STUDI DESKRIPTIF KUALIFIKASI PETUGAS CODER DAN KEAKURATAN KODE DIAGNOSIS RAWAT JALAN BERDASARKAN ICD-10 DI PUSKESMAS GEMPOL

Authors

  • Nova Dyawati STIKES Arrahma Mandiri Indonesia Author
  • M. Malik Ibrahim STIKES Arrahma Mandiri Indonesia Author
  • Ika Puspita Sari STIKES Arrahma Mandiri Indonesia Author

Keywords:

Code accuracy, Coder Qualification, ICD-10

Abstract

Coding inaccuracies in Indonesia still often occur in first-level health facilities, one of which is Gempol Health Center. Of the 30 diagnostic codes, 70% of the codes were inaccurate and 30% of the codes were accurate. Inaccuracies in diagnostic codes may be caused by inappropriate qualifications. The purpose of this study is to describe the qualifications of the coder officers and the accuracy of the outpatient diagnostic code based on ICD-10. The type of research is quantitative descriptive. The subject population, namely all outpatient diagnosis coder officers and the object population, were documents coded by officers in March - April 2022. The sample in this study consisted of 7 coders and 245 files with consecutive sampling technique. The results show that the coder qualifications at Gempol Health Center with the inappropriate coder qualifications are 85.7%, and the appropriate coder qualifications are 14.3%. As well as the accuracy of the outpatient diagnosis code at Gempol Health Center from 245 documents, the results obtained were 63.7% inaccurate codes and 36.3% accurate diagnosis codes. Based on the results of the study, it can be concluded that the qualifications of officers and the accuracy of the diagnosis code are quite low.

