ANALISIS KELENGKAPAN PENULISAN DIAGNOSA TERHADAP KETEPATAN PEMBERIAN KODE CEDERA DAN KODE EXTERNAL CAUSE PADA KASUS KECELAKAAN DI RUMAH SAKIT UMUM UNIVERSITAS MUHAMMADIYAH MALANG
DOI:
https://doi.org/10.62951/jurmiki.v3i1.42Keywords:
CompletenessAbstract
In the implementation of coding in the case of accidents at the General Hospital of the University of Muhammadiyah Malang there are still inaccuracies in coding of 79.2% and accuracy of 20.8%. The purpose of this study was to analyze how the completeness of the diagnosis relates to the accuracy of coding injuries and codesexternal cause in case of an accident. The research method used is an analytical survey approachCross Sectional. To determine the relationship between the completeness of writing a diagnosis on the accuracy of coding injuries and codesexternal cause In the case of an accident, a statistical test was carried out with the testWho Squareusing the IBM SPSS application version 25. Using the saturated sampling technique, a total sample of 77 accident cases was obtained in the 2022-2023 period. In this study, the results of the diagnosis accuracy were 20.8% and 79.2% inaccuracy. This inaccuracy is caused because the officer did not do the coding for the codeexternal cause. Based on the SPSS results, it was found that there was a relationship between the completeness of writing a diagnosis and the accuracy of coded injury and external cause codes in accident cases at the General Hospital of the University of Muhammadiyah Malang. These results are due to the writing of the diagnosis which still does not include the chronology of the accident. This can cause coding errors by coding officers at the hospital.
References
Ansyori, A. (2019). Analisis Pengaruh Kualitas Pelayanan terhadap Kepuasan Pasien Rawat Inap di Rumah Sakit. Jurnal Kesehatan Hesti Wira Sakti, 7(2).
Fitriani, A., Ikawati, F. R., & Rusdi, A. J. (2022). Evaluasi penerapan SIMRS di Rumah Sakit Putra Waspada dengan metode HOT-FIT. Jurnal Rekam Medis dan Informasi Kesehatan Indonesia, 2(2), 73–80.
Hatta, Gemala. (2008). Pedoman Manajemen Informasi Kesehatan di. Sarana Pelayanan Kesehatan. Jakarta : Universitas Indonesia.
Ikawati, F. R., Rusdi, A. J., Prisusanti, R. D., Ularan, R. R., Ansyori, A., & Anshori, M. (2022). Redesain out guide (tracer) sebagai optimalisasi pengelolaan dokumen rekam medis Rumah Sakit Bantuan TNI-AD 05.08.02 Malang. Journal of Training and Community Service ADPERTISI (JTCSA), 2(1), 21–26.
Kementerian Kesehatan. 2022. Peraturan Menteri Kesehatan Nomor 24 Tahun 2022 tentang Rekam Medis. Kementerian Kesehatann:Jakarta
Keputusan Menteri Kesehatan Republik Indonesia Nomor 312 Tahun 2020 tentang Standar Profesi Perekam Medis dan Informasi Kesehatan
Manalu, D. F. C., Putra, D. H., Fannya, P., & Indawati, L. 2022. Analisis Ketepatan Kode Cedera dan Kode External Cause Pasien Kecelakaan Lalu Lintas di Rumah Sakit Pusat Angkatan Darat Gatot Soebroto Tahun 2020. Jurnal Manajemen Informasi dan Administrasi Kesehatan, 5(1).
Nurhadi, dkk., 2022. Keakuratan Kode Diagnosis Fraktur Dan External Causes Di RSUD Mardi Waluyo Kota Blitar. Jurnal Rekam Medis dan Informasi Kesehatan Indonesia (Jurmiki) Vol: 2(2) 66-72
Puspita, C. P. Y., Andriani, R., & Igiany, P. D. 2022. Ketepatan Kode External Cause Kasus Kecelakaan Lalu Lintas di RSO PROF. Fr. R. Soeharso Surakarta In Prosiding Seminar Informasi Kesehatan Nasional.
Rusdi, A. J., Prisusanti, R. D., & Ularan, R. R. (2022). Systematic review keakuratan underlying cause of death (UCOD) pada sertifikat kematian di fasilitas pelayanan kesehatan. Indonesian of Health Information Management Journal (INOHIM), 10(1), 57–65. https://doi.org/10.47007/inohim.v10i1.414
Sitti, W. O., & Ramadhan, S. 2021. Faktor Penyebab Belum Dilaksanakannya Kode External Causes Pada Berkas Rekam Medis Kasus Kecelakaan Pasien BPJS di Rumah Sakit Umum Daerah Kota Baubau Factors Causing The External Causes Code On Medical Recording File of BPJS Patient Accidents In Baubau City Public.
Shalatiya, U., Widjaja, L., Indawati, L., & Yulia, N. Tinjauan Kelengkapan Penulisan dan Ketepatan Kode External Cause Kasus Kecelakaan Lalu Lintas di Siloam Hospital Kebon Jeruk.
Widyaningrum, B. N., Destri, M. R., Ratna. 2021. Analisis Kuantitatif Informed Consent Tindakan Sectio Caesarea di Rumah Sakit Roemani Muhammadiyah Semarang Periode Triwulan IV Tahun 2020. Jurnal Rekam Medis dan Informasi Kesehatan Indonesia (Jurmiki), 1(1) Desember 2021: 76-80