ATIKAH, RAMADHANI (2023) TINJAUAN KETEPATAN KODE DIAGNOSA DIABETES MELITUS PASIEN RAWAT INAP DI RUMAH SAKIT UMUM UNIVERSITAS KRISTEN INDONESIA. Diploma thesis, AKADEMI PEREKAM MEDIS DAN INFOKES BHUMI HUSADA JAKARTA.

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Abstract

Atikah Ramadhani, "Review of the Accuracy of the Diabetes Mellitus Diagnosis Code for Inpatients at the General Hospital of the Christian University of Indonesia. Scientific Papers, Jakarta: The D-III Program of the Bhumi Husada Jakarta Medical Recorder and Health Information Academy in 2022." The coding of the diagnosis must be precise, as it will affect the information for the report data, claims for medical expenses, and the nature of administration in the hospital. This study aims to determine the accuracy of the diabetes mellitus diagnosis code at UKI Hospital in accordance with the standards set by WHO based on ICD 10. The study began in April-June 2022. The research method used is descriptive quantitative to obtain an overview of the accuracy of the diabetes mellitus diagnosis code for inpatients at UKI Hospital with observational data collection techniques, checklist sheets and interviews. In this scientific paper study, researchers sampled 75 compendiums. The results of the study obtained 75 samples studied, there were 25 improper codes (33.33%) and 50 exact codes (66.67%). It can be concluded that UKI General Hospital already has standard operating procedures for coding diagnoses. However, there is still improper coding. The main factor being the inaccuracy of the code is due to the incomplete writing of the diagnosis, and the coding officer is not precise in assigning the 4th digit. It is recommended that the coding officer confirm with the doctor if there is an incomplete diagnosis. Bibliography : 14 (1992-2021) Keywords : Accuracy of diagnosis code, Diabetes Mellitus, Discharge Summary.

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