KELENGKAPAN PENULISAN DIAGNOSA PADA RESUME MEDIS TERHADAP KETEPATAN PENGKODEAN KLINIS KASUS KEBIDANAN

Abstract

Purposes of this research is to identify the description of accurate medical coding, to identify the description of complete written diagnosis in medical resume and to identify the relation between complete written diagnosis in patient medical resume with obstetrics cases and accurate medical inpatient coding in Atma Jaya Hospital. Type of research which is used is quantitative with cross sectional method used as a design to collect primary data. Data populations are the medical records of patient with obstetric cases in 2014 which about 819 records and sample calculated are 44 records which calculated by using Beda 2 Proporsi formula. Statistics test used in this research are divided into 2 main parts which are univariate analysis by using distribution frequency and multivariate analysis by using chi square test. Results of the research show us that there are inaccurate medical coding which calculated 50% and incomplete written diagnosis in patient medical resume in application of health information management practices in Atma Jaya Hospital. And based from relationship test by applying chi square test founded that incomplete written diagnose in medical resume is a factor that influence inaccurate medical coding with p value = 0,000 and OR = 26,667 (95% CI = 4,727-150,428). Conclusion taken are the practice of medical coding so does the completing medical resume in Atma Jaya still need to be improved and complete medical resume is a factor that influence accurate coding.