Akurasi dan Ketepatan Pengkodean Diagnosis pada Kasus Obstetric di RST Dr. Asmir DKT Salatiga
DOI:
https://doi.org/10.53416/jurmik.v4i1.262Abstract
Accurate and precise diagnosis coding in obstetric cases at Dr. Asmir DKT Hospital, Salatiga, is crucial for effective medical record management. This study utilized an analytical quantitative approach with a cross-sectional method to explore the relationship between the accuracy and precision of diagnosis coding. The sample comprised 100 obstetric cases selected from inpatients during the first quarter (January – March 2024). Data analysis revealed that 68% of the 72 analyzed cases had accurate diagnosis coding, while 32% were inaccurate. Similarly, 71% of the cases were coded precisely, with 29% coded imprecisely. Chi-Square analysis indicated a significant relationship between accuracy and precision of diagnosis coding (p = 0.002). Factors influencing inaccuracies and imprecisions in coding included legibility of physician notes in medical records, inadequate understanding of the coding system (ICD-10), and completeness of medical documentation. To enhance coding quality, regular training for healthcare staff is recommended, alongside strengthening internal audit systems and developing more efficient medical record information systems.
References
Dewi, R. K. (2021). Elderly Cognitive Functions at Tresna Werdha Islamic Village Nursing Home, Tangerang. Jurnal PROMKES, 9(2), 142. https://doi.org/10.20473/jpk.v9.i2.2021.142-150
Dewi, R. K., Sumantrie, P., Rahmasari, R., Simbolon, S., Husaeni, H., Ashari, A. E., Hutomo, C. S., Taswin, T., Rasmaniar, R., & Argaheni, N. B. (2022). Pengantar Manajemen Kesehatan. Yayasan Kita Menulis.
Dewi, T. S., & Silva, A. A. (2023). Hambatan Implementasi Rekam Medis Elektronik dari Perspektif Perekam Medis Dengan Metode PIECES. Jurnal Manajemen Informasi Kesehatan Indonesia, 11(2).
Fadila, A., Marbun, M. N., Siregar, A. S., & Gurning, F. P. (2023). Analisis Faktor Yang Mempengaruhi Kepatuhan Membayar Iuran Jaminana Kesehatan Nasional (Bpjs Kesehatan). Jurnal Kesehatan, 1(2), 451–456.
Glaser, J., Henley, D. E., Downing, G., Brinner, K. M., & Community, P. H. C. W. of the A. H. I. (2008). Advancing personalized health care through health information technology: an update from the American Health Information Community’s Personalized Health Care Workgroup. Journal of the American Medical Informatics Association, 15(4), 391–396.
Indira, Z. N., Widodo, A. P., & Agushybana, F. (2023). Literature Review: The Effectiveness of Electronic Medical Records (RME) On Hospital Service Quality. J-Kesmas: Jurnal Fakultas Kesehatan Masyarakat (The Indonesian Journal of Public Health), 10(1), 57–64.
Juharni, S., Widarsa, I. K. T., & Wirawan, D. N. (2013). Faktor risiko kematian ibu sebagai akibat komplikasi kehamilan, persalinan dan nifas di Kabupaten Bima tahun 2011–2012. Public Health and Preventive Medicine Archive, 1(2), 96–102.
Kemp, T., Fernandes, L., Barnes, C., Marshall, D., Burns, M., Mandapam, S. K., Hatta, G., Kim, O., & Butler-Henderson, K. (2021). Working as a Health Information Manager. The Health Information Workforce: Current and Future Developments, 269–280.
Khumaira, N. F., & Yastori, Y. (2024). PELATIHAN KODEFIKASI KASUS OBSTETRIC BERDASARKAN ICD 10 DI RSIA CICIK PADANG. Jurnal Abdimas Bina Bangsa, 5(1), 854–862.
Ma, J., Stahl, L., & Knotts, E. (2018). Emerging roles of health information professionals for library and information science curriculum development: a scoping review. Journal of the Medical Library Association: JMLA, 106(4), 432.
Mahmood, S., Hassan, S. Z., Tabraze, M., Khan, M. O., Javed, I., Ahmed, A., Siddiqui, O. M., Narmeen, M., Ahmed, M. J., & Tariq, A. (2017). Prevalence and predictors of depression amongst hypertensive individuals in Karachi, Pakistan. Cureus, 9(6).
