HUBUNGAN KELENGKAPAN INFORMASI DENGAN KEAKURATAN KODE DIAGNOSIS DAN TINDAKAN PADA DOKUMEN REKAM MEDIS RAWAT INAP

Abstract

This study aims to analyze the relationship between the accuracy of the information completeness diagnosis code and action on a document medical records of hospitalized patients. This is a type of observational study using cross-sectional design. The population of this research is all the patient's medical record documents on 5 major diseases by 2013 variables in this study are the completeness and accuracy of the diagnosis code information. The research instrument is a check list, ICD-10 book. The analysis in the study using the chi-square test. The results showed no signiicant relationship completeness of the information in the medical record documents with the accuracy of the diagnosis codes on the inpatient medical record documents (p = 0.000).