ANALISIS FAKTOR-FAKTOR YANG MEMENGARUHI KETIDAKAKURATAN KODE DIAGNOSIS PENYAKIT RAWAT JALAN DI PUSKESMAS PANDANWANGI KOTA MALANG

Abstract

The accuracy of the patient's disease diagnosis code has an important role in the smooth running of health services. An inaccurate code will have an impact on reporting and quality of service to patients because it has a low level of data validation. The inaccuracy of disease diagnosis codes is influenced by several factors according to the conditions of the health care facility. This research uses a type of quantitative research with a descriptive approach. This study aims to analyze the level of accuracy and inaccuracy of disease diagnosis codes and the factors that influence the inaccuracy of disease diagnosis codes at the Puskesmas Pandanwangi which include coding officers, completeness of medical record documents, coding policies and facilities infrastructure. The population in this study were 4702 medical record documents with a total sample of  98 medical record documents. How to collect data by observing and interviewing. The results showed that the percentage of accuracy of the disease diagnosis code was 40,8% (40 files) and the percentage of inaccuracy was 59,2% (58 files). The factors that influence it are that the coding officer in general poly is still carried out by doctors and nurses, all coding officers have never attended coding training, the work experience of coding officers is around 3 years, the completeness of medical record documents is not yet 100% complete, the use of SOP and ICD-10 has not been used optimally, and there has been no decree on the determination of the coding officer and the English dictionary to translate foreign words.