ANALISIS PENYEBAB KETIDAKTEPATAN KODE DIAGNOSIS GASTRITIS DI RUMAH SAKIT UMUM YAPIKA KABUPATEN GOWA PROVINSI SULAWESI SELATAN

Pramana, Alfian (2022) ANALISIS PENYEBAB KETIDAKTEPATAN KODE DIAGNOSIS GASTRITIS DI RUMAH SAKIT UMUM YAPIKA KABUPATEN GOWA PROVINSI SULAWESI SELATAN. Undergraduate thesis, POLITEKNIK NEGERI JEMBER.

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Abstract

The process of assigning a disease code (coding) is the process of assigning a code by using letters or numbers or a combination of letters in numbers (alphanumeric) to represent data components. Errors were found in coding the diagnosis of gastritis caused by coding not based on the correct coding rules, namely not using ICD 10 but only using smart books, the absence of disease coding references such as Standard Operating Procedures (SPO) and coders not from the medical record profession. This study uses a qualitative research method using interview, observation and documentation techniques involving 4 informants, namely the head of the RM, 2 coders and a doctor verifier. The results of the study related to the factors causing the inaccuracy of coding the gastritis diagnosis based on the knowledge variable Man element, the knowledge of the coder about the coding rules was still lacking because in coding the diagnosis only used a smart book and it was not in accordance with the ICD-10 coding rules, the educational variable showed that from 2 coders only 1 person educated in medical records, the variable period of service shows the average working period is 1-2 years because this hospital is still new. The Money element shows that there has never been a budget provided, the Method element shows that the coding SOP has never been made. The Material element shows that the doctor's writing is not clear. The Machine element shows that ICD-10 and Electronic ICD-10 books are not available. Suggestions in this study are that the HRD of the hospital should recruit a medical recorder profession in coding diagnosis, the leader gives orders to take part in medical record training/seminars, especially those related to coding to improve the ability of officers in coding diagnoses, pay attention to the correct coding procedures, and the part Hospital procurement needs to immediately procure ICD-10 books.

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