Ketepatan Kode Penyakit Bronkopneumonia dan Kelengkapan Rekam Medis di Rumah Sakit St. Elisabeth Medan Tahun 2022

Abstract

The accuracy of the bronchopneumonia case code is that all diagnoses are filled out correctly based on the completeness of filling out the medical record with code J18.0 as the code in the ICD 10 book. Completeness of filling out the medical record is a medical record that has been completely filled out by a doctor within 1x24 hours, after completing outpatient services. or after an inpatient is decided to go home which includes a patient identity sheet, medical resume, and supporting diagnostic examination sheet. Researchers take specific cases of bronchopneumonia because during the practice service at St. Hospital. Elisabeth in 2021 there are 10 files of bronchopneumonia patients, there are 3 medical record files with incorrect codes. Based on this background, researchers are interested in conducting research with the title of code accuracy and completeness of medical records of bronchopneumonia patients at St. Hospital. Elisabeth Medan 2022. The type of research design used was a descriptive design with a sampling method of 82 respondents in total at St.Elisabeth Hospital Medan 2022. The instrument used in data collection was a checklist study documentation. The results of the study obtain that the correct category code was 70 medical records (85.3%) and the incorrect category are 12 medical records (14.7%) medical record files. While the completeness of the patient identity sheet is 85.3%, the medical resume sheet is 85.3%, and the laboratory support results sheet is 81.7% complete.