Abstract
An accurate diagnostic code is required to achieve the goal of the classification system for disease diagnosis, one of which is the recording of mortality and morbidity data. Based on preliminary study of 7 samples of medical records in health centers Kagok, get results 2 medical records (28.57%) there is an accurate diagnosis and diagnostic code and 4 medical records (57.14%) there is an inaccurate diagnosis and diagnosis code, while 1 medical record (14.29%) no diagnosis. The purpose of this research is to determine the accuracy of the disease diagnosis code based on ICD-10 in the outpatient medical record in health centers Kagok. This study used a quantitative descriptive research with cross sectional research design. The number of samples on this study was 98 medical records of outpatient patients, taken with a proportional stratified sampling method. The results showed that the medical record was diagnosed as much as 57 medical records (58%) while the unwritten diagnosis is as much as 41 medical record (42%). From 57 medical records that have been diagnosed, there are only 18 medical records (32%) with accurate code and 39 medical records (68%) with inaccurate code. The officers of the Diagnosis Code no one has the educational background of the medical record, never participated in special training on coding ICD-10, and did not use the facilities in the health centers in the form of an electronic ICD-10 in giving code diagnosis.
Highlights
Abstrak Kode diagnosis yang akurat diperlukan untuk mencapai tujuan sistem klasifikasi diagnosis penyakit, salah satunya yaitu pencatatan data mortalitas dan morbiditas
An accurate diagnostic code is required to achieve the goal of the classification system for disease diagnosis, one of which is the recording of mortality and morbidity data
The purpose of this research is to determine the accuracy of the disease diagnosis code based on ICD-10 in the outpatient medical record in health centers Kagok
Summary
Tabel 1 menunjukkan bahwa kelengkapan penulisan diagnosis penyakit pada Klinik Gigi keseluruhan terisi penulisan diagnosis, sedangkan pada Klinik Umum dan KIA hanya setengah yang terisi penulisan diagnosis dari masing-masing rekam medis yang diambil sebagai sampel dan dalam dalam penulisan diagnosis terdapat 18 rekam medis yang menggunakan singkatan. Penjelasan dokter dan bidan menyatakan bahwa tidak menuliskan diagnosis pada semua rekam medis pasien yang datang berkunjung adalah untuk efisiensi dan efektifitas waktu pelayanan. Menggunakan beberapa singkatan untuk menuliskan diagnosis penyakit harus menggunakan standar singkatan yang menjadi pedoman di Puskesmas Kagok, sedangkan di Puskesmas Kagok belum memiliki standar singkatan yang digunakan sebagai pedoman. Total 98 sampel rekam medis yang dapat dinilai keakuratannya hanya 57 rekam medis (58%), yang terdiri dari 33 rekam medis Klinik Umum, 15 rekam medis KIA, dan 9 rekam medis Klinik. Tidak dapat dinilai keakuratannya karena tidak terdapat penulisan diagnosis
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