Ketepatan dan Kelengkapan Informasi Medis dalam Kaitannya dengan Keakuratan Kode Diagnosis

Santi, Maya Weka and Azizah, Ratna Umi and Erawantini, Feby and Alfiansyah, Gamasiano (2022) Ketepatan dan Kelengkapan Informasi Medis dalam Kaitannya dengan Keakuratan Kode Diagnosis. Jurnal Penelitian Kesehatan Suara Forikes, 13 (3). pp. 630-635. ISSN 2502-7778

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Abstract

In the medical record, the diagnosis code is used as a reference in determining the cost of health services for patients. This study aims to determine the relationship between the accuracy and completeness of medical information with the accuracy of the diagnostic code. The method used was a literature review by analyzing 10 articles from various sources. There were 6 articles that discussed the relationship between the accuracy of medical information and the accuracy of the diagnosis code, with 5 articles showing that accuracy had a relationship with the factors of writing inappropriate medical terminology and not in accordance with the ICD-10, as well as writing an unclear diagnosis. Regarding the completeness of medical information, there were 4 articles that discussed the relationship between the completeness of medical information and the accuracy of the diagnosis code, with 3 articles that showed a relationship between the completeness of medical information and the incomplete and unclear writing factor of the patient's condition, as well as the lack of awareness of filling in the information. patient medical.

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