AVIANAH, DELLA (2025) HUBUNGAN KELENGKAPAN INFORMASI MEDIS DENGAN KETEPATAN KODEFIKASI DIAGNOSIS DIABETES MELITUS TIPE 2 PASIEN RAWAT INAP DI RUMAH SAKIT CIREMAI TAHUN 2024. Diploma thesis, POLITEKNIK KESEHATAN TASIKMALAYA.
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Abstract
Latar Belakang: Diabetes Melitus (DM) Tipe 2 merupakan penyakit kronis yang menyerang sebagian besar masyarakat dan memiliki potensi komplikasi serius seperti penyakit jantung, gagal ginjal, dan amputasi. Ketepatan kodefikasi diagnosis Diabetes Melitus tipe 2 pada rekam medis sangat bergantung pada informasi medis yang lengkap, khususnya dalam sistem Rekam Medis Elektronik (RME). Penelitian ini difokuskan untuk mencapai tujuan berupa mengetahui hubungan antara kelengkapan informasi medis dengan ketepatan kodefikasi diagnosis DM tipe 2 pada pasien rawat inap di Rumah Sakit Ciremai tahun 2024. Metode Penelitian: Penelitian kuantitatif dengan desain cross-sectional. Sampel sebanyak 171 dokumen rekam medis dari 300 populasi diambil menggunakan teknik simple random sampling. Data dianalisis menggunakan uji Chi-square dengan bantuan SPSS. Hasil Penelitian: Persentase kelengkapan pengisian Informasi Medis sebesar 62,6%, Persentase ketepatan kodefikasi Diagnosis Diabetes Melitus Tipe 2 sebesar 60,2%. Odds Ratio (OR) yang bernilai 17,66 dan nilai p-value 0,000 atau (p < 0,005) yang berarti terdapat hubungan yang signifikan antara kelengkapan informasi medis dengan ketepatan kodefikasi diagnosis Diabetes Melitus tipe 2. Kesimpulan: Kelengkapan informasi medis mempengaruhi ketepatan kodefikasi diagnosis. Oleh karena itu, peningkatan kualitas pengisian rekam medis menjadi krusial untuk mendukung akurasi pengkodean. Background : Diabetes Mellitus (DM) Type 2 is a chronic disease that affects most people and has the potential for serious complications such as heart disease, kidney failure, and amputation. The accuracy of the coding of the diagnosis of DM type 2 in medical records is highly dependent on complete medical information, especially in the Electronic Medical Record (EMR) system. This study focuses on achieving the goal of determining the relationship between the completeness of medical information and the accuracy of the coding of the diagnosis of DM type 2 in hospitalized patients at Ciremai Hospital in 2024. Research Methods: Quantitative research with cross-sectional design. A sample of 171 medical record documents from 300 populations was taken using simple random sampling technique. Data were analyzed using the Chi-square test with the help of SPSS. Research Result: The percentage of completeness of filling in Medical Information is 62.6%, the percentage of accuracy of coding the Diagnosis of Type 2 Diabetes Mellitus is 60.2%. Odds Ratio (OR) which is 17.66 and p-value 0.000 or (p <0.005) which means there is a significant relationship between the completeness of medical information and the accuracy of coding the diagnosis of Type 2 Diabetes Mellitus. Conclusion: The completeness of medical information affects the accuracy of the diagnosis coding. Therefore, improving the quality of filling in medical records is crucial to support coding accuracy.
Item Type: | Thesis (Diploma) | ||||||||||||||||
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Uncontrolled Keywords: | Diabetes Melitus Tipe 2 Kelengkapan Informasi Medis Ketepatan Kodefikasi Rekam Medis Elektronik ICD-10. ktirmik2025,rmikcrb | ||||||||||||||||
Subjects: | L Education > L Education (General) R Medicine > R Medicine (General) T Technology > T Technology (General) |
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Divisions: | Jurusan RMIK > D3 Rekam Medis & Informasi Kesehatan | ||||||||||||||||
Depositing User: | CRBR DELLA AVIANAH | ||||||||||||||||
Date Deposited: | 08 Jul 2025 03:28 | ||||||||||||||||
Last Modified: | 08 Jul 2025 03:28 | ||||||||||||||||
URI: | http://repo.poltekkestasikmalaya.ac.id/id/eprint/6240 |
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