| Summary: | Background: Completeness and accuracy in coding patient diagnosis is very
important because it is useful to facilitate the service at the presentation of
information to support the planning function of management and research in
health, facilitate classification of disease, know what kind of diseases are on the
rise, penentukan drugs and on the INA CBG's functioning as a determinant of
patient treatment costs. As well as in the implementation of encoding encoding
officers must use the ICD-10. In RSJD Dr. RM Soedjarwadi Klaten still many files
are incomplete medical records and diagnosis code and there are some codes
that are not appropriate in JAMKESMAS verification sheet. Code inaccuracy will
affect the size of the cost of claims JAMKESMAS, so the officer must be able to
specify the encoding proper code so that there is no injured party.
Objective: Knowing the implementation of coding in inpatient psychiatric patients
and outpatients JAMKESMAS, determine the level of compliance and occupancy
diagnosis and code between the sheets with the patient's medical record
verification JAMKESMAS soul, knowing the level of accuracy of coding
JAMKESMAS psychiatric patients, determine the causes of the discrepancy and
inaccuracies in patient diagnosis code and determine the impact of mental
JAMKESMAS discrepancies and inaccuracies diagnosis code
Research Methodology: This type of research is a descriptive study with a
qualitative approach. Phenomenological research design. Methods of data
collection by interview, observation and documentation.
Results: Implementation of the encoding is done by two officers encoding D3
Medical Record. Officers carry out coding coding on the verification sheet
JAMKESMAS coding clerk not to file medical record coding. Implementation of
smart book and coding using ICD-10. Implementation was delayed because
officials coding coding coding not only do the job but it will still happen dual task.
Level of compliance and occupancy codes and diagnosis between sheets of
verification and file medical records in the outpatient setting by 6% and the
hospitalization of 41.33%. Level of accuracy verification code on the sheet on an
outpatient at 72.80% and 81.33% in hospitalization. Factors causing the
discrepancy and incompleteness of diagnosis code and influenced by human
resource consisting of physicians and coding personnel and the lack of facilities
and infrastructure, while the factors causing inaccuracy diagnosis code on the
verification sheet caused by the human resources and existing operating
procedures. Impact of Non-compliance and inaccuracy diagnosis code resulting
in a lack of quality of medical record content, complicate the data processing
officer, hamper for research students and in the process claim JAMKESMAS
cause the injured party.
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