Analisis Ketepatan Kode Diagnosis Utama Pada Berkas Rekam Medik Pasien Rawat Jalan Berdasarkan ICD-10 Dengan Metode Focus PDCA Di RSUD dr. Abdoer Rahem Situbondo Periode Triwulan II Tahun 2016

Apriliansyah, Udin (2016) Analisis Ketepatan Kode Diagnosis Utama Pada Berkas Rekam Medik Pasien Rawat Jalan Berdasarkan ICD-10 Dengan Metode Focus PDCA Di RSUD dr. Abdoer Rahem Situbondo Periode Triwulan II Tahun 2016. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

The results of health service to the patient recorded in the medical records and are determined by diagnosis code. Determination of diagnosis in medical records is filled completely and clearly accordance with the ICD-10. Problems inaccuracy coding are often found in hospitals, one of them is in dr.Abdoer Rahem General Hospitals Situbondo where the hospital files that contains patient data is not yet clear and accurate especially in the determination of diagnosis codes where the recording and determination of the main diagnosis code in outpatient case encountered discrepancy between diagnosis of disease and the code is written. There are 16 files (80%) files that are not in accordance with the provisions of the ICD-10, so the code is not accurate. This research used FOCUS PDCA method as settlement of the problem in order to improve the quality of health services. The method used is a qualitative method and the data collection techniques through observation, interviews and brainstorming. The results of this research is there are medical record files that inappropriate in the determination the codes and diagnosis. Factors that affect on accuracy of coding diagnosis in medical records are human resources, diagnosis completeness, equipment used, and the standard operational procedure. Therefore, it needs to improve the skills of employee, do reshuffle especially in the field of coding with accordance majoring in education (medical records), the completeness code monitoring, antivirus updates on the computer, and revise of SOP.

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