KEAKURATAN KODE DIAGNOSA UTAMA DOKUMEN REKAM MEDIS PADA KASUS PARTUS DENGAN SECTIO CESAREAN DI RUMAH SAKIT PANTI WILASA CITARUM TAHUN 2009

Abstract

Primary diagnosis should be coded in accordance with ICD 10 coding rules, in order to generate qualified data and information of health. Coding officer at Panti Wilasa Citarum
Hospital sometimes did not using the morbidity coding rules correctly at the time of primary diagnosis coding. Officers only encodes a particular classification. This study aims to determine the accuracy of primary diagnosis codes in medical record documents in the case of parturition (delivery) with sectio cesarean in Panti Wilasa Citarum Hospital year 2009. This study is using descriptive method, with cross sectional’s approach., Population of this
study is all medical record documents in case of cesarean sectio during year 2009, which sample counted 74 documents.

The result of the study found that officers are not yet using ICD 10 coding rules as expected, and this study showed that the inaccurate code is found in 50 documents (67,57%) and 24 documents were accurate (32,43%).

The conclusion of this study is that coding process at Panti Wilasa Citarum Hospital Semarang is not in accordance with coding rules, therefore it is necessary to improve the accuracy of primary diagnosis codes on medical record documents by applying the coding rules of ICD 10.

Keywords : ICD 10 coding rules, Accuracy primary diagnosis code