Hotmawati, Hotmawati (2021) TINJAUAN KEAKURATAN KODE DIAGNOSIS PASIEN OBGYN DI RUANG BERSALIN RUMAH SAKITPELITA INSANI TAHUN 2021. [Tugas Akhir]

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Abstract

Minister of Health Regulation Number 269/MENKES/PER/III/2008 concerning Medical Records states that every doctor or dentist in carrying out medicine is required to make medical records. Precise and accurate coding required a complete medical record. Based on the preliminary study conducted, there were inaccurate medical record files at Pelita Insani Hospital. The purpose of this study is to identify and determine the factors that influence the inaccuracy of the codification of ob-gyn patients at Pelita Insani Hospital. This type of research is descriptive with checklist data collection methods, interview guidelines and questionnaires. The subjects of this study were coder officers who carried out two people and medical record installations with a total sample of 80 medical record files of ob-gyn patients at Pelita Insani Hospital. The results of the study were 27 (33.75%) with accurate codification and 53 (66.25%) with inaccurate codification. The results of the study are that there is no standard operating procedure in the coding process and the officers have sufficient knowledge of the category and have never attended training or socialization, which means that the officers do not fully understand the provision of diagnostic codes for obgyn patients and the tenure of the officer is classified as a new tenure, which means officers do not have experience. The conclusion of this study is that the inaccuracy of the diagnosis code is due to the absence of standard operating procedures, unclear doctor writing and officers who have never been given training or socialization. The researcher suggests that Pelita Insani Hospital plans to make standard operating procedures for providing diagnosis codes and improving network connections so that the implementation of the codeification runs smoothly. Keywords: Accuracy, Diagnostic Code, Obgyn, Medical Records

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