Analisis Faktor Penyebab Ketidaklengkapan Dan Ketidakakuratan Kodefikasi Kasus Neoplasma Di Rumah Sakit Tingkat III Baladhika Husada Jember

Cayuga, Eden Shella Abia (2024) Analisis Faktor Penyebab Ketidaklengkapan Dan Ketidakakuratan Kodefikasi Kasus Neoplasma Di Rumah Sakit Tingkat III Baladhika Husada Jember. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

The comprehensive coding of Neoplasm diagnoses according to ICD-10 and ICDO classification, it is essential to include both topographical and morphological codes. The topographical code denotes the site of origin of the neoplasm, while the morphological code describes the type of tumor cells and their biological activity. A research conducted at Baladhika Husada Jember Hospital Level III revealed that 73% of medical records had incomplete topographical codes as per ICD-10 standards, and none had complete morphological codes. This research aims to analyze the factors contributing to the incompleteness and inaccuracy of Neoplasm case codification. This qualitative study employed data collection techniques such as in-depth interviews, observations, and documentation. The sources regarding this research is included 3 inpatient coders, 1 oncology specialist, and 1 medical record officer. Problem prioritization was conducted using a scoring method, with improvement efforts initiated through brainstorming sessions. The findings highlighted several issues: insufficient knowledge among staff as an individual variable; psychological factors such as delays in disease diagnosis and lack of specificity in documenting diagnoses by doctors; uneven distribution of specialized training; and absence of reward and punishment mechanisms. Organizational variables identified included the absence of Standard Operating Procedures (SPO) for Neoplasm case codification, inadequate monitoring and evaluation of Neoplasm case accuracy and codification. Proposed solutions involved engaging related parties such as medical records staff or nurses to remind doctors about completing diagnoses, conducting knowledge-enhancing activities like workshops and standardized training, especially concerning Neoplasm case codification

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