Tinjauan Kejelasan dan Ketepatan Diagnosa Pada Resume Medis Pasien Rawat Inap dengan Keakuratan Kode Berdasarkan ICD-10 di RSHD Kota Bengkulu

Abstract

Problem : Completeness, clarity in filling out the medical resume form is an absolute must
because all patient health data information is on the medical resume sheet, but based on an
initial survey that researchers conducted on January 23, 2021 at the Harapan and Prayer
Hospital in Bengkulu City , from 14 inpatient medical record documents there are 7 (50%)
medical record documents that are not clearly written with the rules of ICD-10 medical
terminology and 7 (50%) medical record documents are not written correctly with the ICD10 medical terminology rules
Objective: This study aims to determine the description of the clarity and accuracy of the
diagnosis on the Medical Resume Sheet of Inpatients with Code Accuracy based on ICD-10 at
the Bengkulu City Hospital.
Methods : This type of research is a descriptive study using a cross sectional design. The
population in this study was the medical record files of inpatients in April 2021, which
amounted to 120 files with a total sample of sampling, using secondary data that was
processed univariately. This research was carried out from 03 to 10 May 2021 at the
Bengkulu City Hospital Medical Record Unit.
Results : From 120 medical resume sheets for inpatients at the Harapan Hospital and
Prayers in Bengkulu City, the lack of clarity in writing the diagnoses of inpatients in a small
percentage of 40 diagnoses (33.3%) was not clearly written and the inaccuracy of writing
diagnoses for inpatients was a small percentage of 40. diagnoses (33.3%) were written
incorrectly and the determination of the diagnosis code was also a small part, namely 40
codes (33.3) were not accurate. It is expected that doctors and coders always rely on medical
terminology in accordance with ICD-10 in writing patient diagnoses so that a clear, precise
and accurate diagnosis is obtained