Faktor-Faktor Yang Menyebabkan Tingkat Akurasi Kode Diagnosis Dokumen Rekam Medis Rawat Jalan Di Puskesmas Pungpungan

Abstract

Background: The accuracy of the diagnostic code in the medical record file is used as the basis for making the report. Patient diagnosis code if it is not accurately coded results in the information generated will have a low level of validation. This certainly will lead to inaccuracy in making reports. Research method: This research method is descriptive with a survey approach. The subjects of this study were outpatient medical record documents at Pungpungan Health Center, Kalitidu Subdistrict, Bojonegoro District, with 99 medical record documents. Result: The results of this study can be seen that less than part of the accurate diagnosis code is 43 (43.43%) and more than a few inaccurate diagnostic codes are 56 (56.57%), most or 66.7% are medical record officers. fill in the code (although not a graduate of medical records) and less than half of the respondents or 33.3% did not have medical record staff but were not tasked with filling in coding. Conclusion: It is known that less than half of the accurate diagnostic codes are 43 (43.43%) and more than a few inaccurate diagnostic codes are 56 (56.57%). It is recommended that officers be able to control the medical record file with ICD 10 books so that there are no obstacles and there must be cooperation between units that will be interrelated to achieve optimal service.