Hubungan Ketersediaan Informasi Medis dengan Keakuratan Kode Diagnosa Diabetes Mellitus di Unit Rawat Inap RSU Dr. H. Koesnadi Bondowoso

Maharani, Tyas Errica Dewi (2023) Hubungan Ketersediaan Informasi Medis dengan Keakuratan Kode Diagnosa Diabetes Mellitus di Unit Rawat Inap RSU Dr. H. Koesnadi Bondowoso. [Experiment] (Unpublished)

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Abstract

The availability of complete medical information is very important and influences the accuracy of diabetes mellitus codes. It was found that the percentage of medical information available in 27 medical records of DM cases of inpatients at RSU Dr. H. Koesnadi Bondowoso was 100% age, 100% history taking, 37.03% physical examination, 70.38% laboratory examination, 3.7% diagnosis and 48.15% code inaccuracy rate. This study aims to determine the relationship between completeness of medical information and the accuracy of diabetes mellitus diagnosis codes in inpatient medical records. This type of quantitative research with an observational analytical design and a cross sectional approach. The sampleused was 235 medical records using random sampling technique. Data analysis used the contingency coefficient correlation test. Percentage of availability of medical information on age 100%, history taking 76.17%, physical examination 96.17%, laboratory examination 17.87%, and diagnosis 0.43%. Inaccurate diabetes mellitus diagnosis codes amounted to 97.02% (228 medical records). Statistical tests show that age and code accuracy cannot be tested for a relationship because they are constant, history taking and code accuracy have no relationship with p 0.133 > 0.05 and contingency coefficient 0.098, physical examination and code accuracy have no relationship with p 0.592 > 0.05 and contingency coefficient 0.035, laboratory examination and code accuracy have no relationship with p 0.801 > 0.05 and contingency coefficient 0.016, diagnosis and code accuracy have a significant relationship with p 0.000 < 0.05 and contingency coefficient 0.350. The author suggests that auditing of the completeness of medical information and accuracy of diagnosis codes should be improved as well as providing training to coding officers regarding the classification of DM diagnoses.

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