Analisis Ketepatan Kode Diagnosis Penyakit Gastroenteritis Akut Pada Pasien Rawat Inap Berdasarkan Dokumen Rekam Medis Triwulan I Tahun 2015 Di Rumah Sakit Daerah Balung Jember

Nurmalia, Puput Septining (2016) Analisis Ketepatan Kode Diagnosis Penyakit Gastroenteritis Akut Pada Pasien Rawat Inap Berdasarkan Dokumen Rekam Medis Triwulan I Tahun 2015 Di Rumah Sakit Daerah Balung Jember. Undergraduate thesis, Politeknik Negeri Jember.

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Abstract

Analysis accuracy of replenishment diagnosis codes on the document medical records so because if the diagnosis code is not right / not in accordance with the ICD-10, it can cause a decline in the quality of care in hospitals as well as the influence of data, information reporting, and accuracy rates INA-CBG's that are currently used as a method of payment for patient care. The purpose of this study was to analyze the accuracy of disease diagnosis codes acute gastroenteritis in hospitalized patients by medical record documents the first quarter of 2015 in the Regional Hospital Balung Jember. This research uses qualitative. Acquisition of data from this study through interviews and observations. Results obtained from the observation of medical record documents at the inpatient unit in the first quarter 2015 in RSD. Balung Jember, there are numbers determining the accuracy of disease diagnosis codes as many as 19 medical record documents with acute gastroenteritis illness and the determination of improper diagnosis codes as many as 61 medical records document acute gastroenteritis illness. From the analysis of the cause of the problem is the accuracy of the diagnosis that affects the accuracy of writing code, but it does not pernahnya be disseminated to physicians and medical records personnel related to the management of medical records. Therefore, it is necessary to implement activities that can improve the accuracy of disease diagnosis code and quality of human resources, among others, include doctors and medical records personnel in training and socialization related to the management of medical records.

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