Analysis of the Diagnosis’s Inaccuracy Codes for Infection Cases in Dahlia Ward’s Inpatients at Majenang Regional Hospital

Syifa Khurotun Azizah; Agya Osadawedya Hakim; Gunawan  Gunawan

doi:10.21070/pels.v6i1.1925

(1) * Syifa Khurotun Azizah Medical Record & Health Information Universitas Muhammadiyah Purwokerto
Indonesia
(2) Agya Osadawedya Hakim Medical Record & Health Information Universitas Muhammadiyah Purwokerto
Indonesia
(3) Gunawan Gunawan Medical Record & Health Information Majenang Regional Hospital Majenang
Indonesia
(*) Corresponding Author

DOI: https://doi.org/10.21070/pels.v6i1.1925

Abstract

The large number of infection cases in Indonesia has caused the number of BPJS claims related to these cases to continue to increase. The claim process carried out by the hospital must go through various stages in order to be claimed, including the coding process. The medical recorder's role as a coder is responsible for the correctness and accuracy of the code for a diagnosis that has been determined by medical personnel (doctors). Inaccuracies in diagnosis codes will impact the effectiveness of health service data and information management as well as pending claims. Pending claims that occur due to inaccuracies can impact hospital cost profit which will result in the hospital experiencing losses. Based on a preliminary study conducted in the Dahlia Ward, Majenang Regional Hospital, 3 medical records with incorrect codes were found (3.54%) out of 58 medical records. This study aims to calculate the inaccuracy of diagnosis codes for cases of infection for inpatients in the Dahlia Ward, Majenang Regional Hospital and identify the factors that cause inaccurate diagnosis codes for cases of infection for inpatients in the Dahlia Ward, Majenang Hospital.The research method used is a qualitative method with a narrative descriptive design. Data collection techniques were carried out using two methods, namely observation and interviews. Interviews were conducted to obtain reasons for inaccurate diagnosis codes, while observations were used to verify interview results. There were 3 resource persons in this study, namely the head of medical records and 2 inpatient coders. The research results showed that inaccuracies occurred due to incomplete diagnosis writing by the DPJP, such as doctors tending to write abbreviations, and coders tending to use rote memorization in determining diagnosis codes.

Downloads

Download data is not yet available.

References

[1] Menteri Kesehatan Republik Indonesia, Keputusan Menteri Kesehatan Republik Indonesia Nomor : HK.01.07/Menkes/312/2020 Tentang Standar Profesi Perekam Medis dan Informasi Kesehatan. Indonesia, 2020, p. 42.
[2] N. dan D. R. K. Puspitasari, “EVALUASI TINGKAT KETIDAKTEPATAN PEMBERIAN KODE DIAGNOSIS DAN FAKTOR PENYEBAB DI RUMAH SAKIT X JAWA TIMUR Nurmalinda Puspitasari * , Diah Retno Kusumawati * *,” Eval. Tingkat Ketidaktepatan Pemberian Kode Diagnosis Dan Fakt. Penyebab Di Rumah Sakit X Jawa Timur, vol. 3, no. 1, 2017.
[3] Y. F. Nanjo et al., “Analisis Pengaruh Ketidaktepatan Kode Diagnosis Dan Kode Tindakan Pasien Rawat Inap Peserta Jaminan Kesehatan Nasional Terhadap Tarif Di Rumah Sakit Umum Daerah Wangaya Kota Denpasar,” J. Heal. Care Media ISSN 2089-4228, vol. 6, no. 2, pp. 86–94, 2022.
[4] E. S. D. H. Suryandari, R. N. Rahmadhani, A. Z. Pitoyo, H. S. Sangkot, and A. Wijaya, “Hubungan Ketepatan Penulisan Diagnosis Penyakit dengan Keakuratan Kode Diagnosis pada Pasien Rawat Inap di Rumah Sakit,” J. Manaj. Kesehat. Indones., vol. 11, no. 3, pp. 249–259, 2023, doi: 10.14710/jmki.11.3.2023.249-250.
[5] A. A. Noor Mutsaqof, W. -, and E. Suryani, “Sistem Pakar Untuk Mendiagnosis Penyakit Infeksi Menggunakan Forward Chaining,” J. Teknol. Inf. ITSmart, vol. 4, no. 1, p. 43, 2016, doi: 10.20961/its.v4i1.1758.
[6] M. Badar, “Manajemen Kualitas Pelayanan Rumah Sakit Umum Daerah Batara Siang Kabupaten Pangkep,” KAIZEN Kaji. Ekon. Manajemen, Akuntansi, dan Kewirausahaan, vol. 1, no. 1, pp. 1–9, 2022.
[7] Nurdahniar, “Pelayanan Kesehatan Rawat Inap Rumah Sakit Umum Daerah Tenriawaru Kabupaten Bone,” Univ. Negeri Makassar, no. 1465142006, pp. 1–12, 2019.
[8] D. Mardiawati, L. Handayuni, R. Afrima Yenni, and D. Giovani, “Faktor-Faktor Yang Mempengaruhi Ketepatan Pengodean Pada Kasus Cedera Berdasarkan Icd-10 Di Rumah Sakit Khusus Bedah,” Ensiklopedia J., vol. 4, no. 3, pp. 228–234, 2022, doi: 10.33559/eoj.v4i3.305.
[9] M. Salehudin, D. Harmanto, and A. Budiarti, “Tinjauan Kejelasan dan Ketepatan Diagnosa Pada Resume Medis Pasien Rawat Inap dengan Keakuratan Kode Berdasarkan ICD-10 di RSHD Kota Bengkulu,” J. Manaj. Inf. Kesehat., pp. 34–43, 2021.
[10] Kementerian Kesehatan Republik Indonesia, Peraturan Menteri Kesehatan RI No 24 Tahun 2022 Tentang Rekam Medis. Indonesia, 2022.
[11] M. K. Wirajaya and N. Nuraini, “Faktor Faktor yang Mempengaruhi Ketidaklengkapan Rekam Medis Pasien pada Rumah Sakit di Indonesia,” J. Manaj. Inf. Kesehat. Indones., vol. 7, no. 2, p. 165, 2019, doi: 10.33560/jmiki.v7i2.225.
[12] L. Indawati, “Identifikasi Unsur 5M dalam Pemberian Kode Penyakit Dan Tindakan (Systematic Review),” Indones. Heal. Inf. Manag. J., vol. 5, no. 2, pp. 59–64, 2017.