Jurnal EduHealth
Vol. 14 No. 01 (2023): Jurnal eduHealth, Periode Januari-Maret, 2023

Factors Causing Incorrect External Cause Code In Accident Cases In General Hospital Mitra Medika In 2022

Marta Simanjuntak (Program Studi Perekam dan Informasi Kesehatan, Universitas Imelda Medan, Medan, Indonesia)
Esraida Simanjuntak (Program Studi Perekam dan Informasi Kesehatan, Universitas Imelda Medan, Medan, Indonesia)
Siti Permata Sari Lubis (Program Studi Perekam dan Informasi Kesehatan, Universitas Imelda Medan, Medan, Indonesia)
Nurhalimah Nasution (Program Studi Perekam dan Informasi Kesehatan, Universitas Imelda Medan, Medan, Indonesia)



Article Info

Publish Date
23 Mar 2023

Abstract

The external cause code is the code used to classify the external causes of a disease whether caused by accidents, injuries, burns, poisoning, side effects or other causes. The purpose of this study is to find out what are the factors causing the inaccuracy of the external cause code in accident cases at Mitra Medika General Hospital and how the procedure for coding the external cause code is carried out at the hospital. The type of research used is quantitative. The number of samples in this study were 4 coder officers and 32 medical record file forms with a percentage of 25% incomplete and 75% completely filled out. SOPs for disease codes and actions already exist, however, there is still no SOP for external cause cases in detail. Coding is carried out by coding officers with a background in D3 Medical Records who are guided by SOPs using ICD-10 of 2010 electronically and then entered into the INA-CBGs. The method of coding is done by first looking at ICD-10 Volume 3 and then confirming again on ICD-10 Volume 1. Chronological information on external cause events can be seen on the emergency assessment sheets, CPPT, and resumes of discharged patients. The cause of the inaccuracy of the code on the emergency assessment sheet had not been clearly written down on the chronology of events and blank sheets were still found. For encoding, it has reached the 5th character.

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Journal Info

Abbrev

healt

Publisher

Subject

Health Professions Public Health Veterinary

Description

The EduHealt journal contains articles based on research results or equivalent in the health field. The research includes research related to the community environment as well as in the general public. Articles published in this journal have never been published/published by other ...