FAKTOR-FAKTOR YANG MEMPENGARUHI KETIDAKAKURATAN KODE DIAGNOSA TB (TUBERCULOSIS) PADA BERKAS REKAM MEDIS PASIEN RAWAT INAP DI RSUD PRAYA TAHUN 2022
DOI:
https://doi.org/10.32585/jmiak.v5i2.2915Abstract
Kecepatan dan keakuratan kode dari suatu diagnosis sangat tergantung kepada pelaksana yang menangani rekam medis tersebut seperti tenaga medis maupun tenaga non medis. Berdasarkan survey awal terdapat 74% yang behasil dikode akurat dan yang tidak akurat sebanyak 26%. Tujuan penelitian ini untuk mengetahui faktor-faktor yang mempengaruhi ketidakakuratan kode diagnosis TB (Tuberculosis) di RSUD Praya Tahun 2022. Jenis penelitian menggunakan penelitian kuantitatif deskriptif yang didukung dengan kualitatif. Teknik pengumpulan data dengan observasi, wawancara dan check-list. Subjek penelitian yaitu dokter, koder, dan petugas laboratorium. Objek penelitian yaitu BRM pasien RI diagnosis TB dengan teknik pengambilan sampel purposive sampling dan didapatkan 36 berkas. Lokasi & Waktu penelitian di RSUD Praya tanggal 20 Juli s/d 20 Agustus 2022. Analisis data menggunakan kuantitatif dan kualitatif. Hasil penelitian menunjukkan persentase akurasi kode diagnosis TB di RSUD Praya adalah 24 (67%) akurat dan 12 (33%) tidak akurat, dari 12 diagnosis yang tidak akurat terdapat 5 (14%) diagnosis tidak spesifik dan 2 (6%) ketidaklengkapan hasil laboratorium. Faktor yang mempengaruhinya adalah koder kurang teliti, penulisan diagnosis tidak spesifik, dan ketidaklengkapan hasil laboratorium. Sebaiknya petugas lebih teliti dalam melakukan pengkodean, jika ditemukan kode diagnosis yang kurang jelas/tidak spesifik maka melakukan konfirmasi, serta seluruh staff memperhatikan kelengkapan pengisian berkas rekam medis.
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