ANALISIS KODE DIAGNOSIS PADA BERKAS REKAM MEDIS DAN SISTEM INFORMASI MANAJEMEN RUMAH SAKIT BERDASARKAN ICD-10 PASIEN RAWAT INAP RSUD PANEMBAHAN SENOPATI BANTUL

• Main Authors: , KUNI MAGHFUROH, , Nuryati, A. Md, S. Far, MPH.
• Format: Theses and Dissertations NonPeerReviewed
• Published: [Yogyakarta] : Universitas Gadjah Mada 2013
• Subjects: ETD
• 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
• Institution: Universitas Gadjah Mada

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).