Kelengkapan Informasi Medis sebagai Determinana Keakuratan Pengodean Fracture Femur
DOI:
https://doi.org/10.32585/jmiak.v8i2.7785Abstract
Kelengkapan informasi dalam dokumen rekam medis merupakan faktor penting dalam menjamin keakuratan pengodean diagnosis dan external cause, khususnya pada kasus ortopedi yang membutuhkan data klinis rinci serta dokumentasi mekanisme cedera yang jelas. Penelitian ini bertujuan untuk menganalisis hubungan antara kelengkapan informasi medis dan keakuratan pengodean kasus fraktur leher femur dan external cause. Penelitian ini menggunakan desain observasional analitik dengan pendekatan cross sectional terhadap 102 dokumen rekam medis pasien rawat inap yang dipilih melalui teknik simple random sampling. Pengumpulan data dilakukan menggunakan daftar tilik observasi dan pedoman pengodean ICD-10, kemudian dianalisis secara univariat dan bivariat menggunakan uji Chi-square. Hasil penelitian menunjukkan bahwa 76,25% dokumen rekam medis tergolong lengkap, sedangkan 85,37% pengodean diagnosis dan external cause dinilai akurat. Analisis statistik menunjukkan terdapat hubungan yang signifikan antara kelengkapan informasi medis dan keakuratan pengodean (p = 0,001). Temuan ini menegaskan bahwa ketidaklengkapan informasi medis meningkatkan risiko kesalahan pengodean, khususnya pada kode external cause yang memerlukan dokumentasi rinci mengenai kondisi terjadinya cedera. Oleh karena itu, peningkatan kepatuhan dalam pengisian rekam medis serta penerapan daftar tilik terstruktur sangat direkomendasikan untuk meningkatkan mutu data rumah sakit.
Downloads
Downloads
Published
Issue
Section
License
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International 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.
