ANALISIS FAKTOR-FAKTOR YANG MEMENGARUHI KETIDAKAKURATAN KODE DIAGNOSIS PENYAKIT RAWAT JALAN DI PUSKESMAS DINOYO TAHUN 2023

Abstract

At Dinoyo Community Health Center, inaccurate diagnosis codes contained in medical record documents will affect monthly reports and data validation. Based on the results of a preliminary study, data obtained that the accuracy of diagnosis codes in outpatient medical record documents at the Dinoyo Community Health Center was 82% (41 DRM) and 19% inaccurate (9 DRM). This study aims to determine the flow of outpatient disease coding at Dinoyo Health Center in 2023, the percentage of accuracy and inaccuracy of outpatient disease diagnosis codes at Dinoyo Health Center in 2023, and the factors that influence their inaccuracy. The method used in this research is mixed methods with a retrospective approach where researchers use quantitative and qualitative methods simultaneously. This research was conducted in the medical records unit of the Dinoyo Community Health Center using a DRM population of 10,229. The sample in this study was 100 DRM outpatients with a sampling technique, namely simple random sampling and 1 medical records officer and 1 poly doctor as informants. Method of collection is by observing and interviewing. Data analysis was carried out using descriptive analysis and univariate analysis. The research results showed that the percentage of accuracy of diagnosis codes was 51% (51 documents) and the percentage of inaccuracy was 49% (49 documents). Factors that influence the inaccuracy of diagnostic codes are coders who have never received coding training, working period of less than 5 years, coding work that also coincides with other work, coding carried out by doctors, coding SOPs that have not been implemented properly, the ICD-10 book which is still the old version, there is no supporting dictionary book, namely the Dorland dictionary, the completeness and readability of the doctor's writing in anamnesis and patient assessment and there is no budget to involve coding officers in taking part in training and procuring Dorland medical dictionary books. To prevent inaccuracies in diagnosis codes, the health center needs to hold special coding training for medical record officers, officers who carry out coding according to their competence, namely a Medical Recorder to improve accuracy in determining diagnosis codes as well as procuring the latest ICD-10 books and Dorland medical dictionaries.