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ACHMAD JAELANI RUSDI
Institut Teknologi, Sains Dan Kesehatan RS Dr. Soepraoen Malang, Indonesia
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Development of an Evaluation Method to Measure the Accuracy of Inpatient Diagnosis Codes at Lawang Regional Hospital Diva Nur Asmianova; Achmad Jaelani Rusdi; Rizka Andika Sari
KESMAS UWIGAMA: Jurnal Kesehatan Masyarakat Vol 10 No 2 (2024): July-December
Publisher : Universitas Widya Gama Mahakam Samarinda

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.24903/kujkm.v10i2.2967

Abstract

Background: The provision of diagnosis codes on medical record documents needs to be carried out accurately based on the ICD-10 book. The role of medical personnel and coding officers affects the accuracy of the diagnosis code. The coding officer must ensure that the medical record data is clear and complete such as severe or critical conditions, spesific anatomical positions, the course of health disorders, complications or the patient’s history to support the primary diagnosis. Objectives: The research objevtives to be achieved in this study evaluate and examine several causes that affect the accuracy of the selection of patient diagnosis codes at Lawang Hospital. Research Metodes: The type of research implemented is descriptive with a quantitative approach. Data collection is taken by observation, interviews, and code accuracy checklist. The population used in this study is all medical record files of inpatients in May with a total of 645 medical record documents. The sample was taken using a simple random sampling technique with as many as 25 medical record files of inpatients. Data analysis was carried out by univariate analysis by looking at the percentage of each research variable. Results: This study shows that the level of code accuracy is still said to be low because it still reaches 84% with as many as 21 documents and the code inaccuracy reaches 16% with as many as 4 documents. . Conclusion: The cause of inaccuracy will be due to the completeness of the primary and secondary diagnoses that are less specific, lack of communications between officers regarding clarity in writing in medical record documents, and some diagnoses do not include the 4th character in the case of fracture, namely the close or open description. For the development of evaluation, officers can take part in codification training and make help books such as pocket books that contain a collection of diagnosis codes. Keywords: Accuracy; Diagnosis Code; Medical Record; Hospital
Co-Authors Abdur Rauf, Abdur Agung, Arnoldus Anugerah Agustina Rusfadir Akbar, Prima Soultoni Amalia Nur Kamila Amellia, Elsa Andara Dita Amellia Ana Fitriani Ancah Caesarina Novi Marchianti Anggraini, Retno Dwi Anis Ansyori Annastasia, Shinta Aprilia, Sendi Fantrri Arimbi Ulfa Nazira Aris Setyawan Asroruddin , Muhammad Avid Wijaya Ayu Indah Oktavia Ayu Indah Oktavia Ayuni, Amelia Septi Bulgis, Malikal Choiriyah, Ana Cininta, Sabila Nada Ayunani Dinda Dzurriyyatul Khasanah Dinda Dzurriyyatul Khasanah Diva Nur Asmianova Diva Nur Asmianova Efendi, Farid Eka Agustina, Eka Faid, Roifatul Farma Duana Febrisari Putri Febrisari Putri Ramadani Ferrari, Raynald Fita Rusdian Ikawati Fitriyani, Endang Hammam Abror Asminoto Jannah, syahfira nur jannah Khofiza Ardhani Ali Raharusun Khuriyana Patty Kirana, Erinia Rahayu Okta Kurniawan, Fendi Kusumaningrum, Tyas Lilik Afifah M. Syauqi Haris M. Yogi Riyantama Isjoni Ma'roef, Moch. Noer Hoedan Ma'ruf, Agus Sukron Maharani, Devi Maharani, Happy Eprilia Mahyuni, Ni Putu Reni Margareta, Ananda Agustin Marselina, Elystia Vidia Mawadda, Widdy Ma’ruf, Agus Syukron Melody Muna Anggraeni Moch.Noer Hoedan Ma’roef Moch.Noer Hoedan Ma’roef Mochamad Anshori Muhammad Dudayev Caesar Putra Murcahayaning Wulan, Nadhya Arie Twungga Dewi Muslim, Saepul Nabila, Assiva Putri Nadhya Arie Twungga Dewi Murcahayaning Wulan Nayada Ilfania Arokhta Yunifa Nazira, Arimbi Ulfa Ni Putu Reni Mahyuni Ninda, Rahmaninda Putri Gading Ningsih, Dovi Dwi Mardiyah Nugraheni, Shevia Dwi Nuril Khabibatul Jamilah Oktariyono, Wisnu Rafi Oktoriani, Ervita Nindy Prabowo, Rahmadyo Yudhi Putri , Salsabila Amelia Putri, Alya Nurryta Putri, Febrisari Putri, Fenanda Berliana Putri Putri, Meuthia Berliana Qodar, Mita Lailatul R. A. Rengganis Ularan R.A. Rengganis Ularan Raharusun, Khofiza Ardhani Ali Rahma Putri Kasimbara Rahmadani , Salsa Billa Octavia Rengganis Ularan Retno Dewi Prisusanti Rifqi, Amir Muhammad Risqy Siwi Pradini Rizka Andika Sari Rizka Andika Sari Rusfadir, Agustina Sabila Nada Ayunani Cininta salsabila, Tsabita Amadea Sangkot, Hartaty Sarma Santy Irene Putri Saputri, Giovany Okvia Septya Anggari Salsa Hari Sukma Shoim, Achmad Slamet, Untung Suhairi, Ariski Yantika SUWITO SUWITO Syahira, Nurfathina Syukron Ma'ruf, Agus Trisnanto, Puguh Yudho Umar Yasin, rana zakaria Untung Slamet Untung Slamet Suhariyono Veninda, Nabella Wahandika, Akbar Novando Putra Widasari, Immaculata Vettha Sarasvati Wijanarko , Febbry Noerrahma Y. A. Triana Ohoiwutun, Y. A. Triana Yosin, Kresensia Dasilva Zachary , Nadya Yasa Zein, Eiska Rohmania