Tugas Akhir DIII
ANALISIS KESESUAIAN PENULISAN DIAGNOSIS KETUBAN PECAH DINI DAN KEAKURATAN KODE ICD-10 PADA REKAM MEDIS RAWAT INAP DAN BERKAS KLAIM INDIVIDUAL PASIEN INA-CBG’S PERIODE TRIWULAN III TAHUN 2017 DI RSUD R.A. KARTINI JEPARA
- Bagikan:
(English Title : Analysis of Appropriateness of Premature Rupture of Membrane Written Diagnosis and Its Accuracy of
ICD-10 Code on The In-Patient Medical Record and Sheet of Individual Claim of INA-CBG’s Period of 3rd Quarter of 2017
In RSUD R.A. Kartini Jepara). Based on the interview to the coder of the inpatient medical record, there are still
differences in the ICD-10 code of Premature rupture of membrane between the medical record and sheet of
individual claim of INA-CBG’s. The purpose of this research was to assess the appropriateness of Premature
rupture of membrane written diagnosis and its accuracy of ICD-10 code and also the factors that affecting
inaccuracies of codes and written diagnosis of Premature rupture of membrane on in-patient medical records and
sheet of claim period of 3rd quarter of 2017 in RSUD R.A. Kartini Jepara. The research method used was
descriptive with cross sectional approachment. The data collection method used the observation and interview to
the coder. The results showed that from the research’s population of 21 medical records it is found that all the
diagnoses written by DPJP were not appropriate according to ICD-10. While the diagnosis written on the sheet of
claim is appropriate with ICD-10. The number of inaccuracies of the diagnostic codes on the medical records
sheet is 100% while the code listed in the sheet of claim is 100% accurate. The implementation of coding
procedure has conforms to simple coding guidelines using ICD-10, but due to incomplete diagnosis writing, the
results of code becomes inaccurate. While the sheet of claim had been checked by internal verifier so that the data
results are more accurate. Factors that causing inaccuracies of Premature rupture of membrane diagnosis codes are
the DPJP has not been socialized on how to write diagnosis appropriately on medical records in the ICD-10 in
order to makes accurate code, the coder has not received any specific training on coding based on ICD-10, and
there is no SOP about the correct procedure for filling in the medical records.
Informasi Detail
| Pernyataan Tanggungjawab |
dr. Lily Kresnowati, M.Kes
|
|---|---|
| Pengarang |
Johninda Aulia Akbar - Pengarang Utama
|
| NIM |
P1337437115004
|
| Bahasa |
Indonesia
|
| Deskripsi Fisik |
xii + 88 hlm.; ilus.; tab.; 29 cm
|
| Dilihat sebanyak |
2974
|
| Penerbit | Prodi DIII Rekam Medis dan Informasi Kesehatan Semarang POLTEKKES KEMENKES SEMARANG : POLTEKKES KEMENKES SEMARANG., 2018 |
|---|---|
| Edisi | |
| Subjek | |
| Klasifikasi |
081
|