TINJAUAN KEAKURATAN KODE DIAGNOSIS PPOK BERDASARKAN ICD-10 DOKUMEN REKAM MEDIS PASIEN RAWAT INAP JKN

Abstract

Abstract
Based on preliminary surveys indicate that the inaccuracies primary diagnosis code COPD in four documents inpatient
medical records (80%) of 5 documents inpatient medical records. The purpose of the study was to determine the accuracy
COPD diagnosis codes based on ICD-10 on the document medical record of inpatient JKN in hospitals Tugurejo Semarang
in 2014. Types a descriptive study with retrospective approach. The instrument was a check list and interviews. Methods
of data collection is observation and structured interview. The population is a document medical records of inpatient
JKN in 2014. The samples are 63 medical record documents. The sampling technique Systematic Sampling. Types od
data analysis is descriptive. The results showed that the percentage of accuracy of primary diagnosis code inpatients
accurate JKN amounted to 48 document medical records (76.19%) and primary diagnosis code inaccurate medical
records of 15 documents (23.81%). Factor inaccuracies primary diagnosis code because /due to lack of attention to the
procedures coder coding, terminology understand the language well, and did not immediately communication with the
physician responsible directly, this can affect the accuracy of COPD diagnosis code. Officers are expected to pay more
attention to coding procedures for proper coding in accordance with the WHO (2005) resulting in more accurate code.
Hospitals need to make a list of abbreviations standardized by decree (Decree). Writing diagnosis in the medical record
documents must be complete, clear, and easy to read. Coding clerk should be thorough and meticulous in understanding
the terminology, the selection of diagnosis codes, able to communicate with the doctor in charge.
Keywords : Accuracy code, primary diagnosis, ICD-10
Abstrak
Berdasarkan survey pendahuluan menunjukkan bahwa ketidakakuratan kode diagnosis utama PPOK dari 5 dokumen
rekam medis rawat inap JKN terdapat 4 kode sebesar (80%). Tujuan penelitian adalah untuk mengetahui keakuratan
kode diagnosis PPOK berdasarkan ICD-10 pada dokumen rekam medis pasien rawat inap JKN di RSUD Tugurejo
Semarang tahun 2014. Jenis penelitian deskriptif dengan pendekatan retrospektif. Instrumen pengumpulan data yaitu
check list dan wawancara. Cara pengumpulan data yaitu wawancara terstruktur dan observasi. Populasi penelitian
penelitian adalah dokumen rekam medis pasien rawat inap JKN tahun 2014. Sampel penelitian sebanyak 63 dokumen
rekam medis. Teknik pengambilan dengan Systematic Sampling. Jenis analisis data yaitu deskriptif. Hasil penelitian
menunjukkan bahwa persentase keakuratan kode diagnosis utama PPOK dari 63 dokumen rekam medis pasien rawat
inap JKN terdapat 48 kode (76,19%) kode diagnosis yang akurat dan kode diagnosis yang tidak akurat sebesar 15 kode
(23,81%). Faktor ketidakakuratan kode diagnosis utama PPOK dikarenakan penulisan diagnosis kurang jelas terbaca dan
penggunaan singkatan diagnosis yang tidak baku. Tata cara pengodean diagnosis utama di RSUD Tugurejo Semarang
belum sesuai dengan Prosedur Tetap dan ICD-10. Diharapkan petugas coding lebih memperhatikan tata cara pengodean
yang tepat sesuai dengan WHO, membuat daftar singkatan yang dibakukan melalui surat keputusan, penulisan diagnosis
harus lebih lengkap, jelas, dan mudah dibaca dan perlu mengikuti seminar atau pelatihan pengodean.
Kata kunci : Keakuratan kode, diagnosis PPOK, ICD-10