AKURASI KODE ICD-10 KASUS PEMERIKSAAN KEHAMILAN PADA REKAM MEDIS ELEKTRONIK
DOI:
https://doi.org/10.32585/jmiak.v4i2.2015Keywords:
ICD-10, akurasi, kode diagnosis, rekam medis elektronikAbstract
Akurasi kode klinis penting untuk evaluasi kualitas layanan kesehatan, penagihan klaim biaya, penelitian, dan pelaporan. Kode yang akurat akan menghasilkan data dan informasi yang berkualitas. Pemeriksaan kehamilan merupakan kondisi terbanyak yang ditangani di Klinik Obstetri dan Ginekologi dan ditemukan 60% ketidakakuratan kode. Penelitian bertujuan untuk menganalisis akurasi kode pemeriksaan kehamilan berdasarkan ICD-10. Penelitian ini merupakan mixed method sequential explanatory (kuantitatif-kualitatif) dengan rancangan cross sectional. Sampel penelitian berupa objek terdiri dari 138 data pasien yang terpilih menggunakan teknik total sampling. Subyek penelitian 1 orang coder dan 1 orang dokter yang terpilih melalui teknik purposive sampling. Pengumpulan data dilakukan melalui studi dokumentasi dan wawancara. Instrumen penelitian menggunakan lembar studi dokumentasi dan pedoman wawancara. Analisis data kuantitatif menggunakan analisis univariat dan analisis data kualitatif menggunakan content analysis. Akurasi kode pemeriksaan kehamilan pada kategori akurat sampai 3 digit sebesar 22,4% dan tidak akurat sebesar 77,6%. Ketidakakuratan kode pemeriksaan kehamilan disebabkan oleh ketidaksesuaian kualifikasi SDM, pemilihan diagnosis dan kode hanya berdasarkan kondisi saat pasien melakukan pemeriksaan, dan kode diagnosis pada database rekam medis elektronik belum lengkap. Untuk meningkatkan akurasi kode perlu dilakukan pelatihan ICD-10 untuk dokter, dokter atau bidan melakukan review kondisi dan riwayat lain pasien, audit kode secara berkala, dan melengkapi database pada rekam medis elektronik sesuai ICD-10.
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