ANALISIS KETEPATAN KODE DIAGNOSIS DAN KESESUAIAN DIAGNOSIS PASIEN RAWAT INAP PADA SISTEM INFORMASI MANAJEMEN RUMAH SAKIT DENGAN BERKAS REKAM MEDIS DI RUMAH SAKIT PERTAMINA CIREBON

• Main Authors: , TRIA DISRIANI, , Nur Rokhman, S.Si., M.Kom.
• 格式: Theses and Dissertations NonPeerReviewed
• 出版: [Yogyakarta] : Universitas Gadjah Mada 2014
• 主題: ETD
• 在線閱讀: https://repository.ugm.ac.id/131285/; http://etd.ugm.ac.id/index.php?mod=penelitian_detail&sub=PenelitianDetail&act=view&typ=html&buku_id=71737

The Background of Problem : The encoding of patient diagnosis in Pertamina Hospital - Cirebon has been using a computerized system. It means that for entry data of disease diagnosis and hospitalized patient codes the medical officer using a computer. However, in this case the computerized system has flaws because almost all of the diagnosis and the code has been entered are not precise. The Aim of Research : The aim of research to determine the level of accuracy of the ICD-10 diagnosis of patients using a computerized system at Pertamina Hospital in Cirebon. The Methodology of Research : The research methodology used is descriptive with qualitative approach and cross-sectional design. In this research, Samples were obtained by using the simple random sampling technique. it means the sample drawn from members of the population by using the a random method, regardless of the levels of the members of the population. And the method of data collection by using the documentation study, observation and interviews. The Results of Research :The implementation of hospitalized patients encoding at Pertamina Hospital - Cirebon performed by nurses, no one coder for coding the patient's disease. The right diagnosis code of hospiatlized patients about 35%, or as much as 70 files has right medical record. About 64% diagnosis code of hospitalized patients is not appropriate, or as much as 129 files has not appropriate medical record. And about 1% diagnosis code of hospitalized patients are not filled, or as much as 3 files medical record. Diagnosis hospitalized patients are appropriate about 43% (138 right diagnosis), Diagnosis hospitalized patients are not appropriate about 57% (182 not appropriate diagnosis). The high rates of innaccuracy diagnosis codes and unconfirmity diagnosis hospitalized patients caused by man resource factors. Doctor�s prescription writing is difficult to read, lack of knowledge about ICD-10 in nurses, and there is no one a special officer for coding (coder) are the cause of the high rate of inaccuracy hospitalized patients diagnosis codes.