Analisis Ketepatan Kode Diagnosis Diabetes Melitus Pada Berkas Rekam Medik Pasien Rawat Inap Di RS Citra Husada Jember

Ardiansyah, Rendy (2019) Analisis Ketepatan Kode Diagnosis Diabetes Melitus Pada Berkas Rekam Medik Pasien Rawat Inap Di RS Citra Husada Jember. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

Coding is one of the medical record data processing activities to provide the code with a letter or with a number or combination of letters and numbers that represent components of the data. Citra Husada Hospital Jember have Standard Operating Procedures Code Provision disease using ICD-10 Classification of Diseases ICD 9 CM for Medical Measures that have been set by the director. The provision of this code is a classification of disease activity and action that classifies diseases and actions based on certain agreed criteria. This study aims to analyze the accuracy of the diagnosis code by using tree diagrams and Nominal Group Technique. Qualitative research and collection of data through observation, interviews, documentation and Nominal Group Technique. The results obtained in the tree diagram that there are seven issues including No training coding routine, perceptions differ between the coder with the doctor, fall in tariffs, Post doctor is hard to read, Abbreviations unorthodox, charging the medical record is incomplete, and the diagnosis of DM was not charged. The first issue is a priority doctor writing is hard to read, RM Charging second incomplete, and the third diagnosis of DM is not filled. Advice can be given is to do regular training for officials at least 1 year of coding, it is necessary thoroughness and kefokusan officer coder when coding the diagnosis, the doctor and the clerk agreed coder or use common abbreviations commonly understood by all healthcare workers. Keywords: Diagnosis, Coding, element management 5M, tree diagrams, Nominal Group Technique.

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