Overview of the Accuracy and Completeness of Diagnosis and Procedure Coding for Diabetes Mellitus Cases at Hospital X
DOI:
https://doi.org/10.37160/mijournal.v22i1.1325Keywords:
Medical Records, Diabetes Mellitus, Diagnostic Accuracy, Completeness.Abstract
Background: Complete and accurate medical records are a crucial component in supporting the accuracy of diagnosis coding, particularly for chronic diseases such as Diabetes Mellitus (DM). Incomplete data in medical records can lead to errors in diagnosis coding, which subsequently affects patient management and the quality of healthcare services. Objectives: This study aims to analyze the relationship between the completeness of medical record documentation and the accuracy of DM diagnosis coding at Hospital X. Methods: This study used a quantitative analytical observational design with a cross-sectional approach through observation and analysis of medical record documents. Statistical analysis was performed using the Chi-square test to determine the relationship between documentation completeness and coding accuracy. Results: From 66 medical record samples, it was found that 40 medical records (60.6%) had incomplete diagnosis documentation, while only 26 medical records (39.4%) were completely filled out. Furthermore, the accuracy of diagnosis code assignment also showed suboptimal results, with 42 medical records (63.6%) displaying incorrect code assignment, and only 24 medical records (36.4%) being coded accurately. The findings indicate that complete medical records tend to result in more accurate diagnosis coding. Conclusion: In conclusion, the completeness of medical records has a positive effect on the accuracy of DM diagnosis codes. Therefore, strengthening documentation practices, implementing standard operating procedures (SOPs), and providing regular coding training for medical record personnel are necessary to improve diagnosis coding accuracy and hospital data quality.
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Agung, D.S. dan Siti, J., (2023) ‘Analisis Ketepatan Kode Diagnosis Diabetes Mellitus Berdasarkan Icd-10 Pasien Rawat Jalan Di Puskesmas Pleret Bantul’, Prosiding Seminar Informasi Kesehatan Nasional (SIKesNas) 2023, (December 2022), pp. 102–106. Available at: https://ojs.udb.ac.id/index.php/sikenas/article/view/2838/2064.
Amran, R., Apriyani, A. & Dewi, N.P., (2021). Peran Penting Kelengkapan Rekam Medik di Rumah Sakit.
Damayanti, V. . dan Suhenda, A. (2023) “Analisis Kelengkapan Pengisian Rekam Medis Pasien Diabetes Melitus Di Puskesmas Cijeungjing Kabupaten Ciamis Tahun 2020”, Media Informasi, 19(1), pp. 80–88. doi: 10.37160/bmi.v19i1.37
Dewi, C., Akbar, P. dan Alvionita, C. (2024). The relationship of the completeness of medical information with the accuracy of diagnosis codes for diabetes mellitus at the X Blitar Hospital. Jurnal Informasi Kesehatan Indonesia (JIKI), 10(2), 78-86. doi:10.31290/jiki.v10i2.5040.
Loren, E.R., Wijayanti, R.A. dan Nikmatun, N. (2020) ‘Analisis Faktor Penyebab Ketidaktepatan Kode Diagnosis Penyakit Diabetes Mellitus di Rumah Sakit Umum Haji Surabaya’, J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan, 1(3), pp. 129–140. Available at: https://doi.org/10.25047/j-remi.v1i3.1974.
Mazaya Fitriana, S., Widowati, V. & Susilowati, I.W., 2023. Analisis ketepatan kode diagnosis penyakit berdasarkan ICD-10 di . Jurnal Kesehatan Indonesia
Mellyana, Nurhasanah dan Ardan, M. (2023). Analisis Penyebab Ketidaklengkapan Rekam Medis Rawat Jalan di UPTD Puskesmas Resak Kabupaten Kutai Barat Tahun 2023. Jurnal Pengabdian kepada Masyarakat Nusantara (JPkMN).
Nanjo, Y. F., Kartiko, B. H., Luh, N., Ari, G., Yudha, N., Kesehatan, I., Pura, U. D., dan Cm, I.- I.-. (2022). Analisis Pengaruh Ketidaktepatan Kode Diagnosis Dan Kode Tindakan Pasien Rawat Inap Peserta Jaminan Kesehatan Nasional Terhadap Tarif Di Rumah Sakit Umum Daerah Wangaya Kota Denpasar. Journal Health Care Media ISSN : 2089-4228, 6(2), 86–94. http://stikeswch-malang.e-journal.id
Kementerian Kesehatan Republik Indonesia (2022). Peraturan Menteri Kesehatan RI No 24 Tahun 2022 tentang Rekam Medis. Peraturan Menteri Kesehatan No 24, 19 Juli 2022.
Kementerian Kesehatan Republik Indonesia (2020). Keputusan Menteri Kesehatan Republik Indonesia No. HK.01.O7/MENKES/312/2020 tentang Standar Profesi Perekam Medis dan Informasi Kesehatan. Keputusan Menteri Kesehatan No. HK.01.O7/MENKES/312, 10 Agustus 2020
Siwayana, P. A., Purwanti, I. S., & Murcittowati, P. A. S. (2020). Tinjauan Literatur: Faktor-faktor penyebab ketidaklengkapan pengisian rekam medis rawat inap rumah sakit. Jurnal Rekam Medis dan Informasi Kesehatan, 3(2), 46–51. https://doi.org/10.31983/jrmik.v3i2.5927
Sukawan, A. (2020). Implementasi Ketepatan Pengkodean Diagnosis Dan Tindakan Medis Di Unit Rawat Inap Rumah Sakit Umum Kota Makassar Sulawesi Selatan. Jurnal Mitrasehat, 9(1). https://doi.org/10.51171/jms.v9i1.35
Suryandari, E. S. D. H., Rahmadhani, R. N., Pitoyo, A. Z., Sangkot, H. S., dan Wijaya, A. (2023). Hubungan Ketepatan Penulisan Diagnosis Penyakit dengan Keakuratan Kode Diagnosis pada Pasien Rawat Inap di Rumah Sakit.
World Health Organization. (2010). International Stastical Clasification Of Disease Related Health Problem. Vol 1,2,3
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