Infokes : Jurnal Ilmiah Rekam Medis dan Informasi Kesehatan
Vol 12 No 1 (2022): Jurnal Ilmiah Rekam Medis dan Informatika Kesehatan

Keakuratan Kode Kombinasi Dokumen Rekam Medis Pasien Rawat Inap Jaminan Kesehatan Nasional Di Rumah Sakit Umum Daerah Pandan Arang Boyolali

Linda Widyaningrum (udb)
Hanggargita Nur Wahyuningsih (Fakultas Ilmu Kesehatan, Universitas Duta Bangsa)
Astri Sri Wariyanti (STIKES Mitra Husada Karanganyar)



Article Info

Publish Date
15 Feb 2022

Abstract

Coding is an important role in the implementation of health financing for the National Health Insurance. Implementation of the provision of diagnostic codes in health services must pay attention to coding rules to produce accurate data and information. This study aims to determine the accuracy of the combined category code of medical record documents for inpatients with national health insurance at Pandan Arang Hospital Boyolali. Method of non-experimental research with descriptive analysis. The approach used is retrospective with observation and interview data collection. The sample used was 98 national health insurance inpatient medical records using purposive random sampling technique with inclusion and exclusion criteria. The procedure for assigning a diagnostic code to the combination category is in accordance with the existing SOP. The accuracy of the diagnostic code for the combination category is 64% (63 documents) and 36% (35 documents) is not accurate due to an error in code selection (35 documents). The factors causing the inaccuracy of the diagnostic code for the combination category based on ICD-10 are medical personnel, medical record personnel (coder) and code selection errors. Researchers suggest that hospitals should make standard operating procedures to doctors regarding writing diagnoses with complete medical information this will minimize errors in coding combination categories. Coding officers should look at the results of supporting examinations and patient progress records in order to provide an accurate diagnosis of the code.

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Journal Info

Abbrev

infokes

Publisher

Subject

Health Professions Medicine & Pharmacology Nursing Public Health Veterinary

Description

Medical Record Medical Informatics Health Policy and Management Midwifery Public Health Critical Care and Intensive Care Medicine ...