SAFITRI, CAHYA WULAN (2025) TINJAUAN KETEPATAN KODEFIKASI DIAGNOSIS KASUS OBSTETRI KATEGORI ABORTUS DI RSUD ARJAWINANGUN TAHUN 2024. Diploma thesis, POLTEKKES KEMENKES TASIKMALAYA.
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Abstract
Latar Belakang: Abortus atau keguguran ialah kematian janin saat usia kehamilan <20 minggu atau berat janin <500 gram. Asuhan pasca keguguran/ abortus adalah serangkaian pendekatan yang disusun untuk menangani ibu setelah mengalami keguguran, baik secara spontan maupun melalui induksi.). Hal ini sejalan dengan salah satu tujuan pembangunan berkelanjutan atau SDGs (Sustainable Development Goals), yaitu mengurangi rasio Angka Kematian Ibu (AKI) hingga 70 per 100.000 kelahiran hidup di Indonesia pada tahun 2030. Tujuan penelitian ini adalah mengetahui persentase ketepatan kode diagnosis kasus obstetri kategori abortus di RSUD Arjawinangun. Metode Penelitian: Deskriptif kuantitatif dengan menggunakan teknik total sampling pada 75 dokumen rekam medis pasien rawat inap kasus obstetri kategori abortus di RSUD Arjawinangun tahun 2024 Hasil Penelitian: Proses pengkodean diagnosis di RSUD Arjawinangun masih dalam masa peralihan sejak Desember 2024 dan sebagian besar telah berpedoman Standar Operasional Prosedur (SOP) serta ICD-10 Vol. 1, 2 dan 3. Persentase ketepatan kodefikasi diagnosis kasus obstetri kategori abortus di RSUD Arjawinangun sebesar 72% (54 dokumen) dan persentase ketidaktepatan 28% (21 dokumen). Simpulan: Proses pengkodean diagnosis di RSUD Arjawinangun sebagian besar telah berpedoman Standar Operasional Prosedur (SOP) serta ICD-10 Vol. 1, 2 dan 3. Persentase ketepatan kodefikasi diagnosis kasus obstetri kategori abortus di RSUD Arjawinangun sebesar 72% dan persentase ketidaktepatan 28%. Kata kunci: Ketepatan kode, abortus, keguguran, ICD-10, rekam medis Daftar Pustaka: 37 (2009-2024) Background : Abortion or miscarriage is the death of the fetus when the gestational age is <20 weeks or the fetal weight is <500 grams. Post miscarriage / abortion care is an approach to treating mothers after a miscarriage, either spontaneously or through induction. This is in line with one of the Sustainable Development Goals (SDGs), which is to reduce the maternal mortality ratio (MMR) to 70 per 100,000 live births in Indonesia by 2030. The purpose of this study was to determine the percentage of accuracy of the diagnosis code of obstetric cases in the abortion category at RSUD Arjawinangun.. Methods : Descriptive quantitative using total sampling technique on 75 medical record documents of inpatients for obstetric cases in the abortion category at RSUD Arjawinangun in 2024. Results : The diagnosis coding process at RSUD Arjawinangun is still in a transitional period since December 2024 and has mostly been guided by Standard Operating Procedures (SOP) and ICD-10 Vol. 1, 2 and 3. The percentage of accuracy of diagnosis coding of obstetric cases in the abortion category at RSUD Arjawinangun was 72% (54 documents) and the percentage of inaccuracy was 28% (21 documents). Conclusion : The diagnosis coding process at Arjawinangun Hospital has mostly been guided by Standard Operating Procedures (SOP) and ICD-10 Vol. 1, 2 and 3. The percentage of accuracy of diagnosis coding of obstetric cases in the abortion category at Arjawinangun Hospital is 72% and the percentage of inaccuracy is 28%. Keywords: Code accuracy, abortion, miscarriage, ICD-10, medical record Bibliography :37 (2009-2024)
| Item Type: | Thesis (Diploma) | ||||||||
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| Uncontrolled Keywords: | Ketepatan kode, abortus, keguguran, ICD-10, rekam medis. ktirmik2025,rmikcrb | ||||||||
| Subjects: | L Education > L Education (General) R Medicine > RG Gynecology and obstetrics |
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| Divisions: | Jurusan RMIK > D3 Rekam Medis & Informasi Kesehatan | ||||||||
| Depositing User: | CRBR CAHYA WULAN SAFITRI | ||||||||
| Date Deposited: | 14 Jul 2025 02:41 | ||||||||
| Last Modified: | 14 Jul 2025 02:41 | ||||||||
| URI: | http://repo.poltekkestasikmalaya.ac.id/id/eprint/6311 |
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