TINJAUAN KEAKURATAN KODE DIAGNOSIS KASUS PERSALINAN CAESAR BERDASARKAN ICD-10 PADA PASIEN RAWAT INAP DI RSUD 45 KUNINGAN

KHOERUNNISA, AMALIA (2025) TINJAUAN KEAKURATAN KODE DIAGNOSIS KASUS PERSALINAN CAESAR BERDASARKAN ICD-10 PADA PASIEN RAWAT INAP DI RSUD 45 KUNINGAN. Diploma thesis, POLITEKNIK KESEHATAN TASIKMALAYA.

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Abstract

Latar Belakang: Angka Kematian Ibu (AKI) menjadi indikator penting dalam menilai kualitas sistem kesehatan suatu negara. Salah satu upaya menurunkan AKI adalah melalui penerapan strategi Making Pregnancy Safer (MPS) yang bertujuan memperkuat layanan kesehatan dan mengurangi kebutuhan akan persalinan operasi caesar. Berdasarkan Survei Kesehatan Indonesia (SKI) tahun 2023, angka persalinan caesar di Indonesia mencapai 25,9%, dengan prevalensi tertinggi di Bali (53,2%) dan terendah di Papua Pegunungan (2,0%). Seiring peningkatan angka persalinan caesar, akurasi pengkodean diagnosis menjadi sangat penting dalam pelayanan kesehatan. Penelitian ini bertujuan meninjau tingkat keakuratan kode diagnosis kasus persalinan caesar pada pasien rawat inap di RSUD 45 Kuningan berdasarkan ICD-10. MetodoPenelitian: Penelitian ini menerapkan metode kuantitatif dengan pendekatan deskriptif. Data populasi diambil dari Triwulan III, yaitu antara Juli-September 2024, dengan total 121 dokumen rekam medis tahun 2024. Metode pengambilan sampel yang digunakan adalah total sampling, di mana seluruh populasi dijadikan sampel penelitian. Hasil Penelitian: Tingkat keakuratan kode diagnosis pada kasus persalinan caesar di RSUD 45 Kuningan menunjukkan bahwa dari 121 dokumen, 96 dokumen (79,3%) dikodekan dengan akurat, dan 25 dokumen (20,7%) tidak akurat. Ketidakakuratan terbanyak terjadi pada aspek complication of delivery (96%), outcome of delivery (4%), sementara method of delivery dikodekan tanpa kesalahan. Kesimpulan: Tingkat keakuratan pengkodean diagnosis persalinan caesar di RSUD 45 Kuningan belum optimal. Kesalahan pengkodean umumnya terjadi karena ketidaksesuaian antara data klinis pasien dan kode yang digunakan. Background: Maternal Mortality Rate (MMR) is an important indicator in assessing the quality of a country's health system. One effort to reduce MMR is through the implementation of the Making Pregnancy Safer (MPS) strategy which aims to strengthen health services and reduce the need for cesarean deliveries. Based on the 2023 Indonesian Health Survey (SKI), the cesarean delivery rate in Indonesia reached 25.9%, with the highest prevalence in Bali (53.2%) and the lowest in Papua Pegunungan (2.0%). As the cesarean delivery rate increases, the accuracy of diagnostic coding becomes very important in health services. This study aims to review the level of accuracy of diagnostic codes for cesarean delivery cases in hospitalized patients at RSUD 45 Kuningan based on ICD-10. Research Method: This study applies a quantitative method with a descriptive approach. Population data was taken from Quarter III, namely between July-September 2024, with a total of 121 medical record documents in 2024. The sampling method used was total sampling, where the entire population was used as a research sample. Research Results: The level of accuracy of diagnostic codes in cases of caesarean delivery at RSUD 45 Kuningan shows that out of 121 documents, 96 documents (79.3%) were coded accurately, and 25 documents (20.7%) were inaccurate. The most inaccuracies occurred in the aspects of complication of delivery (96%), outcome of delivery (4%), while the method of delivery was coded without error. Conclusion: The accuracy level of coding of caesarean delivery diagnosis at RSUD 45 Kuningan is not optimal. Coding errors generally occur due to inconsistencies between patient clinical data and the codes used.

Item Type:

Thesis (Diploma)

Contributors:

Contribution	Contributors	NIDN/NIDK	Email
UNSPECIFIED	RAHMAWATI, FITRIA DEWI	UNSPECIFIED	fitria.dew09@gmail.com
UNSPECIFIED	ARYANI, BHAKTI	UNSPECIFIED	bhaktiaryani13@gmail.com
UNSPECIFIED	HARYANTO, YANTO	4002116701	yantohyt@gmail.com