| Summary: | Background : Medical record completeness indicate medical record quality and
reflect medical service quality provided. Information appropriateness and
completeness (coding) determine service quality assessment. Unfilled and
inappropriate topography code and neoplasm morphology can influence medical
record management, particularly on cancer registration and is used as main data to
issue death certificate. It is due to base of death is centre of mortality code. In
addition, filling morphology code is very important to identify neoplasm stadium that
can be used to determine service that should be provided to patient with neoplasm.
Objective : To identify implementation of coding neoplasm case based on ICD-10
on summary of inpatient entry and discharge history in Surgery Unit, Dr. Sardjito
Hospital.
Research method : it is descriptive qualitative research with cross sectional design.
Object sample was taken using table of sample amount determination from certain
population developed from Issac and Michael with 10 error margin with total of 208
medical record of patient with neoplasm in 2012. Subject sample was determined
using purposive sampling on three medical records staff in coding section, one staff
in reporting section and two surgeons.
Results : Filling rate of neoplasm topography code is 100%, while that of neoplasm
morphology code with Anatomic pathology results was 27%, and the remaining 73%
was not filled. For morphology code without anatomic pathology is 26% filled and
74% unfilled. For appropriateness rate, 74% has appropriate and 26% not
appropriate. For appropriateness rate for neoplasm morphology code with anatomic
pathology 19% appropriate and 81% inappropriate. Neoplasm morphology code
without anatomic pathology was 23% appropriate and 77% inappropriate. Factors
causing unfilling and inappropriateness of neoplasm topography and morphology
code is not important by coding staff, reporting staff considering morphology code is
not included in hospital report and completeness of morphology code as additional
code
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