Analisis Faktor Penyebab Ketidakakuratan Kode Diagnosis Cedera di Rumah Sakit 'Aisyiyah Siti Fatimah Tulangan

Abstract

Keakuratan pengodean diagnosis dan prosedur medis dilakukan berdasarkan informasi dalam rekam medis. Hasil survei pendahuluan terhadap 59 rekam medis rawat inap, sebanyak 23 akurat dan tidak akurat sebanyak 36. Tujuan penelitian ini menganalisis faktor penyebab ketidakakuratan pengodean diagnosis cedera di RS ‘Aisyiyah Siti Fatimah Tulangan. Metode penelitian yaitu deskriptif, teknik pengumpulan data observasi dan wawancara. Observasi terhadap 100 rekam medis kasus cedera dan wawancara kepada 2 orang koder. Hasil penelitian menunjukkan bahwa kesalahan pada karakter ke-4 akurat sebanyak 96 (96%) dan 4 (4%) tidak akurat. Penyebabnya yaitu diagnosis yang diinput oleh dokter tidak spesifik. Tidak dikode karakter ke-5 akurat 53 (53%) dan tidak akurat 47 (47%), penyebabnya karena tidak tertera cedera tertutup atau terbuka. Berdasarkan tidak ditambahkan kode external cause hasil akurat 0 (0%) dan tidak akurat (100%), penyebabnya karena kurangnya pengetahuan koder dalam menentukan kode diagnosis cedera dan koder bukan merupakan seorang perekam medis. Saran untuk rumah sakit yaitu perbaikan pendokumentasian klinis, pelatihan kodifikasi penyakit dan pentingnya kolaborasi antara koder dengan dokter.The accuracy of diagnostic and medical procedure coding depends on the completeness and clarity of information in medical records. A preliminary survey of 59 inpatient records showed that 23 were coded accurately, while 36 were inaccurate. This study aims to analyse factors contributing to inaccurate injury diagnosis coding at RS ‘Aisyiyah Siti Fatimah Tulangan. A descriptive design was used, with data collected through observation and interviews. Observations were conducted on 100 inpatient medical records of injury cases, and interviews involved two coders. The results showed that the fourth-character coding was accurate in 96 records (96%) and inaccurate in 4 records (4%), mainly due to non-specific diagnoses documented by physicians. For the fifth character, 53 records (53%) were coded accurately and 47 records (47%) inaccurately, primarily because the documentation did not specify whether the injury was open or closed. No records (0%) included accurate external cause codes, while all records (100%) were inaccurate, largely due to limited coder knowledge and the fact that coders were not trained medical record professionals. Hospitals are advised to improve clinical documentation, provide regular disease coding training, and strengthen collaboration between coders and physicians to enhance coding accuracy.