Factors Affecting the Completeness of Medical Information Related to the Accuracy of Inpatient Diagnosis Coding at Dr. Rasidin Padang Regional General Hospital

Denos Imam Fratama, Vegi Nelya Sari

Abstract


Dr. Rasidin Padang Regional General Hospital (RSUD dr. Rasidin Padang) experienced delayed claims involving 132 inpatient medical record documents. This study aimed to identify the factors related to the completeness of medical information that influence the accuracy of diagnosis coding at RSUD dr. Rasidin Padang. This research employed a quantitative analytical survey design using a cross-sectional approach. The population and sample in this study consisted of 57 healthcare workers responsible for completing patients’ medical information and 132 inpatient medical record documents with pending claims. The sampling technique used was simple random sampling. The instrument used in this study was a questionnaire. Data analysis was conducted using the Chi-square test. The univariate analysis showed that the staff were disciplined, had a low workload, had poor communication, had incomplete facilities and infrastructure, and were compliant in implementing SOPs/policies. The bivariate analysis indicated that there was a relationship between diagnosis coding accuracy and facilities and infrastructure. However, there was no relationship between diagnosis coding accuracy and discipline, workload, communication, or SOPs/policies at RSUD dr. Rasidin Padang. The completeness of medical information affects the level of diagnosis coding accuracy. Efforts to improve diagnosis coding accuracy should focus on facilities and infrastructure, as a significant relationship was found between coding accuracy and facilities and infrastructure.

Full Text:

PDF

References


Agustina, E. A. (2022). Faktor Penyebab Ketidaklengkapan Pengisian Dokumen Rekam Medis Rawat Inap di Rumah Sakit: Literature Review. Jurnal Manajemen Informasi Kesehatan Indonesia, 10(1), 104. https://doi.org/10.33560/jmiki.v10i1.403

Astuti RD, Riyoko, Lena D. (2007). Tinjauan Akurasi Kode Diagnosis Utama Pasien Rawat Inap Berdasarkan ICD-10 Bangsal Dahlia Di RSUD Sukoharjo Triwulan IV Tahun 2007. Jurnal Rekam medis ISSN:1979-9551 Vol 2 No 1 (Maret 2008)

Farista, A. D., & Karyus, A. (2020). Hubungan Motivasi dan Supervisi Terhadap Kelengkapan Pengisian Resume Medis Oleh Dokter. Jurnal Ilmiah Permas: Jurnal Ilmiah STIKES Kendal, 429-442.

Febi, E. Agustina, E, A. Nuraini, N., & Dewi, C (2022). Faktor Penyebab Ketidaklengkapan Pengisian Dokumen Rekam Medis Rawat Inap di Rumah Sakit. Vol. 10 No. 1 Jurnal Manajemen Informasi Kesehatan Indonesia. Jember.2022

Fitriyani Lubis. (2015),. Pengaruh Sikap Petugas Rekam Medis Terhadap Kelengkapan Pengisian Formulir Pemeriksaan Pasien Rawat Inap di Rumah Sakit Umum Hermina Medan.

Hasibuan, A. S., & Malau, G. (2019). Ketidaklengkapan Dokumen Rekam Medis Rawat Inap Pasien Diabetes Mellitus di RSU Imelda Medan. Jurnal Ilmiah Perekam Dan Informasi Kesehatan Imelda, 675.

Rohman H, Hariyono W, Rosyidah. (2011). Kebijakan Pengisian Diagnosis Utama Dan Keakuratan Kode Diagnosis Pada Rekam Medis Di Rumah Sakit PKU

Swari, S. J., & Verawati, M. (2022). Faktor Penyebab Ketidaklengkapan Pengisian Rekam Medis Pasien Rawat Inap Di Rumah Sakit. J-REMI : Jurnal Rekam Medik Dan Informasi Kesehatan, 3(4), 269–275. https://doi.org/10.25047/j- remi.v3i4.3256


Refbacks

  • There are currently no refbacks.


e-ISSN : -
p-ISSN : -


Publish by Universitas Syedza Saintika Padang(Jl. Prof. Dr. Hamka No. 228 Air Tawar Timur Padang)

Contact Person :

Chamy Rahmatiqa, M.Ph
Editor In Chief
Phone: 085263435940

Herman Susilo, M.Kom
Editor
Phone: 082169543410