ANALISIS PENENTUAN SEBAB DASAR KEMATIAN PASIEN BPJS DI RUMAH SAKIT PANTI NUGROHO

ERVI RIFMALASARI, Rita Dian Pratiwi, S.Kep.,M.P.H.

2020 | Tugas Akhir | D3 REKAM MEDIS DAN INFORMASI KESEHATAN

ABSTRAK Latar Belakang: Data kematian pasien digunakan sebagai dasar pembuatan laporan kematian. Ketepatan penentuan menunjang dalam perhitungan angka kematian. Dalam penentuan sebab dasar kematian harus sesuai rule dan crosscheck MMDS untuk menunjang ketepatan. Di RS Panti Nugroho penentuan belum dilakukan crosschesk MMDS serta terdapat kode gagal jantung sebagai diagnosis sebab dasar kematian. Menurut WHO gagal jantung tidak dapat dijadikan sebagai sebab dasar kematian. Hal ini berarti kode sebab dasar kematian belum sesuai dengan aturan ICD-10. Tujuan: Mendeskripsikan pelaksanaan penentuan sebab dasar kematian, Menganalisis faktor ketidaktepatan, Menganalisis dampak yang ditimbulkan terhadap klaim yang diajukan, Mengidentifikasi upaya untuk memperbaiki alur penentuan sebab dasar kematian. Metode penelitian: Jenis penelitian adalah deskriptif dengan pendekatan kualitatif dengan rancangan penelitian studi kasus. Subjek penelitian adalah dua coder. Objek penelitian adalah berkas rekam medis, SOP, dan laporan kematian. Hasil: Penentuan sebab dasar kematian dilakukan oleh dokter kemudian dikode oleh coder tanpa melakukan reseleksi sesuai dalam ICD-10. Faktor yang mempengaruhi ketidaktepatan adalah man, materials, machine, dan method. Upaya yang dilakukan untuk memperbaiki alur penentuan sebab dasar kematian dengan berkoordinasi dengan dokter, melakukan bedah rekam medis, dan melakukan telaah rekam medis kualitatif dengan tim. Kesimpulan: Pelaksanaan penentuan belum sesuai aturan ICD. Faktor ketidaktepatan dipengaruhi unsur man, materials, machine, dan method Upaya yang telah dilakukan untuk memperbaiki alur penentuan yaitu koordinasi dengan dokter, melakukan bedah rekam medis dan melakukan telaah kualitatif. Kata kunci: penentuan, sebab dasar kematian, pasien BPJS

ABSTRACT Background: Patient mortality data is used as the basis for the creation of death reports. The accuracy of the determination supports in the calculation of the death rate. In determining the underlying cause of death must comply with MMDS rules and crosschecks to support accuracy. In Panti Nugroho Hospital the determination has not been done crosscheck MMDS and there is a code of heart failure as a diagnosis of the underlying cause of death. According to the WHO heart failure cannot be used as a underlying cause of death. This means the underlying cause of death code is not in accordance with ICD-10 rules. Objective: This research is aimed at describing the implementation of determining the underlying cause of death of BPJS patients at Panti Nugroho Hospital., analyzing the factors of the inaccuracy in determining the underlying cause of death, and identifying the efforts made to improve the groove determination of underlying cause of death at the respective hospital.. Research methods: This is a descriptive research with a qualitative approach and the research design is a case study. The subjects in this study were two coding officers. The objects in this study are medical record files of patients who died, SOP, and death reports. Results: The determination of death causes at the Panti Nugroho Hospital is made by a doctor and is then coded by a coding officer without the reselection in accordance with ICD-10. The factors affecting the inaccuracy of underlying cause of death are man, materials, machine, and method. The efforts made to improve the groove determination of underlying cause of death is by coordinating with doctors, reviewing medical record, and studying the qualitative medical record in team. Conclusion: The implementation of determining the underlying cause of death at the Panti Nugroho Hospital is not accordance on the ICD. The factors of the inaccurate determination are influenced by 4 elements, namely man, materials, machine, and method. The efforts made to improve the groove determination of underlying cause of death is by coordinating with doctors, reviewing medical record, and studying the qualitative. Keywords: determination, underlying cause of death, BPJS patients

Kata Kunci : penentuan, sebab dasar kematian, pasien BPJS