Comparison of Clinical Codes with Standards of Genitourinary Disease in Public Hospital of Sidoarjo

Vina Fauzia, Umi Khoirun Nisak, Cholifah Cholifah

Abstract


The accuracy of data diagnosis is important for clinical data management, reimbursement, and  issues related to healthcare and services. Based on preliminary observations, it was found that the inaccuracy of the diagnosis code maker with the genitourinary disease standard at the  Sidarjo District Hospital. The purpose of this study was to find out the comparison of coder clinical codes with genitourinary disease standards at the sidoarjo district hospital. The method used was quantitative with random sampling techniques presented  in the form of frequency tables and cross tabulations and tested using the chi-square test. This study used medical records for inpatient genitourinary cases in 2022,   with a total sample of 80 medical records. The results showed that completeness, timeliness,  and accuracy had a significant influence on coding accuracy. Completness ( completeness of  supporting information) obtained 58,8% complete medical record documents and 51.3% incomplete medical record documents (p=0.012). Accuracy (coding accuracy):52.5% of medical  record documents were accurate and 47.5% of medical record documents were inaccurate  (p=0,0001). This study suggests improving the quality of coding by conducting coding training  and evaluating coding audits to support coding speed.

Keywords


Code comparison, Coder , Genitourinary

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References


Abdelhak, M. (2007). Health Information Management of a Startegic Resource. St.Louis,Mo Saunders/Elsevier.

Angelina, F., & Yendri, D. (2022). LITERATURE REVIEW ANALISIS KETEPATAN KODE PENYAKIT GINJAL DI PELAYANAN KESEHATAN. ADMINISTRATION & HEALTH INFORMATION OF JOURNAL, 3(1), 136–143.

Budiyani, V. Y., Wariyanti, A. S., & Wahyuningsih, S. (2021). Literature Review Faktor Yang Mempengaruhi Ketepatan Petugas Koding Diagnosis Berdasarkan Unsur 5M. Indonesian Journal of Health Information Management, 1(1), 14–20.

Erawantini, F., Yuliandari, A., Deharja, A., & Santi, M. W. (2022). Strategi Mengurangi Keterlambatan Pengembalian Berkas Rekam Medis Rawat Inap di RSUD Pasirian Lumajang Tahun 2020. Jurnal Manajemen Informasi Kesehatan Indonesia (JMIKI), 10(2), 160.

FATIMAH, D. (2022). Keakuratan Kode Diagnosisi Chronic KIdney Disease, Stage 5 di RSUD Karanganyar. Universitas Duta Bangsa Surakarta.

Hatta, G. R. (2008). Pedoman Manajemen Informasi Kesehatan di Sarana Pelayanan Kesehatan. UI Press. http://oasis.iik.ac.id/library/index.php?p=show_detail&id=4208

Hatta, G. R. (2013). Pedoman Manajemen Informasi Kesehatan di Sarana Pelayanan Kesehatan. UI Press. https://oasis.iik.ac.id:9443/library/index.php?p=show_detail&id=4795

Indriyani, I., Widyaningrum, L., & Listyorini, P. I. (2021). STUDI LITERATUR KEAKURATAN KODE EXTERNAL CAUSE PADA KASUS KECELAKAAN LALU LINTAS BERDASARKAN ICD-10. Seminar Informasi Kesehatan Nasional (SIKesNas), 209–218.

Juniati, E. (2020). Hubungan Kejelasan Dan Ketepatan Penulisan Diagnosa Penyakit Dengan Ketepatan Pengodean Diagnosa Penyakit Berdasarkan ICD-10 Di Puskesmas Pelompek Kerinci. Administration & Health Information Of Journal, 1(1), 43–54.

Kasim, F. (2011). Sistem Klasifikasi Utama Morbiditas dan Mortalitas. Jakarta: UI Press.

KEPMENKES RI, R. (2018). KEPMENKES RI. In KEPMENKES RI. KEPMENKES RI.

Loren, E. R., Wijayanti, R. A., & Nikmatun, N. (2020). Analisis Faktor Penyebab Ketidaktepatan Kode Diagnosis Penyakit Diabetes Mellitus di Rumah Sakit Umum Haji Surabaya. J-REMI: Jurnal Rekam Medik Dan Informasi Kesehatan, 1(3), 129–140.

Maryati, W. (2016). Hubungan Antara Ketepatan Penulisan Diagnosis Dengan Keakuratan Kode Diagnosis Kasus Obstetri Di Rs Pku Muhammadiyah Sukoharjo. Jurnal INFOKES Universitas Duta Bangsa Surakarta, 6(2).

Maryati, W., Wannay, A. O., & Suci, D. P. (2018). Hubungan Kelengkapan Informasi Medis dan Keakuratan Kode Diagnosis Diabetes Mellitus. Jurnal Rekam Medis Dan Informasi Kesehatan, 1(2), 96–108.

Mathar, I. (2018). Manajemen Informasi Kesehatan: Pengelolaan Dokumen Rekam Medis. Deepublish.

Oashttamadea SM, R. (2019). Analisis Ketepatan Pengodean Diagnosis Obstetri di RS Naili DBS Padang. In Jurnal Manajemen Informasi Kesehatan Indonesia (JMIKI) (2019th-10th–04 ed., Vol. 7, Issue 2). https://jmiki.aptirmik.or.id/index.php/jmiki/article/view/83

Rahmadiliyani, N., & Chia, N. (2020). Tinjauan Penggunaan Simbol dan Singkatan pada Rekam Medis Rawat Inap dalam Menunjang Akreditasi SNARS Edisi 1.1 di RSD Idaman Kota Banjarbaru. Jurnal Kesehatan Indonesia, 11(1), 41–52.

Rahmawati, E. N., & Utami, T. D. (2020). HUBUNGAN KETEPATAN PENULISAN TERMINOLOGI MEDIS TERHADAP KEAKURATAN KODE PADA SISTEM CARDIOVASCULAR DI RUMAH SAKIT PANTI WALUYO SURAKARTA. Jurnal Manajemen Informasi Kesehatan Indonesia (JMIKI), 8(2), 101.

Sulistyo, D. J., & Wariyanti, A. S. (2020). ANALISIS KELENGKAPAN PELAPORAN PENTING DOKUMEN REKAM MEDIS RAWAT INAP PADA PASIEN CHRONIC KIDNEY DISEASE DI RSUD DR. SOEHADI PRIJONEGORO SRAGEN. Prosiding" Seminar Rekam Medis Dan Manajemen Informasi Kesehatan" Tahun 2017.

Utami, Y. T., & Rosmalina, N. (2019). Hubungan Kelengkapan Informasi Medis Dengan Keakuratan Kodetuberculosis Paruberdasarkan ICD-10 Pada Dokumen Rekam Medis Rawat Inap di BBKPM Surakarta. SMIKNAS, 146–152.

World Health Organization. (2015). International statistical classification of diseases and related health problems. In ICD-10 (10th revision, Fifth edition, 2016). World Health Organization; WHO IRIS. https://apps.who.int/iris/handle/10665/246208

Yaasiintha, W. N. (2021). Analisis Penyebab Ketidaktepatan Kodifikasi Diagnosis Persalinan pada Dokumen Rekam Medis di Rumah Sakit: Literature Review.




DOI: https://doi.org/10.33394/j-ps.v11i2.7494

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J-PS (Prisma Sains: Jurnal Pengkajian Ilmu dan Pembelajaran Matematika dan IPA IKIP Mataram) p-ISSN (print) 2338-4530, e-ISSN (online) 2540-7899 is licensed under a Creative Commons Attribution 4.0 International License.

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