TINJAUAN KEAKURATAN KODE SEBAB DASAR KEMATIAN PADA SERTIFIKAT KEMATIAN DI RSUP dr. SOERADJI TIRTONEGORO KLATEN - Eni Nur Rahmawati; Sri Lestari (Universitas Duta Bangsa Surakarta, 2018)
AbstrakKeakuratan kode sebab dasar kematian digunakan sebagai pertimbangan dalam pengambilan keputusan di RSUP dr. Soeradji Tirtonegoro Klaten, tetapi belum melaksanakan penentuan kode sebab dasar kematian sesuai dengan ICD-10. Berdasarkan survei awal didapatkan hasil sertifikat kematian pasien 100% lengkap terisi. Sedangkan keakuratan penentuan kode sebab dasar kematian pada sertifikat kematian berdasarkan tabel MMDS di RSUP dr. Soeradji Tirtonegoro Klaten sebesar 90 % tidak akurat dan 10% akurat. Penelitian ini bertujuan untuk mengetahui keakuratan kode sebab dasar kematian pada sertifikat kematian berdasarkan tabel MMDS di RSUP dr. Soeradji Tirtonegoro Klaten. Metode penelitian yang digunakan dalam penelitian ini adalah jenis penelitian deskriptif, dengan pendekatan retrospektif, pengumpulan data menggunakan observasi dan wawancara, teknik sampling yaitu systematic random sampling. Hasil dari pembahasan menunjukkan belum terdapatnya prosedur pencatatan pengisian diagnosis sebab kematian pada sertifikat kematian, belum terdapatnya prosedur pengkodean sebab dasar kematian, prosentase kelengkapan pengisian diagnosis 100% lengkap terisi, prosentase keakuratan kode sebab dasar kematian berdasarkan tabel MMDS 90.32% tidak akurat. Prosentase ketidakakuratan tertinggi yaitu 67.86% disebabkan kesalahan menentukan kode berdasarkan prinsip umum. Faktor yang mempengaruhi ketidaklengkapan pengisian diagnosis sebab kematian yaitu tidak adanya SPO pengisian diagnosis dan urutan penulisan yang belum sesuai ICD-10 oleh dokter. Faktor yang menyebabkan ketidakakuratan kode diagnosis yaitu tidak adanya SPO, penulisan diagnosis dan pengkodean yang belum sesuai aturan ICD-10, dan audit coding. Kesimpulan ketidakakuratan kode lebih tinggi dari kode yang akurat. Saran sebaiknya dibuat SPO pengisian diagnosis sebab kematian bagi dokter, SPO pengkodean sebab dasar kematian bagi staff coder, pelatihan pengkodean sebab dasar kematian, penyediaan MMDS bagi staff coder, dan dilaksanakan kegiatan audit coding.Kata Kunci: Kelengkapan, Keakuratan, Kode Sebab Dasar Kematian, ICD 10, MMDS.AbstractThe accuracy of the basic cause of death code is used as a consideration in decision making at RSUP Dr. Soeradji Tirtonegoro Klaten, but has not yet implemented the determination of the basic cause of death code in accordance with ICD-10. Based on the initial survey, the patient's death certificate was 100% complete. While the accuracy of the determination of the basic cause of death code on the death certificate based on MMDS table at RSUP dr. Soeradji Tirtonegoro Klaten is 90% inaccurate and 10% accurate. This study aims to determine the accuracy of the basic cause of death codes on death certificates and above based on MMDS table at RSUP dr. Soeradji Tirtonegoro Klaten. The research method used in this study is a descriptive type of research, with a retrospective approach, data collection using observation and interviews, sampling technique is systematic random sampling. The results of the discussion showed that there was no procedure for recording the diagnosis of death cause on death certificates, the absence of the basic cause of death coding procedure, the percentage of complete 100% complete filling in the diagnosis, the percentage accuracy of the basic death code based on MMDS table 90.32% inaccurate. The highest inaccuracy percentage is 67.86% due to an error determining code based on general principles. Factors that influence the incompleteness of filling in the diagnosis of the cause of death are the absence of a filling-in SPO diagnosis and the writing order that is not in accordance with the ICD-10 by the doctor. Factors that cause the inaccuracy of the diagnosis code are the absence of SPO, the writing of diagnoses and coding that do not comply with ICD-10 rules, and coding audits. Conclusion code inaccuracies are higher than accurate codes. Suggestions should be made SPO filing in the cause of death diagnosis for doctors, SPO coding for basic cause of death for staff coders, basic cause coding coding training, provision of MMDS for staff coders, and coding coding activities carried out.Keywords: Completeness, Accuracy, Basic Death Cause Code, ICD 10, MMDS.