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Rismawati Rismawati
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Journal : Jurnal Rekam Medis dan Informasi Kesehatan Indonesia

 1 
Analysis of the Accuracy of Diagnosis and Coding in Patient Medical Records at the Mutiara Delima Clinic Sawoo, Ponorogo Regency Rismawati Rismawati; Ria Fajar Nurhastuti
Jurnal Rekam Medis dan Informasi Kesehatan Indonesia Vol. 4 No. 2 (2025): Jurnal Rekam Medis dan Informasi Kesehatan Indonesia
Publisher : program studi Rekam Medis dan Infomasi Kesehatan ITSK RS dr Soepraoen Malang

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.62951/jurmiki.v4i2.104

Abstract

This research aims to analyze the accuracy of diagnosis and coding in patient medical records at Mutiara Delima Sawoo Clinic, Ponorogo Regency, and to identify the factors influencing it. The research uses a descriptive method with a qualitative approach. Data were obtained through interviews with 1 medical records officer, observations with 1 medical records officer, 1 doctor, 3 midwives, 3 nurses, and the analysis of 260 medical record documents using instruments in the form of observation and interview sheets. The results show that out of the 260 patient medical records analyzed over one month, 31.54% were accurately coded with diagnosis and coding, 59.62% were diagnosed without coding, and 8.85% were neither diagnosed nor coded. The researchers recommend enhancing the training of medical personnel and strengthening the monitoring system to support service quality and insurance claims.  
Co-Authors A Rahim A. Rezeki Asriani Adhitthana Wiguna Adrian Adrian Afna Nadila Agus Priyanto Ahmad Firman Akbar, Mohammad Aldrin ALFIN ADAM Alif Bismillah Allania Hanung Putri Sekar Ningrum Amelia Sri Rizki Andi Arbaina Fariza Andi Haslindah Andi Sugiati Andini Anastasia Andrie Andrie Anggi Maulana Anthonius H. Citra Wijaya Assyfa Putri Amalia Astari Nurisani Ayu Andini Ayu Irawati Budi Pangastuti Budiyono Budiyono Ciansi Deby Angraini Dadan Sumiarsa Dea Dalila Dewi Urip Wahyuni Dieri Apriana Purba Elsa Komala Emya Karunia Br. Pelawi Endah Murtiana Sari Endang Silaningsih Ernawati Ernawati Fahmi Faturahman Faisal Dhermawan Fatimah Azzahra Fibriana Rahmadani As'ha Firmansyah Firmansyah Fitria Lestari Gina Nafsa Mutmaina Hadma Yuliani Haedar Haedar Heti Triwahyuni Icha Septiani Putri Ika Wiani Indra Lila Kusuma Indri Ramadani Irfan Yusuf Iriwi L.S. Sinon Istiyati Mahmudah Jumawan Jasman Jumiati Nur Junaidi Junaidi Khairunnisa Situmorang Khomsah Kamilah Lia Mar’atiningsih Lily Eky Nursia N Lisdayanti Simanjuntak LMS Kristiyanti, LMS Luluk Khusul Dwihestie M. Fikri Abdi Mamay mamay Mardiana Mardiana Masrita Herma Masyhuri Masyhuri Mawadatul Af’idati Meti Rizki Utari Mia Wahyuni Muh. Yusuf Q. Muhajir Muhajir Muhamad Naufal Muhamad Rizki Akbar Muhammad Dirga Bachtiar Muhammad Hadi Sulhan Muhammad Ridwan Rumasukun Muhlis Madani, Muhlis Mutia Indah Wahyuni Nasrizal Nasrizal Nasrudin Nasrudin Nayla Fitri Anjani Nazwa Awlia Maulana Neneng Rani Setiani Nora Novita Nurqalbi SR Nursiah Fitri Palahudin Palahudin Parenta Ritonga Purwanto S.K Putri Delvina Sari Rafli Pahlevi ramadhani ramadhani Rani Maharani Rendy Mario Yoshua Reskiani Reskiani Resti Rohayati Ria Fajar Nurhastuti Riki Saputra Rizqi Ramadhan Rubi Rimonda Rusmiati Rusmiati Sabariah Sabariah Sabri Hasan Sakinah, Alya Salju Salju Samsir Rahim Samsul Bachri Sapar Sapar Shavira Nafa Dilla Simbolon, Anggiat Parlindungan Siti Nuraini Siti Purani Siti Roudhotul Jannah Sri Wahyu Widyaningsih Sri Windayanti Sugiah Sugiah Suhartono Suhartono Supriyanto Supriyanto Suri Purnami Suriyadi Suriyadi Susianti Susianti Syamsir Syamsir T. Alamsyah T. M. Habil Agathan Tabina Farrah Anindya Triani Yuliastanti Usman, Arifa Uswatun Sepri Esti Vanny Ellysia Putri Wa Ode Sifatu Wardianti, Yunita Winda Fara Setiani Yulihasti Yulihasti Yupita Asmul Fauziah Zaitun Qamariah