Analisis Faktor Penyebab Ketidaksesuaian Kode Diagnosis Penyakit Pasien Poli Umum pada Rekam Medis dengan SIMPUS di Puskesmas Purwoharjo

Sulandari, Sulandari (2022) Analisis Faktor Penyebab Ketidaksesuaian Kode Diagnosis Penyakit Pasien Poli Umum pada Rekam Medis dengan SIMPUS di Puskesmas Purwoharjo. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

The appropriate, precise, and accurate diagnosis codes will provide effectiveness in the decision-making process and accuracy of reporting disease data. Based on observational data, 42 of 89 disease diagnosis codes in the outpatient medical record were incompatible or incomplete with the disease code on SIMPUS and 30 of 42 data came from the general polyclinic. The purpose of this study was to analyze factors causing incompatibility of disease diagnosis codes for general polyclinic patients in the medical record with SIMPUS at Purwoharjo Public Health Center. The type of research used was qualitative descriptive with an in-depth interview, observation, documentation, USG, and brainstorming data collection. The subject of this research was 1 nurse SIMPUS, 1 clerk's medical record, 1 doctor UKP and the leader of Puskesmas in Purwoharjo. The object of this study was 96 medical records of general polyclinic patients with simple random sampling. The credibility data using triangulation of sources and techniques. The result obtained during observation of 96 medical records of general poly patients with SIMPUS on Januari-April 2022 found an incompatibility of disease diagnosis codes was 43%. From the analysis it was found that the incompatibility occurred due to staff coding doesn’t know how to code with ICD-10, the demeanor of the coders that doesn’t support the implementation of coding according to standards, inadequate infrastructures, staff coding has never attended to coding training, the contents of the SOP there is no clarity regarding the coding steps and the clarity of the staff who can code a disease diagnosis, and the lack of motivation, so it necessary to add a recommendation for the staff coding can be attended to coding training, maintenance of the coding infrastructure, SOP content improvement then SOP socialization. Keywords: Code incompatibility, Medical Record, Diagnosis

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