Analisis Faktor Penyebab Ketidakakuratan Kode Diagnosis Utama Injury Dan Kode External Causes Pada Rekam Medis Rawat Inap Di RSD dr. Soebandi Jember

Budiningsih, Dyah Palupi (2024) Analisis Faktor Penyebab Ketidakakuratan Kode Diagnosis Utama Injury Dan Kode External Causes Pada Rekam Medis Rawat Inap Di RSD dr. Soebandi Jember. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

The Primary Diagnosis of Injury and External Causes Code is part of the disease classification in ICD-10. Inaccurate coding of injury and external causes diagnosis can lead to hospital losses, and the quality of statistical data had a low rate of validation. In inpatient medical records at Dr. Soebandi Regional General Hospital in Jember from 2020 to 2022, inaccuracy of injury primary diagnosis codes was 70%, and the inaccuracy of external causes codes was 100% because never encoded. This research aimed to analyze the factors causing inaccuracy in the primary diagnosis code of injury and external causes in inpatient medical records based on Robbin's performance theory and improvement efforts through brainstorming. The type of this research was qualitative, used data collection techniques such as in-depth interviews, observations, and documentation. The results of the research on the ability factor indicated that the knowledge of the Emergency Room physicians was lacking in completed the history-taking for injury cases, and the attending physician's knowledge in selected medical terminology was not following ICD-10. The motivation factor revealed that the rewards given were not optimal, punishments were only verbal reprimands and feedback on medical record completion quality evaluation had never been conducting. The opportunity factor included the lack of clear boundaries between coders and internal verifier's roles, and the implementation of injury diagnosis and external causes coding was not following SOP. Efforts to address these issues including performing audits to ensure the quality of medical records completion, suggesting appropriate rewards and punishments, re-socializing SOPs relating to coding and procedures, and conducting internal training on the coding of injury and external causes diagnoses

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