Jurnal Rekam Medik & Manajemen Informasi Kesehatan (RAMMIK)
Vol. 1 No. 2 (2022): Oktober

Analisis Hubungan Ketepatan Penulisan Diagnosis dengan Keakuratan Kode Diagnosis pada Kasus Obstetri dan Ginekologi di Rumah Sakit Tk. IV DKT Kediri

Citra Alifa Puspaningtyas (Poltekkes Kemenkes Malang)
Hartaty Sarma Sangkot (Poltekkes Kemenkes Malang)
Prima Soultoni Akbar (Poltekkes Kemenkes Malang)
Endang Sri Dewi (Poltekkes Kemenkes Malang)
Avid Wijaya (Poltekkes Kemenkes Malang)



Article Info

Publish Date
05 Oct 2022

Abstract

Activity of determining the disease code and writing the diagnosis must be in accordance with the correct medical terminology and the classification rules that apply in Indonesia, namely ICD-10 in order to get the right and accurate code. This study aims to analyze the relationship between the accuracy of writing a diagnosis and the accuracy of the diagnosis code in obstetrics and gynecology cases at Rumah Sakit Tk. IV DKT Kediri. The method used in this research is analytic research with cross sectional approach. Based on Slovin's formula, the sample used was 100 medical record documents of inpatients. The sampling technique used is simple random sampling. The data collection technique used observation with a checklist instrument. Data on the accuracy of writing the diagnosis and the accuracy of the diagnosis code were analyzed univariately, while the relationship between the accuracy of writing the diagnosis and the accuracy of the diagnosis code was analyzed using SPSS with Chi-Square test. The results showed that the accuracy of writing the diagnosis was 56%, the accuracy of the diagnosis code was 43%, and there was a relationship between the accuracy of writing the diagnosis and the accuracy of the diagnostic code for obstetrics and gynecology cases at Rumah Sakit Tk. IV DKT Kediri (p < 0.025).

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Journal Info

Abbrev

rmik

Publisher

Subject

Dentistry Health Professions Medicine & Pharmacology Public Health Veterinary

Description

RAMMIK : Jurnal Rekam Medik & Manajemen Informasi Kesehatan is an journal which provides a platform to scientist and researchers all over the world for the dissemination of knowledge in Health Information Management , medical record and related fields, especially in : Health information management ...