Indones 2022; 10: 31–35
Lubis F, Rizki K. Tinjauan Ketidaklengkapan Pengisian Catatan Medis pada Berkas Rekam Medis Raawat Inap Pasien Penderita Diabetes Melitus terhadap Klaim BPJS di Rumah Sakit Umum IPI Medan Tahun 2018. Jurnal Ilmu Perekam Medis dan Informasi Kesehatan Imelda 2018; 3: 380–385
Kholifah U, Wariyanti AS, Kusumawati EA. Hubungan Kelengkapan Informasi Penunjang CT Scan dengan Keakuratan Kode Diagnosis Cerebral Infarction pada Pasien BPJS di Rumah Sakit Umum Daerah Kabupaten Temanggung. Indonesian Journal of Health Information Management (IJHIM) 2023; 3: 1–7
Kemenkes RI. Berita Acara Kesepakatan Bersama Panduan Penatalaksanaan Solusi Permasalahan Klaim INA-CBG Tahun 2019. 2020
Mardiawati D, Akika TF. Identifikasi Keakuratan Kode Underlying Cause of Death (UCOD) Kasus Stroke Berdasarkan ICD-10 di Rumah Sakit Tk.III dr. Reksodiwiryo Padang. Administration & Health Information of Journal 2020; 1: 10–18
Dorland WAN. Kamus Saku Kedokteran Dorland. 30th ed. Singapore: Elsevier, 2020
Rahmawati EN, Utami TD. Hubungan Ketepatan Penulisan Terminologi Medis Terhadap Keakuratan Kode Pada Sistem Cardiovascular Di Rumah Sakit Panti Waluyo Surakarta. Jurnal Manajemen Informasi Kesehatan Indonesia 2020; 8: 101
Maryati W. Hubungan Antara Ketepatan Penulisan Diagnosis dengan Keakuratan Kode Diagnosis Kasus Obstetri di RS PKU Muhammadiyah Sukoharjo. Jurnal Ilmu Rekam Medis dan Informasi Kesehatan 2016; 6: 1–7
WHO. International Classification of Diseases and Related Health Problems Volume 2 Instruction Manual (Tenth Revision). Geneva: World Health Organization, 2011
Rahmawati FA, Widyaningrum L. Tinjauan Keakuratan Kode Diagnosis Gastroenteritis Acute pada Pasien Rawat Inap Berdasarkan ICD-10 di Rumah Sakit Panti Waluyo Yakkum Surakarta Tahun 2019-2021. Prosiding Seminar Informasi Kesehatan Nasional (SIKesNas) 2022 2022; 483–487
Maryati W, Wannay AO, Suci DP. Hubungan Kelengkapan Informasi Medis dan Keakuratan Kode Diagnosis Diabetes Mellitus. Jurnal Rekam Medis dan Informasi Kesehatan 2018; 1: 96–108
Utami YT, Sahari MA bin, Maryati W, et al. Accuracy of Outpatient Diagnosis Code Based on ICD-10. Proceedings of the International Conference on Nursing and Health Sciences 2022; 3: 89–100
Garmelia E, Kresnowati L, Irmawati. Klasifikasi, Kodefikasi Penyakit dan Masalah Terkait I: Anatomi, Fisiologi, Patologi, Terminologi Medis dan Tindakan pada Sistem Kardiovaskuler, Respirasi, dan Muskuloskeletal. Jakarta, 2017
Pusparini B, Pratiwi RD. Perbedaan Klaim Tarif INA-CBG pada Penyakit Sistem Peredaran Darah. Jurnal Manajemen Informasi Kesehatan Indonesia 2020; 8: 119–125
Widyaningrum L, Wahyuningsih HN, Wariyanti AS. Keakuratan Kode Kombinasi Dokumen Rekam Medis Pasien Rawat Inap Jaminan Kesehatan Nasional di Rumah Sakit Umum Daerah Pandan Arang Boyolali. Jurnal Ilmu Rekam Medis dan Informasi Kesehatan 2022; 12: 49–53
Suryandari ESDH, Rahmadhani RN, Pitoyo AZ, et al. Hubungan Ketepatan Penulisan Diagnosis Penyakit dengan Keakuratan Kode Diagnosis pada Pasien Rawat Inap di Rumah Sakit. Jurnal Manajemen Kesehatan Indonesia 2023; 11: 249–259
Kemenkes RI. Pelayanan Medis. https://upk.kemkes.go.id/new/layanan/pelayanan-medis
Pepo AAH. Kelengkapan Penulisan Diagnosis pada Resume Medis terhadap Ketepatan Pengkodean Klinis Kasus Kebidanan. Jurnal Manajemen Informasi Kesehatan Indonesia 2015; 3: 74–79

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