PELAKSANAAN PENENTUAN KODE DIAGNOSIS UTAMA DI RSU PKU MUHAMMADIYAH BANTUL

LATIFAH NUR P, Nuryati, S.Far., MPH.

2017 | Tugas Akhir | D3 REKAM MEDIS SV

Latar Belakang: Kegiatan pengodean sangatlah penting, karena pengodean berfungsi untuk mengindeks pencatatan penyakit dan tindakan, pelaporan morbiditas dan mortalitas dalam skala nasional maupun internasional, penelitian epidemiologi dan klinis, serta analisis pembiayaan pada sarana pelayanan kesehatan. Tujuan: Mengetahui pelaksanaan penentuan kode diagnosis utama serta persentase ketepatan penentuan pengodean diagnosis utama berdasarkan per spesialisasi Metode: Menggunakan jenis penelitian deskriptif dengan pendekatan kualitatif serta rancangan case study. Hasil: Pelaksanaan penentuan kode diagnosis utama di RSU PKU Muhammadiyah Bantul sudah sesuai dengan SOP yang ada di rumah sakit. Persentase ketepatan kode diagnosis di RSU PKU Muhammadiyah Bantul yaitu spesialisasi bedah 57,89%, spesialisasi obsgyn 46,15%, spesialisasi urologi 40%, spesialisasi anak 66,67%, spesialisasi syaraf 20%, dan spesialisasi penyakit dalam 74,19%. Kesimpulan: Masih terdapat beberapa kode diagnosis utama yang tidak tepat, maka perlu dilakukan audit koding guna meningkatkan ketepatan kode diagnosis utama.

Background: Coding activity is important, because the coding function for indexing the recording of diseases and medical measures, reporting morbidity and mortality in a national and international scale, epidemiological and clinical research, as well as the analysis of financing on health care facilities. Objective: To determine the accuracy of the percentage main code of diagnosis is based on per specialties Methods : Using a descriptive research with a qualitative approach and a draft case study. Results: Implementation of the determination of principal diagnosis code in RSU PKU Muhammadiyah Bantul are in accordance with the SOP's in the hospital. The percentage of accuracy main of code diagnose in RSU PKU Muhammadiyah Bantul is surgical specialties 57.89%, obsgyn specialties 46,15%, urology specialties 40%, children specialties 66,67%, specialties nerve 20%, and specialties internal disease 74,19%. Conclusion: There are still some code of main diagnose is not right it is necessary to audit the coding in order to improve the precision of the code of main diagnose.

Kata Kunci : pelaksanaan, penentuan ,ketepatan, kode diagnosis utama