Nugraheni, N. N. N. (2021). The Effect of Accuracy of Giving Diagnosis Codes on Diseases in the Verification of the Sosial Security Organizing Agency (BPJS) in PKU Muhammadiyah Sruweng Hospital. Health Media, 2(2), 1–5.
Permana, I. P. A. Y., Sutrisnawati, G. A. E., & Juniati, N. K. (2023). Analysis Of Hospital Management Information System (SIMRS) And Its Relation To The Readiness Of Electronic Medical Record (RME) Implementation In RSUP. Sanglah Denpasar. Jurnal Health Sains, 4(7), 74–81.
Rachmad, E., Indawati, L., Fannya, P., & Widjaja, L. (2023). Ketepatan Pengodean Diagnosis Pasien Klinik Penyakit dalam di RSAL Dr. Mintohardjo Jakarta Pusat 2021. COMSERVA: Jurnal Penelitian Dan Pengabdian Masyarakat, 2(09), 1935–1941.
Rahayu, H., Ernawati, D., & Kresnowati, L. (2011a). Akurasi kode diagnosis utama pada rm 1 dokumen rekam medis ruang karmel dan karakteristik petugas koding rawat inap rumah sakit mardi rahayu kudus periode desember 2009. Jurnal Visikes, 10(1), 1–5.
Rahayu, H., Ernawati, D., & Kresnowati, L. (2011b). Akurasi kode diagnosis utama pada rm 1 dokumen rekam medis ruang karmel dan karakteristik petugas koding rawat inap rumah sakit mardi rahayu kudus periode desember 2009. Jurnal Visikes, 10(1), 1–5.
Sari, P. I., Hatta, G. R., & Nuraini, A. (2023). Analisis Pengaruh Pengetahuan, Kepatuhan Dokter dan Peran Rumah Sakit Terhadap Kelengkapan Pengisian Berkas Rekam Medis Rawat Inap RSIA Brawijaya. Jurnal Manajemen Dan Administrasi Rumah Sakit Indonesia (MARSI), 7(4), 369–378.
Sudra, R. I. (2021). Standardisasi resume medis dalam pelaksanaan PMK 21/2020 terkait pertukaran data dalam rekam medis elektronik. Jurnal Ilmiah Perekam Dan Informasi Kesehatan Imelda (JIPIKI), 6(1), 67–72.
Sudra, R. I., Dewi, R. K., Widiyanto, W. W., Jamaludin, J., Argaheni, N. B., Koibur, M. E., & Purnawinadi, I. G. (2021). Manajemen Informasi Kesehatan. Yayasan Kita Menulis.
Utami, Y. T., Widyaningrum, L., & Santi, S. (2024). ANALISIS KETEPATAN KODE DIAGNOSIS DAN TINDAKAN KASUS OBSTETRI PASIEN RAWAT INAP DI RSUD WARAS WIRIS BOYOLALI. Infokes: Jurnal Ilmiah Rekam Medis Dan Informatika Kesehatan, 14(1), 14–21.
Vobecky, A., Siméoni, O., Hurych, D., Gidaris, S., Bursuc, A., Pérez, P., & Sivic, J. (2024). Pop-3d: Open-vocabulary 3d occupancy prediction from images. Advances in Neural Information Processing Systems, 36.
Wasir, R., Irawati, S., Makady, A., Postma, M., Goettsch, W., & Feenstra, T. (2020). The implementation of health technology assessment (HTA) in medicine pricing and reimbursement policies in Indonesia: insights from multiple stakeholders. Riswandy Wasir, 69.
Zulkarnain, L. G., & Ariyanti, R. (2023). Analisis Ketidaktepatan Kode Diagnosis Penyakit Hipertensi Berdasarkan Icd-10 Pada Pelayanan Rawat Jalan Di Puskesmas Kedungkandang Kota Malang. Bioedutech: Jurnal Biologi, Pendidikan Biologi, Dan Teknologi Kesehatan, 2(2), 150–160.
Downloads
Published
How to Cite
Issue
Section
License
Copyright (c) 2024 Jurnal Rekam Medis & Manajemen Infomasi Kesehatan
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
