TINJAUAN KEAKURATAN KODE DIAGNOSIS KASUS BIRTH ASPHYXIA BERDASARKAN ICD-10 PADA REKAM MEDIS RAWAT INAP TRIWULAN III DI RSUD WALED TAHUN 2023

FAIDAH, NUR (2025) TINJAUAN KEAKURATAN KODE DIAGNOSIS KASUS BIRTH ASPHYXIA BERDASARKAN ICD-10 PADA REKAM MEDIS RAWAT INAP TRIWULAN III DI RSUD WALED TAHUN 2023. Diploma thesis, POLITEKNIK KESEHATAN TASIKMALAYA.

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Abstract

Latar Belakang : Angka Kematian Bayi di Indonesia di tahun 2023 terjadi pada periode neonatal sebanyak 27.530, penyebab utama kematian tersebut, yaitu respiratory dan cardiovascular. Asphyxia salah satu gangguan yang termasuk dalam sistem respiratory dan cardiovascular perinatal, dalam ICD-10 tahun 2010 terdapat pada bab XVI blok P20-P29. Keakuratan kode diagnosis menjadi aspek penting dalam pembuatan laporan. Seorang koder harus mampu menetapkan kode diagnosis sesuai dengan ketentuan pengkodean berdasarkan ICD-10 tahun 2010. Tahun 2023 di RSUD Waled mencatat angka kasus Birth Asphyxia pada tahun 2023 merupakan penyebab utama dan paling banyak yaitu sebesar 1.317 kasus. Selain itu, di RSUD Waled belum ada penelitian terkait keakuratan kode diagnosis Birth Asphyxia. Penelitian ini bertujuan untuk mengetahui persentase keakuratan kode diagnosis kasus Birth Asphyxia. Metode Penelitian: Penelitian ini menggunakan metode kuantitatif dengan desain deskriptif dengan jumlah sampel sebanyak 163 rekam medis bayi rawat inap pada periode triwulan III tahun 2023, teknik sampel yang digunakan oleh peneliti adalah teknik purposive sampling. Hasil Penelitian: Pelaksanaan Rekam Medis elektronik di RSUD Waled Kabupaten Cirebon dimulai pada awal tahun 2025. Tahun 2023-2024 masih masa peralihan atau hybrid. Penetapan kode diagnosis sedah sesuai SPO yang telah disetujui oleh kepala direktur rumah sakit. Dari hasil perhitungan analisis data sampel berupa persentase keakuratan menunjukan bahwa dari 163 data sampel rekam medis bayi rawat inap dengan diagnosis kasus Birth Asphyxia yang akurat sebanyak 119 kasus (73%) dan kode diagnosis Birth Asphyxia yang tidak akurat sebanyak 44 kasus (27%). Simpulan: Penetapan kode diagnosis pada kasus Birth Asphyxia di RSUD Waled Kabupaten Cirebon triwulan III di RSUD Waled Kabupaten Cirebon tahun 2023 menunjukan bahwa keakuratan kode diagnosis sebesar 73% atau sebanyak 119 kode diagnosis sudah akurat. Background: The Infant Mortality Rate in Indonesia in 2023 occurred in the neonatal period of 27,530, the main causes of death were respiratory and cardiovascular. Asphyxia is one of the disorders included in the perinatal respiratory and cardiovascular systems, in the 2010 ICD-10 it is in chapter XVI block P20-P29. The accuracy of the diagnosis code is an important aspect in making reports. A coder must be able to determine the diagnosis code in accordance with the coding provisions based on the 2010 ICD-10. In 2023, the Waled Regional Hospital recorded the number of Birth Asphyxia cases in 2023 as the main and most common cause, namely 1,317 cases. In addition, at the Waled Regional Hospital there has been no research related to the accuracy of the Birth Asphyxia diagnosis code. This study aims to determine the percentage of accuracy of the Birth Asphyxia case diagnosis code. Research Methods: This study uses a quantitative method with a descriptive design with a sample size of 163 medical records of hospitalized infants in the third quarter of 2023, the sampling technique used by the researcher is the purposive sampling technique. Research Results: The implementation of electronic Medical Records at Waled Regional Hospital, Cirebon Regency began in early 2025. 2023-2024 is still a transitional or hybrid period. The determination of the diagnosis code is in accordance with the SPO that has been approved by the head director of the hospital. From the results of the calculation of sample data analysis in the form of a percentage of accuracy, it shows that out of 163 sample data of inpatient infant medical records with an accurate diagnosis of Birth Asphyxia cases, there were 119 cases (73%) and inaccurate Birth Asphyxia diagnosis codes were 44 cases (27%). Conclusion: Determination of the diagnosis code in cases of Birth Asphyxia at Waled Regional Hospital, Cirebon Regency in the third quarter at Waled Regional Hospital, Cirebon Regency in 2023 showed that the accuracy of the diagnosis code was 73% or as many as 119 diagnosis codes were accurate.

Item Type:

Thesis (Diploma)

Contributors:

Contribution	Contributors	NIDN/NIDK	Email
UNSPECIFIED	RAHMAWATI, FITRIA DEWI	UNSPECIFIED	UNSPECIFIED
UNSPECIFIED	ARYANI, BHAKTI	UNSPECIFIED	UNSPECIFIED
UNSPECIFIED	HARYANTO, YANTO	UNSPECIFIED	UNSPECIFIED