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All Journal Jurnal Pengabdian Masyarakat dan Riset Pendidikan
Vanisa Nur Sadila Br Sitorus
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Humanities Education Languange, Linguistic, Communication & Media Mathematics Other

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Tinjauan Ketepatan Penulisan Kode Skizofrenia pada Rekam Medis Elektronik Rawat Jalan Rsud Dr. Rm. Djoelham Binjai: Penelitian Vanisa Nur Sadila Br Sitorus; Sri Lestari
Jurnal Pengabdian Masyarakat dan Riset Pendidikan Vol. 4 No. 4 (2026): Jurnal Pengabdian Masyarakat dan Riset Pendidikan Volume 4 Nomor 4 Tahun 2026
Publisher : Lembaga Penelitian dan Pengabdian Masyarakat

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.31004/jerkin.v4i4.5922

Abstract

Background: The high standard required for accurate Medical Records (MR) and precise diagnosis coding based on ICD-10 is vital for healthcare quality and efficient BPJS claims management. However, at RSUD Dr. RM. Djoelham Binjai, there is an ongoing issue with the inaccurate coding of Schizophrenia diagnoses (F20) in outpatient Electronic Medical Records (EMR), posing a threat to the validity of critical health data. Objective: The primary goal was to comprehensively analyze both the level of accuracy and the underlying causes of inaccuracy pertaining to Schizophrenia (F20) coding within the outpatient EMR system, employing the 5M framework of analysis (Man, Material, Machine, Method, Money). Method: This was a qualitative research study. Data were gathered through interviews with coding and claim officers, alongside an observation and documentation study carried out on a sample of 25 Schizophrenia codes from outpatient EMR over July to September 2025. Results: The analysis revealed a commendable overall coding accuracy rate of 80%. Critically, however, 20% (5 cases) were coded non-specifically (where specific F20.x codes were inappropriately recorded as the general F20.9). This inaccuracy was predominantly attributed to the Man factor, as coding personnel often lacked specialized psychiatric training, and the Machine factor, given the EMR system’s lack of preventative tools like soft alerts and full INA-CBGs claim integration. Conclusion: In summation, the accuracy of F20 coding is demonstrably compromised by the 20% non-specificity rate. This issue is fundamentally rooted in a significant competency gap among coding officers and the limitations of the current EMR system, which necessitates reactive correction rather than proactive support.
Co-Authors SRI LESTARI