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All Journal Jurnal Informasi Kesehatan Indonesia (JIKI) J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan JURNAL KESEHATAN, SAINS, DAN TEKNOLOGI (JAKASAKTI) Media Informasi Edukasi Masyarakat Sehat Sejahtera (EMaSS)
Rahmawati, Fitria Dewi
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Agriculture, Biological Sciences & Forestry Biochemistry, Genetics & Molecular Biology Chemistry Computer Science & IT Dentistry Health Professions Medicine & Pharmacology Nursing Public Health

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Journal : J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan

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Akurasi Pengkodean Injury dan External Causes Berdasarkan ICD-10 dan ICD-9 CM di Rumah Sakit X Sukawan, Ari; Putra, Dony Setiawan Hendyca; Barsasella, Diana; Rahmawati, Fitria Dewi
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 6 No 1 (2024): December
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v6i1.5572

Abstract

Accurate disease diagnosis coding is essential as it affects morbidity reporting, errors in determining medical procedures, billing issues, and invalidity as legal evidence. One example is injury coding, where ICD-10 guidelines require the 4th and 5th digits to indicate the location and activity associated with the injury. A preliminary study at X Hospital revealed that 80% of medical records had inaccurate injury coding, and external cause codes were absent. The issue is suspected to stem from the lack of coder training on injury and external cause coding. This study aims to assess the accuracy of injury and external cause coding based on ICD-10 and ICD-9 CM. It uses a descriptive approach with a sample of 65 medical records out of a total population of 77 from the fourth quarter of 2023, selected using simple random sampling. Data were collected through observation by reviewing medical records and completing observation sheets, then analyzed univariately. The results showed 66.2% of injury codes were inaccurate, 100% of external cause codes were inaccurate, and 83.08% of procedure codes were accurate. Most inaccuracies were due to the omission of the fifth digit for fractures and the absence of external cause coding.
Co-Authors Adhari, Febriyani Aisy, Moza Rahadatul Apriliani, Niken Dwi Aryani, Bhakti Aryanti, Diva Avianah, Della Budiyanti, Nita Clarissa, Stefannie Diana Barsasella Elfi Erawati Haryanto, Yanto Luthfiyyah, Deisya Rifda Malinda, Ratu Mohammad, Maula Ismail Nur Faidah, Nur Putra, Dony Setiawan Hendyca Safitri, Cahya Wulan Salma, Ghina Sabila Sidqi, Raissa Aulia Subianto, Totok Sukawan, Ari Syari’ati, Zahra Mulki Triyana, Enjel Pira Wulan, Ade