Audit keakuratan penentuan kode underlying cause of death pada formulir keterangan penyebab kematian di RS Bethesda

Janna Windi Farahdila, Nuryati, S.Far., M.P.H.

2023 | Tugas Akhir | D4 MANAJEMEN INFORMASI KESEHATAN

Latar Belakang: Penentuan diagnosis dan kode penyebab dasar kematian masih menjadi polemik. Akurasi data Underlying Cause of Death (UCoD) dari Formulir Keterangan Penyebab Kematian (FKPK) sering dipertanyakan ketika audit. Penentuan UCoD harus memperhatikan ICD-10 dan Tabel MMDS (Mortality Medical Data System). Dengan demikian, dibutuhkan audit keakuratan penentuan kode UCoD pada FKPK sebagai bentuk problem solving.

Tujuan: Melakukan audit terhadap keakuratan penentuan kode UCoD pada Formulir Keterangan Penyebab Kematian di RS Bethesda.

Metode: Penelitian ini menggunakan mixed methods. Pengumpulan data melalui studi dokumentasi, wawancara, dan focus group discussion. Pemilihan sampel dengan cara purposive sampling sejumlah 262 berkas untuk kuantitatif dan satu orang petugas rekam medis, satu orang kepala Bidang Rekam Medis dan Informasi Kesehatan, satu orang dokter, serta Standar Prosedur Operasional pengodean diagnosis penyebab dasar kematian untuk kualitatif.

Hasil: Penentuan UCoD yang tepat sejumlah 197 berkas dan yang tidak tepat sejumlah 65 berkas dengan rincian UCoD yang tidak tepat karena salah menentukan UCoD sejumlah 28 berkas, tidak akurat dalam menentukan kode 3 karakter sejumlah 20 berkas, tidak akurat dalam menentukan subkategori 4 karakter sejumlah 13 berkas, tidak akurat dalam menentukan subkategori 5 karakter sejumlah 1 berkas, dan UCoD tidak dikode sejumlah 3 berkas; tidak memiliki Standar Prosedur Operasional penentuan UCoD; ada faktor yang mendasari ketidaktepatan dalam penentuan kode UCoD.

Kesimpulan: Penentuan UCoD belum 100% tepat, belum memiliki Standar Prosedur Operasional mortalitas, serta terdapat unsur-unsur penyebab ketidaktepatan UCoD. Sebaiknya pengodean UCoD memperhatikan kaidah koding mortalitas, mengimplementasikan Standar Prosedur Operasional, dan memperbaiki faktor penyebabnya.

Background: Determining the diagnosis and code of the underlying causes of death is still a polemic. The accuracy of Underlying Cause of Death (UCoD) data from Death Certificate (FKPK) is often questioned during an audit. The determination of UCoD must pay attention to the ICD-10 and the MMDS (Mortality Medical Data System) Table. Thus, it is necessary to audit the accuracy of determining the UCoD code on the Death Certificate as a form of problem-solving.

Objective: Conducting an audit of coding accuracy in determining the UCoD code in Death Certificate at Bethesda Hospital.

Methods: This study used mixed methods. Data collection through documentation studies, interviews, and focus group discussions. The sample was selected by purposive sampling of 262 files for quantitative and one medical record officer, one head of the Medical Records and Health Information Division, one doctor, as well as Standard Operating Procedures for coding the diagnosis of the underlying cause of death for qualitative.

Results: Correct UCoD determination of 197 files and incorrect UCoD of 65 files with incorrect UCoD details due to incorrect UCoD determination of 28 files, inaccurate determination of 3-character codes of 20 files, inaccurate determination of 4-character subcategories of 13 files, inaccurate determination of 5-character subcategories of 1 file, and UCoD was not encoded of 3 files; does not have a Standard Operational Procedure for determining UCoD; there are factors underlying the inaccuracy in determining the UCoD code.

Conclusion: UCoD determination is not 100% correct, did not yet have Standard Operating Procedures on mortality, and there were elements that cause UCoD inaccuracies. UCoD coding should pay attention to mortality coding rules, implement Standard Operating Procedures, and improve causal factors.

Kata Kunci : FKPK, Underlying Cause of Death, Keakuratan, MMDS/FKPK, Underlying Cause of Death, Accuracy, MMDS