Analisis Faktor Penyebab Ketidakakuratan Kode Diagnosis Pasien Rawat Inap Di Rumah Sakit Citra Husada Jember

Amellya, Zahwa Naning (2023) Analisis Faktor Penyebab Ketidakakuratan Kode Diagnosis Pasien Rawat Inap Di Rumah Sakit Citra Husada Jember. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

Coding is the process of assigning a code to a computer program for classification or identification using letters and numbers that represent data components that aim to ensure the accuracy of the selected code representing a diagnosis made by a doctor. Citra Husada Hospital Jember, in coding activity, has a Standard Operating Procedure using ICD-10 for disease classification and ICD-9 CM for medical procedures. This study aims to analyze the factors causing the inaccuracy of the inpatient diagnosis code which consists of individual, psychological, and organizational variables. This qualitative research and data collection type uses interviews, observation, documentation, USG (Urgency, Seriousness, Growth), and formulate solutions. Identification results obtained 33% inaccurate codes and 66% accurate codes from 97 samples of medical records. The results obtained as the cause of the inaccuracy of the diagnosis code were inconsistent checking on the ICD-10, the doctor's writing was unclear or incomplete, the doctor's abbreviation was not standard, did not participate in coding training, there was no reward and punishment, and double jobs. The priority problem is that the doctor's writings must be precise and complete, the officers have not attended training, and the doctor's abbreviations need to be revised. The solution to this problem is implementing a comprehensive electronic medical record system. Coding officers need to attend training on coding general diagnoses or diagnoses with specific cases and hold meetings between doctors and coding officers to socialize the standard book of signs and abbreviations that apply at Citra Husada Hospital.

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