Clarity of Diagnosis Writing and Accuracy of Coding in Heart Failure Based on ICD-10 at Hospital X
Kejelasan Penulisan Diagnosa dan Keakuratan Kodefikasi pada Heart Failure Berdasarkan ICD-10 di Rumah Sakit X
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(1) * Deno Harmanto
Sekolah Tinggi Ilmu Kesehatan Sapta Bakti, Bengkulu
Indonesia
(2) Anggia Budiarti Sekolah Tinggi Ilmu Kesehatan Sapta Bakti, Bengkulu
Indonesia
(3) Dinda Sri Rahayu Sekolah Tinggi Ilmu Kesehatan Sapta Bakti, Bengkulu
Indonesia
(*) Corresponding Author
Abstract
It is very important to code the diagnosis of Heart Failure correctly and accurately, inaccuracies in codes are often found in medical record files such as unclear writing of the diagnosis or even incomplete supporting documents and the absence of a 4th character code in the diagnosis of Heart Failure. If coding is not carried out accurately, it will result in errors in disease recording indexes and actions, inaccurate report information data and inaccurate INA-CBG rates. The purpose of this study aims to determine the clarity of writing diagnoses and the accuracy of heart failure coding based on ICD-10 at Rafflesia Hospital, Bengkulu. The type of research is descriptive. The data used are primary data and secondary data which are processed univariately, data collection methods are through interviews and observation. The tool used is a checklist sheet with direct observation of 176 medical record files for the diagnosis of heart disease. Of the 176 medical record files for the diagnosis of Heart Failure, there is clarity in writing the diagnosis on the medical resume, a small number of 56 files (32%) are clear, but the majority of 120 files (68%) are unclear and the accuracy of codes based on ICD-10 is mostly 64 files (36% ) were accurate and as many as 112 files (64%) were inaccurate.
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References
Adang Durachim,S.Pd, M. K.,& Dewi Astuti, Ss. M. B. (2006). Klasifikasi, Kodefikasi Penyakit dan Masalah Terkait. bahan ajar teknologi laboraturium medik (TLM), 1999(December), 1–6.
Ahmad, J. M., Harmanto, D., Laboratorium, P., & Medis, K. I. (2019). Faktor Penyebab Ketidakakuratan Kode Diagnosis Pada Causes of Inaccurate Diagnosis Code on Inpatient Medical Record Documents Based on Medical Information in the Hospital Bhayangkara Bengkulu City.
Akbar, P. S. (2018). Tata cara penentuan kodefikasi penyakit berdasarkan ICD-10. Politeknik Kesehatan Kemenkes Malang.
Gunawan, D., & Nada, I. K. W. (2017). Fisiologi Kardiovacular. Tesis Fisiologi Kardiovacular Fakultas Kedokteran UNUD RSUP Sangla Denpasar., 1–70. https://simdos.unud.ac.id/uploads/file_penelitian_1_dir/d86da803a59b17df42 85c9445d002869.pdf
Ilmi, K. T.,, L., Al-fiah, F., Y., (2021). Tinjauan penyebab ketidaktepatan pemberian kodediagnosis pada rekam medis.
Karimah, R. N., Setiawan, D., & Nurmalia, P. S. (1970). Diagnosis Code Accuracy Analysis Of Acute Gastroenteritis Disease Based on Medical Record Document in Balung Hospital Jember. Journal of Agromedicine and Medical Sciences, 2(2), 12. https://doi. org/10.19184/ams.v2i2.2775
Kemenkes. (2019). Kementerian Kesehatan Republik Indonesia. In Kementerian Kesehatan RI (Vol. 1, Nomor 1, hal. 1). https://www.kemkes.go.id/article/ view/19093000001/penyakit-jantung- penyebab-kematian-terbanyak-ke-2-di- indonesia.html
Khornelis Dehotman. (2016). Pengaruh Pendidikan terhadap Kinerja Karyawan. Jebi (Jurnal Ekonomi dan Bisnis Islam), 1(2), 217–234. Http://Journal.Febi. Uinib.Ac.Id/Index.Php/Jebi/Article/ View/36
Kurnianingsih, W. (2020). Hubungan Pengetahuan Coder dengan Keakuratan Kode Diagnosis Pasien Rawat Jalan BPJS berdasarkan ICD – 10 di Rumah Sakit Nirmala Suri Sukoharjo. Jurnal Manajemen Informasi dan Administrasi Kesehatan (JMIAK), 3(01). https://doi. org/10.32585/jmiak.v3i01.680
Maisharoh1, & , Dian Sari2, D. R. (2022). Hubungan Kejelasan dan Kelengkapan Penulisan Diagnosa Penyakit Bronchitis Acute dengan Ketepatan Pengodean Diagnosa Penyakit Berdasarkan ICD 10 di Bangsal Rawat Inap Penyakit dalam RS Mitra Medika Batang Hari. Maisharoh1 , Dian Sari2, Dea Rosanti3, 10(1), 1–52. Https://Doi.Org/10.21608/ Pshj.2022.250026
Notoatmodjo, S. (2012). Metodologo Penelitian Kesehatan. 144.
Nurbudiman, rezky ilham. (2020). Hubung- an Jumlah Perdarahan dengan Kejadian Hipotensi pada Pasien Sectio Caesarea dengan Spinal Anestesi di RSUD Banjarnegara. 1–26. http:// eprints.poltekkesjogja.ac.id/2515/
Nurjannah, N. S., Mudiono, D. R. P., Farlinda, S., & Djasmanto, D. (2022). Determinan Ketepatan Kode Diagnosis Utama di RS Pusat Pertamina Jakarta Selatan. Jurnal Rekam Medik & Manajemen Informasi Kesehatan, 1(1), 35–40. https://doi.org/10.47134/rmik. v1i1.14
Permatasari, I. (2017). Diagnosa Ke- perawatan Pasien Bedah. Jurnal Askep pasien bedah, 13–36.
Pertiwi, J. (2019). Systematic Review: Faktor yang Mempengaruhi Akurasi Koding Diagnosis di Rumah Sakit. Smiknas, 41–50. http://ojs.udb.ac.id/ index.php/smiknas/article/view/692
Rahmawati, E. N., & Utami, T. D. (2020). Hubungan Ketepatan Penulisan Terminologi Medis terhadap Ke- akuratan Kode Pada Sistem Cardiovascular di Rumah Sakit Panti Waluyo Surakarta. Jurnal Manajemen Informasi Kesehatan Indonesia, 8(2),101. https://doi.org/10.33560/jmiki. v8i2.251
Salehudin, M., Harmanto, D., & Budiarti, A. (2021). Tinjauan Kejelasan dan Ketepatan Diagnosa pada Resume Medis Pasien Rawat Inap dengan Keakuratan Kode Berdasarkan ICD-10 di RSHD Kota Bengkulu. Jurnal Manajemen Informasi Kesehatan, 34– 43.
Suparyanto dan Rosad (2020). Diagnosis yang terekam dalam lembar rekam medis. Suparyanto dan Rosad (2015, 5(3), 248–253.
Yulia, N. (2020). Anatomi Dan Fisiologi Sistem Cardiovascular. 0–14. https:// lms-paralel.esaunggul.ac.id/pluginfile. php?file=%2F442107%2Fmod_ resource%2Fcontent%2F28%2FModul Sesi 11 RMIK140 Anatomi Fisiologi. pdf&forcedownload=1
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