Hubungan Ketepatan Terminologi Medis Terhadap Keakuratan Kode Diagnosis Pasien Rujukan Berdasarkan ICD-10 Di Puskesmas Baki Sukoharjo Triwulan IV Tahun 2019

Pratama - Poltekkes Bhakti Mulia, Bangkit Ary (Poltekkes Bhakti Mulia)

IJMS - Indonesian Journal on Medical Science
Vol 7, No 2 (2020): IJMS 2020

Abstract: The use of medical terminology is also one of the important things in supporting codingfication because it is a means of communication between medical professions, in writing a diagnosis must be in accordance with the correct terminology that is based on ICD-10. The purpose of this study was to determine the relationship between the accuracy of medical terminology and the accuracy of diagnosis codes for referral patients based on ICD-10 in Puskesmas Baki Sukoharjo in the fourth quarter of 2019. This type of research was analytic with a sample of 94 and a population of 1615 forms. The research instrument used observation guidelines, interviews and ICD-10 books. The results showed from a sample of 94 diagnoses and their codes, there were 27 (29%) precise terminology and 67 (71%) incorrect terminology, and an accurate outpatient diagnosis code of 24 (26%) and an inaccurate outpatient diagnosis code of 70 (74%) code. From the Chi-Square Test statistic, the p-value was 0.022. The conclusion of this study is that there is a relationship between the accuracy of medical terminology with the accuracy of the diagnosis code for referral patients based on ICD-10 in Puskesmas Baki Sukoharjo in the fourth quarter of 2019.Keyword: accuracy, medical terminology, accuracy, diagnosis code, ICD-10 Abstrak: Penggunaan terminologi medis juga menjadi salah satu hal penting dalam menunjang kodefikasi karena merupakan sarana komunikasi antar profesi medis, dalam penulisan diagnosis harus sesuai terminologi yang benar yaitu berdasarkan ICD-10. Tujuan penelitian ini untuk mengetahui hubungan ketepatan terminologi medis terhadap keakuratan kode diagnosis pasien rujukan berdasarkan ICD-10 di Puskesmas Baki Sukoharjo triwulan IV tahun 2019. Jenis penelitian adalah analitik dengan sampel sebanyak 94 dan populasi yaitu 1615 formulir. Instrumen penelitian dengan menggunakan pedoman observasi,wawancara dan buku ICD-10. Hasil penelitian menunjukkan dari sampel sebanyak 94 diagnosis serta kodenya, terdapat 27 (29%) terminologi tepat dan 67 (71%) terminologi tidak tepat, serta kode diagnosis rawat jalan akurat sebanyak 24 (26%) dan kode diagnosis rawat jalan tidak akurat sebanyak 70 (74%)  kode. Dari hasil uji statistik Chi-Square Test, diperoleh nilai p-value sebesar 0,022. Kesimpulan dari penelitian ini adalah terdapat hubungan antara ketepatan terminologi medis dengan keakuratan kode diagnosis pasien rujukan berdasarkan ICD-10 di Puskesmas Baki Sukoharjo triwulan IV tahun 2019.Kata kunci:  ketepatan, terminologi medis, keakuratan, kode diagnosis, ICD-10