Analisis Faktor Penyebab Ketidakakuratan Kodefikasi Diagnosis Pasien Rawat Jalan di Puskesmas Kotaanyar Kabupaten Probolinggo

Kholisa, Siti Nurul (2026) Analisis Faktor Penyebab Ketidakakuratan Kodefikasi Diagnosis Pasien Rawat Jalan di Puskesmas Kotaanyar Kabupaten Probolinggo. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

The accuracy of diagnosis coding is critically important as it directly affects the quality of clinical data, report preparation, and healthcare services. Based on observational findings in Puskesmas Kotaanyar, Probolinggo Regency, during the period of January–June 2025, it was found that out of 99 medical records examined, only 28.28% of codes were accurate, while 71.72% were inaccurate, with the highest rate of inaccuracy occurring at the fourth character level. This study aims to analyze the causal factors contributing to the inaccuracy of outpatient diagnosis coding in Puskesmas Kotaanyar, Probolinggo Regency, based on the 5M management elements: man, money, material, method, and machine. This study employed a qualitative research design. The research subjects consisted of one midwife, two nurses, one general practitioner, one dentist, and one head of medical records. Data collection techniques included interviews, observation, documentation, and brainstorming sessions. The findings revealed that the inaccuracy of outpatient diagnosis coding was influenced by the following 5M management elements: the man element, encompassing mismatches in educational background, limited knowledge, and the absence of training; the money element, characterized by the unavailability of a training budget; the material element, reflected in the incomplete recording of diagnoses; the method element, indicated by the absence of a Standard Operating Procedure (SOP) for coding; and the machine element, attributable to the unavailability of ICD-10 references. Recommended corrective measures include the recruitment of additional medical records personnel and the development of job descriptions aligned with staff educational backgrounds, enhancement of staff competency through training and dissemination activities, submission of proposals for diagnosis coding training and the implementation of internal dissemination within the health center, submission of budget planning for diagnosis coding training, monitoring and evaluation of diagnosis completeness, formulation of SOPs and the establishment of sanctions and rewards for personnel, as well as the provision of references in both electronic and physical formats.

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