KEAKURATAN KODE DIAGNOSIS HEPATITIS BERDASARKAN ICD-10 PASIEN RAWAT INAP DI RUMAH SAKIT LANCANG KUNING PEKANBARU

Abstract

Abstract Activities and actions as well as the diagnosis in medical record should be coded and subsequently will be indexed in order to facilitate the presentation of information services to support the planning, management, and research in health. In this regard, this research employs quantitative method with a qualitative approach that aimed to determine the accuracy code of Hepatitis diagnosis based on ICD-10 at Hospital Lancang Kuning Pekanbaru. The result of this research shows that the accuracy codes of Hepatitis diagnosis at Hospital Pekanbaru Lancang Kuning can not be said to be good because there are many discovery of an inaccurate diagnosis codes which 29 of the 90 samples were inaccurate with a percentage of 32.2% and 61 files were accurate from 90 samples with a percentage of 77.8%. Standard Operating Procedures (SOP) at Hospital Lancang Kuning Pekanbaru have been executed by officers in accordance with the procedure remains in the hospital and Human Resources (HR) at the hospital Lancang Kuning Pekanbaru is good. it can be seen in terms of educational backgrounds D3 Medical Record the officer but they had never attended training on coding properly.Keywords: Accuracy, ICD-10 codes, and Diagnosis HepatitisAbstrakKegiatan dan tindakan serta diagnosa yang ada didalam rekam medis harus diberi kode dan selanjutnya di indeks agar memudahkan pelayanan pada penyajian informasi untuk menunjang fungsi perencanaan, manajemen, dan riset bidang kesehatan. Metode penelitian yang digunakan adalah gabungan kuantitatif – kualitatif. Tujuan penelitian n untuk mengetahui jumlah keakuratan kode diagnosis Hepatitis berdasarkan ICD-10 di Rumah Sakit Lancang Kuning Pekanbaru. Hasil penelitian diperoleh bahwa keakuratan kode diagnosis Hepatitis belum dapat dikatakan baik karena masih banyak ditemukannya kode diagnosis yang tidak akurat yaitu 29 (32,2%) dan 61(77,8%) berkas yang akurat. Standar Prosedur Operasional (SPO) di rumah Sakit Lancang Kuning Pekanbaru sudah dijalankan oleh petugas sesuai dengan dengan prosedur tetap di rumah sakit dan Sumber Daya Manusia (SDM) di rumah sakit Lancang Kuning Pekanbaru sudah baik hal ini dilihat dari segi pendidikan yang berlatar belakang D3 Rekam Medis akan tetapi petugas belum pernah mengikuti pelatihan tentang pengkodingan yang baik dan benar. Kata Kunci: Keakuratan, Kode ICD-10, dan Diagnosa Hepatitis.