ANALISIS KEAKURATAN KODE DIAGNOSIS PADA KASUS TUBERKULOSIS BERDASARKAN ICD 10 DI RUMAH SAKIT PRIMA MEDIKA

Abstrak

Coding of disease diagnoses at Prima Medika Hospital is carried out separately for inpatient and outpatient services. Based on the results of a preliminary study of a total sample of 30 medical records with a diagnosis of Tuberculosis, there were 11 medical records with an incorrect diagnosis code and 19 correct medical records. This study aims to analyze the accuracy of the diagnosis code in tuberculosis cases based on ICD 10 at Prima Medika Hospital in 2022 using the 5M analysis method. This type of research uses qualitative analysis, namely by narrating the results of the research based on the data obtained. Informants in this study amounted to 5 people and supporting data 30 medical records. Based on the research results, it is known that based on the Man element, it is known that the coding of diagnoses has been carried out by the coder for inpatient services, while for outpatient care it is still carried out by nurses. Based on the elements of the method, the medical record section already has SPO coding, but SPO socialization has never been carried out. Based on the machine element, coding for inpatients already uses ICD 10 and SIMRS but for inpatients only uses ICD 10 and SIMRS code guidelines. Based on the machine elements, inpatient and outpatient services use electronic medical records and conventional medical records. Based on the element of money, it is known that officers have not attended special training related to diagnosis coding. It was concluded that based on the results of the 5M analysis of the accuracy of the tuberculosis diagnosis code, it was found that the cause of the inaccuracy of the diagnosis code came from the elements of Man, Method, Machine, Material and Money.