Analysis of obstetric code accuracy at hospital X in Padang 2018 based on international classification of diseases the 10th revision

Abstract

Background: Coding is one of the competencies of the  health  information  recorder  which has  a  very  important  role  in  supporting  the  improvement  of  the  quality  of health services in accordance with the republic of Indonesia decree  No. 377/Menkes/SK/III/2007 regarding the professional standards of medical record  and health information, medical recorders must be able to establish codes for diagnosis of disease and medical treatment appropriately. The accuracy of coding is related to financing claims, especially for hospitals that work with health service providers such as health insurance. The purpose of this study is to analyze the accuracy of coding based on international classification of diseases the 10th revision (ICD-10).Methods: Research using descriptive methods with a qualitative approach. The data collection technique used is the observation method that is direct observation of the medical record file. 56 medical records were randomly selected and recoded blindly (as gold standard). Processing statistical data using pivot tables and for coding analysis using ICD-10.Results: Accurate diagnosis code based on the ICD-10 is 14 (25%) and an inaccurate 42 (75%) of 56 diagnoses in the medical record file.  The most inaccurate code found is the fourth character with 22 codes.Conclusions: The inaccuracy of coding at hospital X in Padang was caused among others by the doctor's writing that was not clearly read, errors in the selection in sub categories and in the selection of the character code. In addition, people who work in the medical records section are generally not from a medical record background.