ANALISIS KETEPATAN KODE ICD-10 PADA DIAGNOSIS PASIEN RAWAT JALAN DI PUSKESMAS KIJANG

Wulandari, Siti (2023) ANALISIS KETEPATAN KODE ICD-10 PADA DIAGNOSIS PASIEN RAWAT JALAN DI PUSKESMAS KIJANG. D3 Rekam Medis dan Informasi Kesehatan thesis, Universitas Awal Bros.

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Abstract

PROGRAM STUDI DIII REKAM MEDIS DAN INFORMASI KESEHATAN UNIVERSITAS AWAL BROS Karya Tulis Ilmiah (KTI), 2023 ANALISIS KETEPATAN KODE ICD-10 PADA DIAGNOSIS PASIEN RAWAT JALAN DI PUSKESMAS KIJANG Siti Wulandari, 00419020 X+ 89 Halaman + 2 Bagan + 7 Lampiran ABSTRAK Latar Belakang : Ketepatan pengodean sangat penting dalam rekam medis. hal ini terkait dengan kegunaan rekam medis dilihat dari aspek administrasi, aspek medis, aspek hukum, aspek keuangan, aspek penelitian dan aspek dokumentasi. Ketepatan kode menghasilkan rekam medis yang baik yang dapat digunakan sebagai sumber pengambilan keputusan. Kode diagnosis dianggap tepat dan akurat apabila sesuai dengan kondisi pasien. Tujuan : Untuk meiingeiitahui faktor peiinyeiibab dan persentase keiiteiipatan kodeii ICD-10 pada diagnosis pasieiin rawat jalan di Puskeiismas Kijang. Metode : deiiiskriiiiptiiiif kuantiiiitati iiif deiiingan meiiinggunakan peiiindeiiikatan cross seiiictiiiional Hasil Peirseintasei keiteipatan kodei diiagnosiis pasiiein yang teipat seibeisar 66.7% atau 66 reikam meidiis dan kodei diiagnosiis yang tiidak teipat seibeisar 33.3% atau 33 reikam meidiis. Faktor yang mempengaruhi yaitu dari mam, methode dan material. Kesimpulan : Peilaksanaan peingodeian peinyakiit tiidak diilakukan oleih peitugas reikam meidiis. Beilum adanya standar opeirasiional proseidur teintang siisteim kodiifiikasii peinyakiit. Proseis peingodeian diiagnosiis dii Puskeismas Kiijang tiidak meinggunakan buku IiCD-10 teitapii meinggunakan kodei yang sudah ada pada keirtas peidoman yang teilah diibuatkan oleih peitugas reikam meidiis Kata Kunci : Pengodean, Ketepatan, ICD-10 Kepustakaan : 20 Buku (2006-2021) + 15 Jurnal ANALYSIS OF THE ACCURACY OF THE ICD-10 CODE IN THE DIAGNOSIS OF OUTPATIENT PATIENTS AT KIJANG PUSKESMAS Siti Wulandari, 00419020 XI+ 89 Pages + 2 Charts + 7 Appendices ABSTRACT Background: Coding accuracy is very important in medical records. this is related to the use of medical records seen from administrative aspects, medical aspects, legal aspects, financial aspects, research aspects and documentation aspects. Code accuracy produces good medical records that can be used as a source of decision making. The diagnosis code is considered appropriate and accurate if it matches the patient's condition. Objective: To know the causal factors and the percentage of ICD-10 coding coincidence in the diagnosis of outpatients at the Kijang Health Center. Methods: quantitative descriptive analysis using cross-sectoral cross-sectoral assessment Results: the result of the accuracy of the correct patient-diagnosed code of 66.7% or 66 medical records and incorrectly diagnosed coding of 33.3% or 33 medical records. The influencing factors are mam, method and material. Conclusion: The implementation of disease treatment was not carried out by medical examiner officers. There is no standard operating procedure regarding the disease codification system. The coding process for diagnosing at the Kiijang Puskeismas does not use the ICD-10 book but uses the code that already exists on the guide sheet that has been prepared by the Medical Registrar Officer Keywords : Coding, Accuracy, ICD-10 Libraries: 20 Books (2006-2021) + 15 Journals

Item Type:	Thesis (D3 Rekam Medis dan Informasi Kesehatan)
Subjects:	D3 Rekam Medis > Coding
Divisions:	D3 Rekam Medis
Depositing User:	Siti Wulandari
Date Deposited:	05 Dec 2023 06:32
Last Modified:	05 Dec 2023 06:32
URI:	http://repositori.psdku.univawalbros.ac.id/id/eprint/293

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