Analisis Ketidakakuratan Kode Diagnosis Penyakit Berdasarkan ICD-10 pada Rekam Medis Rawat Jalan di Puskesmas Sumberasih Kabupaten Probolinggo

Alhakim, Aminatuzahro (2026) Analisis Ketidakakuratan Kode Diagnosis Penyakit Berdasarkan ICD-10 pada Rekam Medis Rawat Jalan di Puskesmas Sumberasih Kabupaten Probolinggo. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

Inaccurate diagnosis coding is one of the problems that can affect the quality of data in medical records in health services, including at the primary care level such as community health centers. The purpose of this study was to analyze the inaccuracy of disease diagnosis codes based on ICD-10 codes in outpatient medical records at the Sumberasih Community Health Center. This study used a sequential explanatory design with a mixed-method approach. The population in this study consisted of 7241 medical records with a sample size of 379 medical records for quantitative research, while for qualitative research, a total sample of 6 informants was used. The quantitative research result showed that there were still many inaccurate diagnosis codes found, amounting to 82,3% with the most common type of inaccuracy being the lack of synchronization between the diagnosis code and the clinical data, especially diagnosis codes that did not match the medical history and the highest distribution of inaccuracies was found in the KIA clinic. The results of the qualitative study showed that inaccuracies in diagnosis coding were related to the factors of ability, motivation, and opportunity factors, as explained in Robbins and Judge's AMO theory. The factors include the limited understanding staff regarding diagnosis coding, the habit of selecting simpler diagnosis codes, and the limited supporting tools used. The conclusion that can be drawn is that the inaccuracy of diagnosis coding in outpatient medical records at the Sumberasih Community Health Center is high and is related to the limitations of the ability, motivation, and opportunity of the staff. The results of this study indicate that strengthening the staff capabilities, system support, and the provision of facilities and infrastructure are very important for improving the accuracy of diagnosis coding.

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