Hubungan Antara Kelengkapan dan Ketepatan Informasi Medis Terhadap Keakuratan Kode Diagnosis Pada Dokumen Rekam Medis di Rumah Sakit: Literature Review

Azizah, Ratna Umi (2021) Hubungan Antara Kelengkapan dan Ketepatan Informasi Medis Terhadap Keakuratan Kode Diagnosis Pada Dokumen Rekam Medis di Rumah Sakit: Literature Review. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

One of the important data in the management of good medical records is the provision of diagnosis codes, the code is used as a reference in determining the large health costs. The results of previous research by Ayu (2012) found that 83.87% of documents were written on the correct main diagnosis and 16.13% of the incorrect main diagnosis were written which could affect the accuracy of the diagnosis code. Accurate coding requires a complete and proper medical record. Inaccurate provision of diagnosis codes due to incomplete and improper medical information has the potential to cause a decrease in the quality of services in health care facilities can also affect report information, data quality, and INA- CBG's rates. The purpose of the study was to analyze the relationship of completeness and accuracy of medical information on medical record documents to the accuracy of the diagnosis code of medical record documents in hospitals. The method used is a literature review by analyzing 20 articles from Google Scholar, Portal Garuda, and Crossref. The results of this study from 5 (25%) literature showed there is a relationship between the completeness of medical information to the accuracy of the diagnosis code with the factor of filling out incomplete and nonspecific medical information, incomplete medical information due to the limited time for examination and file filled by many officers, incomplete medical information due to the limited time for examination and low awareness of the completeness of filling in medical information also 10 (50%) indicated that there was a relationship between the accuracy of medical information and the accuracy of the diagnosis code with the factors of writing a diagnosis that not according to terminology and ICD-10, the writing of an unclear diagnosis, and determining the main diagnosis was not correct. There is a relationship between the completeness and accuracy of medical information with the accuracy of the diagnosis code on medical records documents in hospital.

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