Faktor-faktor Ketepatan Kode Diagnosa Penyakit Dyspepsia di Rumah Sakit Umum Harapan dan Doa Kota Bengkulu

Abstract

Pendahuluan: Kegiatan pengokodingan pada diagnosis penyakit sangatlah penting dilakukan di instalasi rumah sakit. Di RSUD Harapan dan Do’a Kota Bengkulu dimana ketidaktepatan kode diagnosis dalam berkas rekam medis tertera pada diagnosis GEA dikode menjadi Dyspepsia, karena GEA tidak memiliki pemeriksaan penunjang, hal tersebut tidak memenuhi syarat untuk dilakukannya sistem pembiayaan, maka menyebabkan diagnosis GEA dikode sebagai kode Dyspepsia. Penelitian ini untuk mengetahui ketepatan terhadap kode diagnosa penyakit Dyspepsia di Rumah Sakit Umum Daerah Harapan dan Do’a Kota Bengkulu. Metode: Penelitian ini menggunakan metode penelitian deskriptif dengan pendekatan retrospektif. Populasi pada penelitian ini berkas rekam medis pasien rawat inap tahun 2019 dengan diagnosa penyakit Dyspepsia berjumlah 490. Menggunakan teknik simple random sampling dengan jumlah sampel  83 berkas rekam medis. Hasil dan Pembahasan: Dari 83 BRM yang tidak tepat 42 (50,50%) dikarenakan masih terdapat beberapa berkas rekam medis tertera diagnosis GEA yang dikode K30 seharusnya kode yang tepat untuk penyakit GEA yaitu A90. Kelengkapan pengisian berkas rekam medis dari 83 berkas rekam medis kasus Dyspepsia berkas yang tidak lengkap sebesar 44 (53,01%) faktor yang menyebabkan masih terdapat banyaknya berkas yang tidak lengkap dikarenakan terdapat sebagian item item pengisian pada berkas rekam medis masih ada yang tidak diisi oleh dokter/petugas medis lainnya dan pada bagian assembling.

ABSTRACT

Introduction: Coding activities in disease diagnosis are very important in hospital installations. At Harapan and Do'a Hospital in Bengkulu City where the inaccuracy of the diagnosis code in the medical record file was listed on the diagnosis of GEA coded as Dyspepsia, because GEA did not have supporting examinations, this did not meet the requirements for carrying out the financing system, causing the GEA diagnosis to be coded as Dyspepsia code. This study was to determine the accuracy of the Dyspepsia diagnosis code at the Harapan and Do'a Regional General Hospital, Bengkulu City  Method: This study used a descriptive research method with a retrospective approach. The population in this study were 490 inpatient medical record files with a diagnosis of Dyspepsia. Using a simple random sampling technique with a sample size of 83 medical record files. Results and Discussion: The 83 BRMs that were incorrect, 42 (50.50%) were due to the fact that there were still several medical record files with a GEA diagnosis coded as K30, which should be the correct code for GEA disease, namely A90. The completeness of filling out the medical record files from the 83 medical record files of Dyspepsia cases were incomplete by 44 (53.01%) the factor that caused there were still many incomplete files because there were some filling items in the medical record files that were not filled out by doctors/other medical personnel and in the assembling department. Conclusion: Based on the results of observations of 50 BRM in BPJS inpatients at the Bengkulu City Hospital, there were 34 (68%) BRM who did not have a diagnosis code and 16 (32%) BRM who had a diagnosis code. Based on observations of 35 BRMs, there were 20 (57.14) BRMs who did not have a diagnosis code and 15 (42.85) BRMs who had a diagnosis code