Tinjauan Ketepatan Kode Diganosis Tuberkulosis Paru Pasien Rawat Jalan di Rumah Sakit SHL Pandeglang

Authors

  • Rahelia Putri Universitas Esa Unggul
  • Lily Widjaja Universitas Esa Unggul
  • Dina Sonia Universitas Esa Unggul
  • Daniel Happy Putra Universitas Esa Unggul

DOI:

https://doi.org/10.55123/sehatmas.v3i2.3423

Keywords:

Accuracy, Encoding, Diagnose, Outpatient, Pulmonary Tuberculosis

Abstract

In coding activities, medical recorders and health information are needed who master how to give disease codes according to ICD-10 and actions according to ICD-9 CM so that the resulting code has accuracy according to the diagnosis or action given. One of the most frequently used coding accuracy is accuracy in coding for Pulmonary Tuberculosis. One of the important things is how to describe the accuracy of the Outpatient Pulmonary Tuberculosis diagnosis code at SHL Pandeglang Hospital. This study was shown to determine the accuracy of the diagnosis code for Outpatient Pulmonary Tuberculosis at SHL Pandeglang Hospital. This research method uses a descriptive method with a quantitative approach. The sample of this study was taken by saturated sampling technique. Data were taken using interviews and observations. The results of the study of 122 medical records obtained accuracy of 93 (76.2%) files and inaccuracy of 29 (23.8%) files. Based on the identification of factors causing the inaccuracy of the diagnosis code, there are 4 factors, namely the man factor: occurs due to the lack of accuracy of the coder in coding, the workload of the coder, and the lack of training for coders with non-RMIK backgrounds. Material factors: the unavailability of the Medical Dictionary (Dictionary of Medical Terminology) and the absence of an abbreviated list of diagnoses (standard). Machine factors: damage to the computer, software hangs, and computers that are too old. Method factor: incomplete SPO diagnosis coding.

Downloads

Download data is not yet available.

References

Garmelia, E., Kresnowati, L., & Irmawati. (2017). Klasifikasi, Kodefikasi Penyakit dan Masalah Terkait I: Anatomi, Fisiologi, Patologi, Terminologi Medis dan Tindakan Pada Sistem Kardiovaskuler, Respirasi, dan Muskuloskeletal (Edisi 2017). Pusat Pendidikan Sumber Daya Manusia Kesehatan Badan Pengembangan Dan Pemberdayaan Sumber Daya Manusia Kesehatan.

Hatta, G. R., Sampurna, B., Erkadius, Kasim, F., Garmelia, E., Thabrany, H., Daswati, I., Trihandini, I., Djojosugito, M. A., Zailani, M., Sudra, R. I., Ahmad, S. A., Suwarjo, S., & Mengko, T. L. R. (2017). Pedoman Manajemen Informasi Kesehatan di Sarana Pelayanan Kesehatan (G. R. Hatta & Erkadius (eds.); Revisi 3). Penerbit Universitas Indonesia.

KBBI. (2021). Arti Ketepatan. Kbbi.Web.Id. https://kbbi.web.id/tepat

Kemenkes RI. (2011). TBC Masalah Kesehatan Dunia. Kemkes.Go.Id. https://kemkes.go.id/article/view/1444/tbc-masalah-kesehatan-dunia.html

Kemenkes RI. (2014). Peraturan Menteri Kesehatan Republik Indonesia Nomor 27 Tahun 2014 tentang Petunjuk Teknis Sistem Indonesia Case Base Groups (INA-CBGs).

Kemenkes RI. (2020). Profil Kesehatan Indonesia 2019. In Kementrian Kesehatan Republik Indonesia. https://pusdatin.kemkes.go.id/resources/download/pusdatin/profil-kesehatan-indonesia/Profil-Kesehatan-indonesia-2019.pdf

Kemenkes RI. (2022a). 5 Penyakit Terbanyak di Indonesia, Menurut Data Klaim BPJS. Hellosehat. https://hellosehat.com/sehat/gejala-umum/penyakit-terbanyak-di-indonesia/

Kemenkes RI. (2022b). Peraturan Menteri Kesehatan Republik Indonesia Nomor 24 Tahun 2022 Tentang Rekam Medis Elektronik (Issue 8.5.2017, pp. 2003–2005).

Kemenkes RI. (2022c). Prof. Dante Usulkan Global Fund Fokus Penanganan COVID-19, HIV, TBC, dan Malaria di Asia Tenggara. Kemkes.Go.Id. https://www.kemkes.go.id/article/view/22112100001/prof-dante-usulkan-global-fund-fokus-penanganan-covid-19-hiv-tbc-dan-malaria-di-asia-tenggara.html

Sukma, R. S., & Siswati. (2017). Tinjauan Pelaksanaan Standar Prosedur Operasional Distribusi Rekam Medis Rawat Jalan di Rumah Sakit Umum Daerah Kota Bekasi. Tinjauan Pelaksanaan Standar Prosedur Operasional Distribusi Rekam Medis Rawat Jalan Di Rumah Sakit Umum Daerah Kota Bekasi, 5.

Downloads

Published

2024-04-28

How to Cite

Rahelia Putri, Lily Widjaja, Dina Sonia, & Daniel Happy Putra. (2024). Tinjauan Ketepatan Kode Diganosis Tuberkulosis Paru Pasien Rawat Jalan di Rumah Sakit SHL Pandeglang . SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat, 3(2), 316–321. https://doi.org/10.55123/sehatmas.v3i2.3423

Issue

Section

Articles