HUBUNGAN KELENGKAPAN INFORMASI MEDIS DAN KEAKURATAN KODE DIAGNOSIS DIABETES MELLITUS

Abstract

Completeness of medical information is very important in supporting the accuracy of the diagnosis code for diabetes mellitus. This study aims to determine the relationship between the completeness of medical information and the accuracy of the diagnosis code for Diabetes mellitus in hospitalization documents. This research is an analytical study with a cross sectional approach. The sample used was 84 documents with simple random sampling technique. Data analysis using Chi-Square. The percentage of completeness of medical information was 54.7% while the incompleteness of medical information was 45.3%. The highest incompleteness is in the 26 discharge summary (31%). Percentage accuracy of diagnosis code Diabetes mellitus is 29.8% while inaccuracy is 70.2%. The most inaccuracies are caused by incorrect in determining the type of Diabetes mellitus as many as 24 documents. Chi square statistical test showed that p = 0.001. The conclusion is that there is a relationship between the completeness of medical information and the accuracy of the diagnosis code for Diabetes mellitus. The author suggests that there should be coordination between medical record officers and other health workers to improve the completeness of medical information, coding officers are more thorough in coding and confirming to physician if the information is incomplete.