Analisis Faktor-Faktor Penyebab Ketidaktepatan Kode Diagnosis dan Tindakan Berkas Rekam Medis di Rumah Sakit: Literatur Review
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Institusion
Politeknik Negeri Jember
Author
Ayu, Anggita Eka
Subject
Sistem Informasi Kesehatan
Datestamp
2022-04-07 01:24:44
Abstract :
Hospitals need to provide quality health services. This will improve the quality and efficiency of health services in hospitals with the supporst of various related factors, one of them is medical records implementation. The implementation of the Medical Record in question is the accuracy of giving a diagnosis code and medical treatment codes. In fact, there are still many high rates of inaccuracy in diagnosis and treatment codes. The purpose of this research is to know the factors which effect the inaccuracy of the diagnostic code and medical treatment codes. The method of this research is literature review. The results of the review of 13 articles found the inaccuracy of the diagnostic code and medical treatment caused by man, money, mechine, method, and material. Overall, the contributing factors are the lack of officer knowledge level, lack of officer discipline, limited funding that affects the claim process, monitoring and evaluation is still not effective, the absence of Standard Operating Procedures (SOP) related to the inaccuracy of medical record coding, SOPs that are available but have not gone well, there is no giving sanctions and gifts from the leadership. Hospitals need to review SOPs related to coding activities, provide coding training for coders and rearrange coding procedures in accordance with ICD 10 and ICD-9CM.
Hospitals need to provide quality health services. This will improve the quality and efficiency of health services in hospitals with the supporst of various related factors, one of them is medical records implementation. The implementation of the Medical Record in question is the accuracy of giving a diagnosis code and medical treatment codes. In fact, there are still many high rates of inaccuracy in diagnosis and treatment codes. The purpose of this research is to know the factors which effect the inaccuracy of the diagnostic code and medical treatment codes. The method of this research is literature review. The results of the review of 13 articles found the inaccuracy of the diagnostic code and medical treatment caused by man, money, mechine, method, and material. Overall, the contributing factors are the lack of officer knowledge level, lack of officer discipline, limited funding that affects the claim process, monitoring and evaluation is still not effective, the absence of Standard Operating Procedures (SOP) related to the inaccuracy of medical record coding, SOPs that are available but have not gone well, there is no giving sanctions and gifts from the leadership. Hospitals need to review SOPs related to coding activities, provide coding training for coders and rearrange coding procedures in accordance with ICD 10 and ICD-9CM.
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