Ketepatan Kode Diagnosa Kasus Fraktur Di RSUD dr. La Palaloi Maros Tahun 2021

Accuracy of Fracture Case Diagnosis Code at dr. La Palaloi Maros Hospital in 2021

Abstract

Hospital must provide high quality services, including improvement on medical recording, a
good quality medical record can be recognize from disease coding. This research is aimed to
determine the accuracy of diagnostic code on fracture case at Regional Public Hospital dr. La
Palaloi Maros in 2021. This research used quantitative method with descriptive approach
type. Total population is 129 medical record emlpoyee by using total sampling technique.
This research is conducted by interview and observation based on checklist table. the result
of the research showed percentage is 61%, while inaccurate diagnostic code is on 39%. The
low percentage of the diagnosa code acuracy is caused by several things, such as incomplete
doctors hand writing of diagnosa fracture cases, hand writing that is not clear and difficult to
understand, so the officers can only code up to the 4th character. Giving diagnostic code to
the fracture case on Regional Public Hospital dr. La Palaloi Maros still not reach coding
procedure using ICD-10. The accuracy of diagnosa code especially on fracture case is stil low
and has not reach 100%. This caused applied SPO coding is not in accordance with the basic
9-step procedure of determining the code based on ICD-10.