Gambaran Pelaksanaan Kodefikasi Diagnosa Pneumonia Berdasarkan Pendidkan, Pengegtahuan dan Masa Kerja Coder (Rsud Dr. M.Yunus Bengkulu)

Abstract

Coders are fully responsible for the accuracy of diagnosis coding, therefore officers
must have good knowledge and high experience so that coding activities can be carried
out well, based on a survey conducted by researchers at RSUD Dr. M. Yunus Bengkulu,
pneumonia ranks 3rd out of the 10 most common illnesses in inpatients at RSUD Dr. M.
Yunus Bengkulu, by checking the entry and exit sheets in the medical record files for
those diagnosed with pneumonia, there were 11 diagnoses whose diagnosis codes were
incorrect, which would hamper the claim process and would affect the quality of medical
record services. The purpose of this research is to determine the knowledge and work
experience of coders in carrying out codefication of pneumonia diagnoses at RSUD Dr.
M. Yunus Bengkulu. The type of research carried out is descriptive research, namely
describing the results of the data obtained. The research objects were 65 medical record files for pneumonia diagnosis and the research subjects were 5 coders. The method used
is observation using a check list sheet and questionnaire sheet. Data collection uses
secondary and primary data. Of the 65 medical record files for pneumonia diagnosis,
54 or (70%) had correct codes and 11 or (30%) had incorrect codes. 5 people or (100%)
coders have worked for ≥3 years. 2 respondents or (40%) had good knowledge, and 3
people or (60%) officers had sufficient knowledge.