ANALISIS KETEPATAN PENGGUNAAN TERMINOLOGI MEDIS, SINGKATAN, SIMBOL SESUAI KRITERIA 8.4.1. DI PUSKESMAS TERAKREDITASI DAN BELUM TERAKREDITASI WILAYAH KABUPATEN PONOROGO

ZAKIYA WANUDYA ULYA, Nuryati, S.Far., M.P.H.

2018 | Tugas Akhir | D3 REKAM MEDIS SV

ABSTRAK Latar belakang : Terminologi medis merupakan istilah medis yang disesuaikan dengan sistem klasifikasi. Sistem klasifikasi yang diakui secara internasional oleh WHO ada banyak, salah satunya adalah ICD-10. Penggunaan terminologi medis yang tepat pada diagnosis akan memudahkan petugas coding dalam memberikan kode diagnosis. Selain itu, di pedoman akreditasi kriteria 8.4.1. menyebutkan tentang standarisasi penggunaan terminologi medis, singkatan dan simbol di puskesmas. Berdasarkan survey awal dan studi pendahuluan serta pengambilan sampel di Puskesmas Ponorogo Utara yang sedang melakukan proses penilaian akreditasi, ditemukan 7 dari 10 diagnosis pada berkas rekam medis belum menggunakan terminlogi medis yang tepat. Tujuan : Mengetahui persentase ketepatan penggunaan terminologi medis, singkatan dan simbol sesuai kriteri 8.4.1. di Puskesmas terakreditasi (Puskesmas Babadan) dan belum terakreditasi (Puskesmas Ronowijayan) wilayah Kabupaten Ponorogo Metode : Jenis penelitian ini adalah deskriptif kuantitatif. Rancangan penelitiannya cross-sectional. Sampel dalam penelitian ini 84 berkas rekam medis di Puskesmas Babadan dan 84 berkas rekam medis di Puskesmas Ronowijayan. Teknik pengambilan data dengan studi dokumentasi dan analisis data menggunakan analisis univariate. Hasil : Di Puskesmas Ronowijayan persentase ketepatan penggunaan terminologi medis sebesar 25 (29,76%), sebesar 7 (8,34%) singkatan tepat, dan 0 % penggunaan simbol. Sedangkan di Puskesmas Babadan persentase ketepatan penggunaan terminologi medis sebesar 51 (60,71%), sebesar 16 (19,05%) singkatan tepat dan 0% penggunaan simbol. Kesimpulan : Persentase ketepatan penggunaan terminologi medis, singkatan dan simbol sesuai kriteria 8.4.1. lebih tinggi pada Puskesmas Babadan daripada Puskesmas Ronowijayan dengan nilai PR (Prevalence Ratio) = 2,09. Kata kunci : Terminologi medis, ICD-10, Ketepatan, Persentase

ABSTRACT Background : Medical terminology is a medical term that is adapted to classification system. There are many internationally recognized classification system by WHO, one of them is ICD-10. The use of appropriate medical terminology on diagnosis will simplify the coding officer in providing diagnostic codes. In addition, in the criteria accreditation guidelines 8.4.1. mentions the standardization of the use of medical terminology, abbreviations and symbols in Primary health centers. Based on preliminary surveys and preliminary studies with sampling at the North Ponorogo Primary health centers which was conducted the accreditation assessment process, it was found that 7 out of 10 diagnoses in the medical record file have not used appropriate medical terminology. Objectives : To know the percentage of accuracy the use of medical terminology, abbreviations and symbols according to criterion 8.4.1. in accredited primary health center (Puskesmas Babadan) and not accredited (Puskesmas Ronowijayan) in Ponorogo Regency Methods : This type of research was descriptive quantitative. The research design was cross-sectional. The sample in this research was 84 medical record file at primary health center Babadan and 84 medical record file at primary health center Ronowijayan. Data retrieval technique with documentation study and data analysis was used analysis univariate. Results : In Primary health center Ronowijayan the percentage of accuracy medical terminology use is 25 (29.76%), 7 (8.34%) for acronym and 0% usage of symbol. While in Primary health center Babadan the percentage of accuracy medical terminology use is 51 (60,71%), 16 (19,05%) for acronym and 0% usage of symbol. Conclusion : Percentage of accuracy the use of medical terminology, abbreviations and symbols according to criterion 8.4.1. was higher at the Babadan Primary health center than the Ronowijayan Primary health center with PR (Prevalence Ratio) = 2.09. Keywords : Medical terminology, ICD-10, Accuracy, Percentage

Kata Kunci : Terminologi medis, ICD-10, Ketepatan, Persentase