Jurnal Genta Kebidanan
Vol 10 No 2 (2021)

Description Of The Accuracy Of The Diagnostic Code For Hospitalized Medical Records Based On Icd 10 In Dharma Yadnya General Hospital

Ni Made Lia Tirtayanti (Universitas Bali Internasional)



Article Info

Publish Date
30 Jun 2021

Abstract

A medical record is a file containing a person's medical records and documents consisting of the patient's identity, the results of both physical examinations and supporting examinations, medication, actions and other services provided by health workers to patients. The purpose of this study was to describe the accuracy of writing a diagnosis code on the medical records of inpatients based on ICD-10. Demographic variables include age, gender and education of 2 respondents including the following: 1 respondent is over 30 years old while 1 other respondent is under 30 years old, 2 respondents are female, and 1 respondent medical record education graduate, while 1 other respondent is non-medical record. 1 respondent has a new category of service period, while 1 other respondent has a long service category. 2 respondents have knowledge value in good category about the accuracy of writing the diagnosis code. 2 respondents have attended training. There were 67,7% medical records with writing the correct diagnosis code and there were 32,3% medical records. by writing an incorrect diagnosis code were not found or the identity of the coder officer coding on the medical record sheet was not found, so the researcher could not find out the coding error of each coder officer who provided the diagnosis code.

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Journal Info

Abbrev

JGK

Publisher

Subject

Health Professions Medicine & Pharmacology Nursing Public Health

Description

The scope of scientific disciplines includes Clinical midwifery, community midwifery, maternal and child health, maternal and child nutrition, adolescent health & nutrition, health promotion, health and midwifery services, health information systems, maternal and child health program, maternal and ...