Analysis of Correspondence of Neoplasm Disease Codes at Hospital X

Hendwita Citraningrum; Zahrasita Nur Indira; Dion Romodon

doi:10.37160/jremikes.v2i2.294

Authors

Hendwita Citraningrum Universitas Muhammadiyah Purwokerto
Zahrasita Nur Indira Universitas Muhammadiyah Purwokerto
Dion Romodon Universitas Muhammadiyah Purwokerto

DOI:

https://doi.org/10.37160/jremikes.v2i2.294

Keywords:

Neoplasm, Codification, Accuracy of Diagnosis

Abstract

Neoplasm is a disease of cell growth. A neoplasm or tumor is an abnormal mass of tissue that growsexcessively and is not coordinated with normal tissue growth and continues to do so even though thestimulus that triggered the change has stopped. Neoplasmsconsist of new cells that have a differentshape, properties, and Kinetics from normal cells of origin. In dealing with these complex cases, complexprocedures and treatment sequences are also required, so more specific disease codes are needed todescribe the disease condition in more detail/completely. In coding neoplasms, there are 3 aspects thatmust be considered in coding cases or diseases of neoplasms, namely the location of thetumor (indicatesthe location of tumor cells), the nature of the tumor (describes the structure andtype of cells or tissuesunder a microscope), temperament/behavior (malignant, benign and in situ).The purpose of this studywas to determine the accuracy of the main diagnostic codes in patients with neoplasms in medical r ecorddocuments at X Hospital. This study uses quantitative descriptive research methods, which are methodsthat aim to create anobjective picture or description of a situation using numbers, ranging from datacollection, Data Interpretation and appearance and results. The results of this study in X Hospital there isstill no SPO regarding the use of morphological codes for neoplasm cases, the determinationof codesbased on PA results has not been done well and the addition of morphological codes in the SIMRS application is still lacking

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