Analisis Faktor Penyebab Ketidaklengkapan Kodefikasi Icd10 Pada Laporan Morbiditas Rawat Inap Rsud dr Soedono Madiun

Ikawati, Susi (2021) Analisis Faktor Penyebab Ketidaklengkapan Kodefikasi Icd10 Pada Laporan Morbiditas Rawat Inap Rsud dr Soedono Madiun. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

Code assignment is code assignment using letter or numeric codes or a combination of letters in numbers representing data components (DepkesRI , 2006). The data obtained was an interview with the head of the medical record installation at RSUD dr. Soedono Madiun, the problem that is still often faced is the incomplete ICD-10 codefication in the inpatient morbidity report. Incomplete ICD-10 coding was found in disease codes M, S, V, W, X and Y. The purpose of this study was to analyze the factors that caused the incompleteness of ICD-10 coding in the morbidity report of hospitalization at dr. Soedono Madiun. This type of research is qualitative by using observation data collection, interviews and priority methods as well as CARL problem solving, brainstorming. The results of this study were the emergence of several problems, namely the officers felt that their skills were still not supportive so that they needed to be updated constantly, the officers cross-checked with medical record documents then re-entered in SIMRS, the contents of the electronic ICD-10 in SIMRS were not in accordance with the contents and provisions of ICD-10 manual, There are methods / tools used to add ICD-10 code by entering the code and disease description in that field. The application of ICD-10 coding SPO at the time of entry in SIMRS has not been executed. Based on calculations using the CARL method, priority problems are obtained and need to be resolved first, namely that there are methods / tools used to add ICD-10 codes by entering the code and disease description in the field with a score of 625. Based on the brainstroming, the head of the medical record installation issued a recommendation in the form of an official note to the IT team to enter the ICD-10 code into the SIMRS. Keywords: CARL, Morbidity Report, Incompleteness, ICD-10.

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