ANALISIS KODE DIAGNOSIS PADA BERKAS REKAM MEDIS DAN SISTEM INFORMASI MANAJEMEN RUMAH SAKIT BERDASARKAN ICD-10 PASIEN RAWAT INAP RSUD PANEMBAHAN SENOPATI BANTUL
Background: In the development of medical records are divided into two types: manual medical record and the computer was then called the Hospital Management Information System (SIM RS). Diagnosis code in the medical records of patients both manual and computer must be documented accurately based on...
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| Main Authors: | , |
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| Format: | Theses and Dissertations NonPeerReviewed |
| Published: |
[Yogyakarta] : Universitas Gadjah Mada
2013
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| Subjects: | |
| Online Access: | https://repository.ugm.ac.id/121320/ http://etd.ugm.ac.id/index.php?mod=penelitian_detail&sub=PenelitianDetail&act=view&typ=html&buku_id=61397 |
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| Institution: | Universitas Gadjah Mada |
| Summary: | Background: In the development of medical records are divided into two
types: manual medical record and the computer was then called the
Hospital Management Information System (SIM RS). Diagnosis code in the
medical records of patients both manual and computer must be
documented accurately based on ICD-10 book. Based on interviews with
the Head of Medical Records, in Hospitals Panembahan Senopati Bantul
found discrepancies of the diagnosis code in the medical record file and
the Hospital Management Information System based (SIM RS), so it will
affect the accuracy of the data for reporting.
Objective: Knowing the implementation of coding, analysis diagnosis
code and the factors that cause discrepancies and inaccuracies inpatient
diagnosis code in the medical record file and the Hospital Management
Information System based on ICD-10.
Research methods: This study used the descriptive research method with
qualitative approach and cross sectional research design.
Results: The implementation of coding in the medical record file and the
Hospital Management Information System is not in accordance with
standard operating procedures. From the results of the data analysis
showed that the diagnosis code compatibility between medical record file
and the Hospital Management Information System is 27.36%. Results of
analysis appropriate diagnosis code accuracy to the third character, fourth,
and fifth on the medical record file as much as 50.44% and 33.92% of
medical records on the Hospital Management Information System based.
Factors leading to discrepancies and inaccuracies inpatient diagnosis code
is the human factor, operating procedures, communications, the method
of determining the diagnosis code, and infrastructure that is the Hospital
Management Information System based (SIM RS). |
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