Analisis Penyebab Ketidaktepatan Kodifikasi Diagnosis Persalinan pada Dokumen Rekam Medis di Rumah Sakit : Literature Review
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Institusion
Politeknik Negeri Jember
Author
Yaasiintha, Wahidha Nurul
Subject
Sistem Informasi Kesehatan
Datestamp
2021-08-31 06:38:43
Abstract :
The role of medical record officers in obstetrical services is to determine the accurate code of disease and accurate treatments based on the classification enforced in Indonesia (ICD-10). According to the results of the literature study on labor codification, many inaccuracies in labor diagnosis still occur. This study was aimed to analyze the causes for the inaccuracy of codification in labor diagnosis based on hospital medical records. This study was a literature review. An article searching from the databases: Google Scholar and Garuda was performed. Twelve articles were found from the search and reviewed based on four inclusion and exclusion criteria determined by the authors. This study found that the average percentage of codification inaccuracy in hospital labor diagnosis was 57.58%. Variables causing inaccuracy of codification of labor diagnosis in this study included education, training, knowledge, thoroughness, workload, ICD-10 crosscheck, all documents crosscheck, non-specific diagnosis, doctor?s writing, use of terms and abbreviations, incompleteness of medical record documents, SOP, facilities, and budgets. Variable of knowledge was most widely correlated with other variables, which was as much as 7 correlation. We recommended increasing knowledge and comprehension of coding officers through training, socialization of standard operational procedure, regulation for coding officers to crosscheck on ICD-10 and all documents, and allocating the budgets for education improvements of coding officers.
The role of medical record officers in obstetrical services is to determine the accurate code of disease and accurate treatments based on the classification enforced in Indonesia (ICD-10). According to the results of the literature study on labor codification, many inaccuracies in labor diagnosis still occur. This study was aimed to analyze the causes for the inaccuracy of codification in labor diagnosis based on hospital medical records. This study was a literature review. An article searching from the databases: Google Scholar and Garuda was performed. Twelve articles were found from the search and reviewed based on four inclusion and exclusion criteria determined by the authors. This study found that the average percentage of codification inaccuracy in hospital labor diagnosis was 57.58%. Variables causing inaccuracy of codification of labor diagnosis in this study included education, training, knowledge, thoroughness, workload, ICD-10 crosscheck, all documents crosscheck, non-specific diagnosis, doctor?s writing, use of terms and abbreviations, incompleteness of medical record documents, SOP, facilities, and budgets. Variable of knowledge was most widely correlated with other variables, which was as much as 7 correlation. We recommended increasing knowledge and comprehension of coding officers through training, socialization of standard operational procedure, regulation for coding officers to crosscheck on ICD-10 and all documents, and allocating the budgets for education improvements of coding officers.
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