Analisis Faktor Penyebab Ketidakakuratan Kode Diagnosis Pasien Poli Umum di Puskesmas Panti Kabupaten Jember

Rahmawati, Zerlina Fitri (2026) Analisis Faktor Penyebab Ketidakakuratan Kode Diagnosis Pasien Poli Umum di Puskesmas Panti Kabupaten Jember. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

A preliminary study conducted at Panti Community Health Center, Jember Regency, found that 14 out of 30 medical records (46.7%) from general outpatient services during October–December 2025 contained inaccurate diagnosis codes. This study aimed to analyze the factors causing inaccurate diagnosis coding based on the 5M management and to develop improvement strategies through discussion. This qualitative study employed interviews, observations, and documentation as data collection techniques. The results showed that the man element included inadequate knowledge of leadterm selection, ICD-10 coding rules and structure, inappropriate educational background, lack of coding training, and limited work experience in medical records. The money element indicated that the training budget had not been optimally utilized. The materials element revealed that although the SOAP components were completely documented, inconsistencies among SOAP components remained, and medical diagnoses were documented by nurses. The machines element showed the unavailability of ICD-10. The methods element identified limited understanding of job descriptions and the absence of a SOP for diagnosis coding. The study concludes that inaccurate diagnosis coding was influenced by all five management elements. Recommended improvements include lead term socialization, diagnosis coding training, recruitment of qualified medical record personnel, optimization of training budgets, monitoring and evaluation of SOAP documentation and healthcare professionals’ authority in medical record documentation, provision of accessible ICD-10 references, review of job descriptions, and development of an SOP for diagnosis coding.

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