Korelasi antara Ketersediaan Informasi Medis dengan Ketepatan Kode Diagnosis Bronchitis pada Dokumen Rekam Medis Rawat Inap di Rumah Sakit Umum Daerah Kabupaten Karanganyar Tahun 2019 - Mega Dwi Astuti; Bangkit Ary Pratama - Politeknik Kesehatan Bhakti Mulia (Indonesian Journal on Medical Science, 2021)
Abstract: One of the factors that affect the accuracy of the diagnosis code was the availability of medical information in the form of filling out the diagnosis. The purpose of the study was to determine the correlation between the availability of medical information and the accuracy of the bronchitis diagnosis code on inpatient medical record documents at the Karanganyar Regency General Hospital in 2019. This type of research was descriptive with a retrospective approach. The method used was observation. The research population was 482 medical record documents and 83 medical record documents were taken as samples. The sampling technique used was simple random sampling. Due to the Covid-19 pandemic, the sample collection became 10 medical record documents. The results of the study were based on a sample of 10 medical record documents with bronchitis cases, there were 3 documents available (30%) of medical information, which was smaller than 7 documents (70%). The accuracy of the code is 2 documents (20%) smaller than the incorrect code, which was 8 documents (80%). From the results of the Chi-Square Test statistical test, the value of (0.016) <0.05, which meant that H0 was rejected and Ha was accepted. The conclusion of this study was that there was a correlation between the availability of medical information and the accuracy of the bronchitis diagnosis code on the medical record document of inpatients at the Karanganyar Regency General Hospital in 2019.Keyword: availability of medical information, accuracy of diagnostic codes, bronchitisAbstrak: Salah satu faktor yang mempengaruhi ketepatan kode diagnosis yaitu ketersediaan informasi medis berupa pengisian diagnosis. Tujuan penelitian adalah untuk mengetahui korelasi antara ketersediaan informasi medis dengan ketepatan kode diagnosis bronchitis pada dokumen rekam medis rawat inap di Rumah Sakit Umum Daerah Kabupaten Karanganyar Tahun 2019. Jenis penelitian deskriptif dengan pendekatan retrospektif. Metode yang digunakan adalah observasi. Populasi penelitian sebanyak 482 dokumen rekam medis dan diambil 83 dokumen rekam medis sebagai sampel. Teknik pengambilan sampel menggunakan simple random sampling. Dikarenakan pandemi Covid-19, maka pengambilan sampel menjadi 10 dokumen rekam medis. Hasil penelitian berdasarkan sampel sebanyak 10 dokumen rekam medis dengan kasus bronchitis terdapat ketersediaan informasi medis sebanyak 3 dokumen (30%) lebih kecil dari yang tidak tersedia informasi medisnya yaitu sebesar 7 dokumen (70%). Ketepatan kode sebesar 2 dokumen (20%) lebih kecil dari yang tidak tepat yaitu sebesar 8 dokumen (80%). Dari hasil uji statistik Chi-Square Test, diperoleh nilai Ï (0,016) < 0,05 yang artinya bahwa H0 ditolak dan Ha diterima. Kesimpulan penelitian ini adalah terdapat korelasi antara ketersediaan informasi medis dengan ketepatan kode diagnosis bronchitis pada dokumen rekam medis pasien rawat inap di Rumah Sakit Umum Daerah Kabupaten Karanganyar Tahun 2019.Kata kunci: ketersediaan informasi medis, ketepatan kode diagnosis, bronchitis