| Summary: | Background: Encoding is an important process in the management of medical
records. So it must be performed by personnel who have the competence to
coding. In the Minister of Health Regulation of the Republic of Indonesia Number
55 of 2013 on the Implementation of Medical Records Jobs mentioned that a
medical recorder has the authority to do the clinical classification system and
codefication diseases related to health and medical treatment appropriate
medical terminology correct. While the standard of competence of doctors,
dentists, nurses, dental nurses and midwives not mentioned that they have the
competence to do the diagnosis coding. Based on this study it is necessary to
look at the coding officers understanding on the implementation of outpatient
diagnosis coding.
Objective: The purpose of this study was to determine the encoding officer
understanding of the implementation of disease diagnosis coding outpatients.
Method : This is a descriptive study using a qualitative approach. This study
used a phenomenological study design. Subjects of this study were doctors,
dentists, nurses, dental nurses and midwives who encodes an outpatient
diagnosis of disease. Object of this study is an understanding of the
implementation of coding officers outpatient diagnosis coding and medical record
file outpatients. Data collection techniques in this study used were interview,
observation, test or exams and study documentation.
Result : Implementation of disease diagnosis coding outpatient implemented by
nurses, dental nurses, doctors, dentists and midwives. There is no policy
regarding coding. Average knowledge officers of the ICD-10 coding amounting
33.33%, the percentage of officers understanding the encoding associated with
the use of ICD-10 by 16.67% and the officers coding knowledge related to the
meaning of punctuation is 43.74%. Average understanding of the medical
terminology coding officers was 96.92%. While understanding of the coding
officers disease diagnosis coding respondents on the BPU is 33.33%, the BPG is
100% and the KIA is 33.33%. Percentage proper code was 37.5% and the
improper code was 62.5%. The improper code then classified based on 4 criteria.
Imprecision in accordance with the criteria of A 20%. Imprecision in accordance
with the criteria of B is 64%. Which is in accordance with the criteria of C is
1.33%. While Imprecision in accordance with the criteria of D amounting 14.67%.
|
|---|