References

Ansyori, A. (2019). Analisis Pengaruh Kualitas Pelayanan terhadap Kepuasan Pasien Rawat Inap di Rumah Sakit. Jurnal Kesehatan Hesti Wira Sakti, 7(2).
Ali, M. dan Sri, E. (2019) “Faktor-faktor yang Berpengaruh pada Akurasi Kode diagnosis di Puskesmas Rawat Jalan Kota Malang Factors that Influence the Accuracy of Codefication in Outpatient Primary Health Cares in Malang,” Jurnal Kedokteran Brawijaya, 30(3), hal. 228–234. Tersedia pada: http://jkb.ub.ac.id/index.php/jkb/article/view/2384.
Budiarti, A. dan Iskandar, S. (2021) “Pengaruh Kinerja Petugas Rekam Medis Terhadap Keakuratan Pengkodingan Fraktur Effect of Performance Medical Recording Offices on The Accuraty of Fracture Coding Sekolah Tinggi Ilmu Kesehatan Sapta Bakti Bengkulu Jalan Raflesia , Ratu Agung , Kota Bengkulu,” Manajemen Kesehatan Yayasan RS. Dr. Soetomo, 7(1), hal. 1–8.
Erawantini, F. dan Nurmawati, I. (2017) “Pendidikan Dan Pelatihan Pada Petugas Rekam Medis Sebagai Persiapan Menjadi Clinical Instructure (Ci) Di Puskesmas Jelbuk,” Prosiding, (Ci), hal. 111–113. Tersedia pada: https://publikasi.polije.ac.id/index.php/prosiding/article/view/693.
Ifalahma, D. (2013) “Hubungan pengetahuan coder dengan Keakuratan kode diagnosis pasien rawat inap jaminan kesehatan masyarakat berdasarkan ICD-10 di RSUD Simo Boyolali,” Jurnal Ilmiah Rekam Medis dan Informatika Kesehatan, 3(2), hal. 14–26.
Ikawati, F. R. (2021). Buku ajar konsep dasar rekam medis informasi kesehatan. CV. Literasi Nusantara Abadi.
Ikawati, F. R., Ansyori, A., & Prisusanti, R. D. (2021). Tinjauan literatur analisis faktor penyebab keterlambatan penyediaan rekam medis rumah sakit di Indonesia. Jurnal Rekam Medis dan Informasi Kesehatan Indonesia, 1(1), 30-38
Ikawati, F. R., Rusdi, A. J. (2021). Evaluation analysis of using tracer on medical record storage. Budapest International Research and Critics Institute-Journal (BIRCI-Journal), 4(4), 9282-9288 DOI: https://doi.org/10.33258/birci.v4i4.2940
Janah, F. M. (2015) Hubungan kualifikasi coder dengan keakuratan kode diagnosis rawat jalan berdasarkan ICD-10 di RSPAU dr S Hardjolukito Yogtyakarta 2015, universutas muhammadiyah surakarta. Tersedia pada: http://eprints.ums.ac.id/37501/6/BAB II.pdf.
Juwita, R. (2019) “Analisis Pengaruh Pelatihan Dan Pengembangan SDM Terhadap Kinerja Pada Pegawai BPS Kabupaten Ogan Ilir,” Jurnal Ilmiah Bina Manajemen, 2(1), hal. 1–11.
Kantara, L. R. (2017) Kualifikasi Petugas coder Terkait Ketepatan Kode Diagnosis Fracture tahun 2017 di Rumah Sakit PKU Muhammadiyah Yogyakarta. STIKES JENDRAL ACHMAD YANI YOGYAKARTA.
Kemenkes (2006) “Penetapan Standar Kode Data Bidang Kesehatan.” Jakarta: Kemenkes RI.
Maimun, N. et al. (2018) “Pengaruh Kompetensi Coder terhadap Keakuratan dan Ketepatan Pengkodean Menggunakan ICD 10 di Rumah Sakit X Pekanbaru Tahun 2016,” KESMARS: Jurnal Kesehatan Masyarakat, Manajemen dan Administrasi Rumah Sakit, 1(1), hal. 31–43. doi: 10.31539/kesmars.v1i1.158.
Permenkes (2013) “Peraturan Menteri kesehatan Republik Indonesia nomor 55 tahun 2013 tentang Penyelenggaraan Pekerjaan Perekam Medi.”
Permenkes RI (2007) “Keputusan Menteri Kesehatan Republik Indonesia Nomor 377/MENKES/SK/III/2007 Tentang Profesi Perekam Medis Dan informasi kesehatan,” keputusan menteri Kesehatan Republik Indonesia Nomor 377/MENKES/SK/III/2007, hal. 16.
Rahmawati, E. N. (2016) Hubungan antara kelengkapan informasi medis dengan keakuratan kode diagnosis tuberculosis pada dokumen rekam medis rawat inap di rumah sakit umum daerah dr. Moewardi, universitas Sumatra Utara. muhammadiyah surakarta.
Rusdi, A. J., & Ohoiwutun, Y. T. (2019). Analisis Yuridis Manajemen Kerahasiaan Visum Et Repertum Tindak Pidana Kesusilaan di Rumah Sakit Bhayangkara Bondowoso. Multidisciplinary Journal, 2(1), 8-11.
Rusdi, A. J., & Ularan, R. A. R. (2021). Tinjauan literatur analisis yuridis manajemen kerahasiaan rekam medis elektronik. Jurnal Rekam Medis dan Informasi Kesehatan Indonesia, 1(1), 87-91
WHO (2016) “International statistical classification of diseases and related health problems ICD-10: instruction manual,” World Health Organization, 2, hal. 252. Tersedia pada: https://icd.who.int/browse10/Content/statichtml/ICD10Volume2_en_2016.pdf.




Downloads

Published

2022-12-30

How to Cite

STUDI DESKRIPTIF KUALIFIKASI PETUGAS CODER DAN KEAKURATAN KODE DIAGNOSIS RAWAT JALAN BERDASARKAN ICD-10 DI PUSKESMAS GEMPOL. (2022). Jurnal Rekam Medis Dan Informasi Kesehatan Indonesia, 2(1), 47-52. https://jurmiki.org/index.php/Jurmiki/article/view/25

Similar Articles

You may also start an advanced similarity search for this article.