Tinjauan Ketepatan Pengkodean Penyakit pada Rekam Medis Pasien Rawat Inap Peserta BPJS di Rumah Sakit Angkatan Udara dr. M. Hassan Toto Bogor Tahun 2021
DOI:
https://doi.org/10.32585/jmiak.v5i1.2098Keywords:
rmikAbstract
ABSTRACT
The accuracy of disease coding is very important for hospitals because it facilitates the presentation of information data and as a determinant of treatment costs. Disease coding was performed by a coder with the ICD-10 and ICD-9-CM manuals. The purpose of this study was to determine the percentage accuracy of coding for inpatients BPJS participants at the Air Force Hospital dr. M. Hassan Toto Bogor Tahun 2021. This study used a descriptive method with a quantitative analysis approach, with 90 samples taken using a simple random sampling technique. From the 90 samples, it was found that the accuracy of coding for the disease of inpatients BPJS participants at the Air Force Hospital dr. M. Hassan Toto Bogor Tahun 2021 as many as 65 (72.2%) and 25 (27.8%) are incorrect. In identifying obstacles in the implementation of coding, the researchers used the 5M element. The inaccuracy of coding disease based on the Man element is due to the lack of officer resources and the coder officers who are less thorough. From the Material element, the doctor's writing was not legible and the medical record file was late in returning from the treatment room. And from the Method element because the SPO regarding the use of the 5th character does not yet exist and the coding officer tends to use rote.
Keyword : the accuracy of disease coding, BPJS, element 5M
ABSTRAK
Ketepatan pengkodean penyakit sangat penting bagi rumah sakit karena memudahkan dalam penyajian data informasi dan sebagai penentu biaya perawatan. Pengkodean penyakit dilakukan oleh koder dengan buku pedoman ICD-10 dan ICD-9-CM. Tujuan dari penelitian ini adalah untuk mengetahui persentase ketepatan pengkodean penyakit pasien rawat inap peserta BPJS di Rumah Sakit Angkatan Udara dr. M. Hassan Toto Bogor Tahun 2021. Penelitian ini menggunakan metode deskriptif dengan pendekatan analisa kuantitatif, dengan pengambilan sampel menggunakan teknik simple random sampling sebanyak 90 sampel. Dari 90 sampel tersebut didapatkan hasil bahwa ketepatan pengkodean penyakit pasien rawat inap peserta BPJS di Rumah Sakit Angkatan Udara dr. M. Hassan Toto Bogor Tahun 2021 sebanyak 65 (72,2%) dan 25 (27,8%) tidak tepat. Dalam mengidentifikasi hambatan dalam pelaksanaan pengkodean, peneliti menggunakan unsur 5M. Ketidaktepatan pengkodean penyakit berdasarkan unsur Man karena kurangnya SDM PMIK dan petugas koder yang kurang teliti. Dari unsur Material karena tulisan dokter yang tidak terbaca dan terlambatnya pengembalian berkas rekam medis dari ruang perawatan. Dan dari unsur Method karena SPO tentang penggunaan karakter ke-5 belum ada dan petugas koding yang cenderung menggunakan hafalan.
Kata Kunci : Ketepatan pengkodean penyakit, BPJS, unsur 5M
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