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
Downloads
References
Agiwahyuanto, F., Indah Sari, T. and Octaviasuni, S. (2019) ‘Analisis Ketepatan Koding dan Kinerja Petugas di Unit Koding-Indeksing Rumah Sakit Mitra Husada Kota Pring Sewu’, Jurnal Manajemen Informasi Kesehatan Indonesia, 7(2), pp. 114–120.
Anggraini, M. et al. (2017) Bahan Ajar Rekam Medis dan Informasi Kesehatan (RMIK) : Klasifikasi, Kodefikasi Penyakit dan Masalah Terkait I:Anatomi, Fisiologi, Patologi, Terminologi Medis dan Tindakan Pada Sistem Kardiovaskuler, Respirasi, dan Muskuloskleletal. 1st edn. Jakarta: PPSDMK.
Depkes, R. (2008) ‘Peraturan Menteri Kesehatan Republik Indonesia No.269/MENKES/PER/III/2008’. Jakarta: Dirjen. Pelayanan Medik.
Depkes, R. (2014) ‘Peraturan Menteri Kesehatan Republik Indonesia Nomor 27 Tahun 2014 tentang Petunjuk Teknis Sistem Indonesian Case Base Groups (INA-CBGs)’. Jakarta: Dirjen. Pelayanan Medik.
Depkes, R. (2016) ‘PMK 76 tentang Pedoman Indonesian Case Based Groups (INA CBG’s) dalam Pelaksanaan Jaminan Kesehatan Nasional’. Jakarta: Dirjen. Pelayanan Medik.
Depkes RI (2007) ‘Permenkes No. 512 Tahun tentang Izin Praktik Dan Pelaksanaan Praktik Kedokteran’, Peraturan Menteri Kesehatan Republik Indonesia Nomor 512/Menkes/Per/IV/2007, p. 4.
Ilmi, L. R. (2018) ‘Keakuratan Kode Diagnosis dengan ICD-10 di Puskesmas Pengasih I dan Pengasih II’, Manajemen Informasi Kesehatan Indonesia, 6(2), pp. 118–122.
Indawati, L. (2017) ‘Identifikasi Unsur 5M dalam Ketidaklengkapan Pemberian Kode Penyakit dan Tindakan (Systematic Review)’, In, 5(2), pp. 59–64.
Karimah, R. N., Setiawan, D. and Nurmalia, P. S. (2016) ‘Analisis Ketepatan Kode Diagnosis Penyakit Gastroenteritis Acute Berdasarkan Dokumen Rekam Medis di Rumah Sakit Balung Jember’, Journal of Agromedicine and Medical Sciences, 2(2), pp. 12–17. doi: 10.19184/ams.v2i2.2775.
Masturoh, I. and Temesvari, N. A. (2018) Bahan Ajar Rekam Medis dan Informasi Kesehatan (RMIK) Metodologi Penelitian Kesehatan. 1st edn. Jakarta: PPSDMK.
RI (2009) ‘Undang-Undang Republik Indonesia No.44 Tahun 2009 tentang Rumah Sakit’. Jakarta: Sekretariat Negara.
RI (2011) ‘Undang-Undang Republik Indonesia No.24 Tahun 2011 tentang Badan Penyelenggara Jaminan Sosial’. Jakarta: Sekretariat Negara.
Windari, A. and Kristijono, A. (2016) ‘Analisis Ketepatan Koding yang Dihasilkan Koder di RSUD Ungaran’, Jurnal Riset Kesehatan, 5(1), pp. 35–39.
Downloads
Published
Issue
Section
License
The copyright to this article is transferred to Jurnal Manajemen Informasi dan Adminstrasi Kesehatan (JMIAK) if and when the article is accepted for publication under Creative Commons Attribution-ShareAlike 4.0 International License. The undersigned hereby transfers any and all rights in and to the paper including without limitation all copyrights to Jurnal Manajemen Informasi dan Adminstrasi Kesehatan (JMIAK). The undersigned hereby represents and warrants that the paper is original and that he/she is the author of the paper, except for material that is clearly identified as to its original source, with permission notices from the copyright owners where required. The undersigned represents that he/she has the power and authority to make and execute this assignment.
We declare that:
1. This paper has not been published in the same form elsewhere.
2. It will not be submitted anywhere else for publication prior to acceptance/rejection by this Journal.
3. A copyright permission is obtained for materials published elsewhere and which require this permission for reproduction.
Furthermore, I/We hereby transfer the unlimited rights of publication of the above mentioned paper in whole to Jurnal Manajemen Informasi dan Adminstrasi Kesehatan (JMIAK). The copyright transfer covers the right to reproduce and distribute the article, including reprints, translations, photographic reproductions, microform, electronic form (offline, online) or any other reproductions of similar nature. The corresponding author signs for and accepts responsibility for releasing this material on behalf of any and all co-authors. After submission of this agreement signed by the corresponding author, changes of authorship or in the order of the authors listed will not be accepted.
Retained Rights/Terms and Conditions
1. Authors retain all proprietary rights in any process, procedure, or article of manufacture described in the work.
2. Authors may reproduce or authorize others to reproduce the work or derivative works for the author’s personal use or for company use, provided that the source and the Jurnal Manajemen Informasi dan Adminstrasi Kesehatan (JMIAK) copyright notice are indicated, the copies are not used in any way that implies Jurnal Manajemen Informasi dan Adminstrasi Kesehatan (JMIAK)l endorsement of a product or service of any employer, and the copies themselves are not offered for sale.
3. Although authors are permitted to re-use all or portions of the work in other works, this does not include granting third-party requests for reprinting, republishing, or other types of re-use.