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All Journal Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) Journal of Nursing and Public Health (JNPH) Jurnal Sains Kesehatan Infokes : Jurnal Ilmiah Rekam Medis dan Informasi Kesehatan Jurnal Ilmu Kesehatan Indonesia (JIKSI) J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan ANJANI Journal (Medical Science & Healthcare Studies) PELS (Procedia of Engineering and Life Science) Jurnal manajemen informasi kesehatan Jurnal Ilmiah Kesehatan Mandira Cendikia Jurnal Ilmiah Multidisiplin Keilmuan Mandira Cendikia (JIMK-MC)
Harmanto, Deno
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Journal : PELS (Procedia of Engineering and Life Science)

 1 
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 Harmanto, Deno; Budiarti, Anggia; Rahayu, Dinda Sri
Procedia of Engineering and Life Science Vol. 7 (2025): Prosiding Seminar Nasional dan Rakernas PORMIKI X
Publisher : Universitas Muhammadiyah Sidoarjo

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.21070/pels.v7i0.2098

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.
Factors Supporting the Accuracy of External Cause Codes Traffic Accident Injury Cases: Faktor Pendukung Keakuratan Kode External Cause Kasus Cedera Kecelakaan Lalu Lintas Budiarti, Anggia; Harmanto, Deno; Rahayu, Dinda Sri
Procedia of Engineering and Life Science Vol. 7 (2025): Prosiding Seminar Nasional dan Rakernas PORMIKI X
Publisher : Universitas Muhammadiyah Sidoarjo

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.21070/pels.v7i0.2102

Abstract

Injuries due to traffic accidents are one of the third largest causes of death in Indonesia after HIV/AIDS and TB. Based on WHO data (2015), injuries due to traffic accidents are the main cause of death and disability throughout the world, deaths due to traffic accidents worldwide amounted to 1.25 million in 2013. In Indonesia, injuries due to traffic accidents and deaths occurred has become a very serious problem (Djaja et al, 2016). Based on data from the Traffic Accident Unit of the Bengkulu Police Traffic Unit, in 2019 the number of traffic accidents recorded was 33 cases of serious injuries and 173 minor injuries (Munte et al, 2022). Implementation of external cause coding of traffic accident injury cases is very important to be done accurately, because the coding results external cause can be said to be accurate if it has the 4th and 5th characters. If coding is not carried out accurately it will have an impact on disease and action recording index errors, inaccurate report information data and inaccurate INA-CBG rates. all officers provide external cause coding and it is hoped that the head of the medical records unit will make a policy for filling in external cause codes.
Co-Authors Anggia Budiarti Anggia Budiarti Anggia Budiarti Anggoa Bidiarti Ari Herisandi ARI HERISANDI Ayu, Dinda Budiarti, Anggia Dega Putri Nanda Dega Dias Sinta Kusumawati Dinda Sri Rahayu Dinda Sri Rahayu Djusmalinar Hari Hersandi Hendra Cahyana Putra Isma Windartini Ismail Arifin Liza Putri Maha Tri Yudha Putra Dinata Muhammad Salehudin Nengke Puspita Sari Ningsih, Sari Widya Nofri Heltiani Nur Elly Nur Elly Qaka Rahma Tita Rachella Putri Prichilla Rahayu, Dinda Sri Reka Dwi Syaputra Rezki Haryandha Rezki Haryandha Rosdiana Saputra, Ripo Andi Siska Iskandar Sri Andika Sopiawati Sri Rahayu, Dinda Umita Sari Yayan Kurniawan Yoki Hermansyah