| Summary: | Background: coding has an important role in the management of the
hospital. Accuracy in coding disease will affect the report to be made by the
hospital. Medical record if the quality is said medical records are accurate,
complete, and reliable, valid and timely. One form of treatment in the medical
record is a documentation and coding (coding) diagnosis. Through a
preliminary study of 30 diagnoses of data entry on a summary sheet out of
obstetrics and gynecology patients by 20% obtained results are not in
accordance with the diagnosis code ICD 10.
Objective: Knowing the diagnosis coding implementation on a summary
sheet in and out patient obstetrics and gynecology, determine the percentage
of accuracy of diagnosis coding on a summary sheet in and out patient
obstetrics and gynecology, and determine the factors that cause inaccuracies
in diagnosis coding sheet entry quick exit obstetrics and gynecology patients.
Methods: This study used a descriptive study with a qualitative approach.
Research design used a study design cross sectional. Methods of data
collection by observation, documentation studies and interviews. Subjects in
this study is two coding clerk, two medical specialists in obstetrics and
gynecology, and head of the medical record installation. Objects used by the
researchers is inpatient medical record file of obstetrics and gynecology in
2012 as many as 2243 medical record file, and the obtained samples were
obtained medical record file number of the sampled object of research is as
much as 339 files.
Results: Implementation of coding diagnoses on the summary sheet in and
out patient obstetrics and gynecology in Medical Records Installation Panti
Rapih Hospital Yogyakarta done by 2 medical record officer with a
background 3 Diploma in Medical Record education and non-education
background Medical Record, to two officers recoding ever training on coding
and medical record management. Implementation of coding in Hospital Panti
Rapih been computerized using the SIRS encoding menu, if the code is not
found in the SIRS database encoding menu, then the implementation of the
coding is done manually according to encoding steps on ICD-10 Volume 2
and then add the code into the program. Analysis of the accuracy of
diagnosis coding results on a summary sheet in and out-patient obstetrics
and gynecology, there is 44.56% which is in accordance with the code of
ICD-10. Factors causing inaccurate diagnosis codes entered on the summary
sheet out inpatient obstetrics and gynecology, namely: human factors (HR),
update ICD-10, and have not done the evaluation.
Keywords:Coding,accuracy,Inpatient.
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