Niessa, Nadzwa Nahdatun (2025) HUBUNGAN KELENGKAPAN RESUME MEDIS DENGAN KEAKURATAN KODEFIKASI DIAGNOSIS PERSALINAN INDIKASI PREEKLAMPSIA BERAT DI RUMAH SAKIT SUMBER HURIP CIREBON TAHUN 2024. Diploma thesis, Politeknik Kesehatan Tasikmalaya.
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Text (PERNYATAAN ORISINALITAS)
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Text (LEMBAR PENGESAHAN)
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Text (PERSETUJUAN PUBLIKASI)
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Text (HALAMAN JUDUL)
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Text (BAB I PENDAHULUAN)
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Text (BAB II TINJAUAN PUSTAKA)
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Text (BAB V KESIMPULAN DAN SARAN)
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Abstract
Latar Belakang: Rumah sakit sebagai penyedia layanan kesehatan menyeluruh bertanggung jawab untuk menyelenggarakan rekam medis yang berkualitas, mencakup kelengkapan dan keakuratan informasi. Salah satu komponen penting adalah resume medis yang berperan sebagai ringkasan perawatan pasien dan menjadi indikator kelengkapan rekam medis. Ketidaklengkapan resume medis dapat menghambat pengkodean diagnosis, termasuk pada kasus persalinan indikasi preeklampsia berat. Ketidaklengkapan resume medis dan ketidaktepatan pengkodean diagnosis pada kasus ini berdampak pada ketidaksesuaian tarif INA-CBG, yang berpotensi merugikan rumah sakit. Oleh karena itu, diperlukan kerja sama seluruh tenaga kesehatan, terutama perekam medis, untuk memastikan kualitas rekam medis yang lengkap dan akurat guna mendukung efisiensi pelayanan kesehatan. Metodologi Penelitian: Penelitian kuantitatif dengan pendekatan cross-sectional. Sampel diambil menggunakan teknik simple random sampling dari rekam medis pasien persalinan indikasi preeklampsia berat di Rumah Sakit Sumber Hurip Cirebon sejumlah 115 berkas rekam medis. Analisis data dilakukan menggunakan uji chi-square untuk melihat hubungan antar variabel menggunakan SPSS. Hasil penelitian: Berdasarkan hasil uji chi square diperoleh nilai sig (p) sebesar 0,000 sehingga nilai sig (p) < 0,05 maka hipotesis nol (H0) ditolak, berarti terdapat hubungan yang signifikan antara kelengkapan resume medis dengan keakuratan kodefikasi diagnosis persalinan indikasi preeklampsia berat di Rumah Sakit Sumber Hurip. Simpulan: Kelengkapan resume medis berkontribusi terhadap penetapan kode yang akurat, Ketidaklengkapan dokumen menyebabkan kekeliruan dalam pengkodean yang dapat berdampak pada klaim tarif INA-CBGs dan mutu informasi kesehatan rumah sakit. Background: Hospitals as comprehensive healthcare providers are responsible for organising quality medical records, including completeness and accuracy of information. One important component is the medical resume, which acts as a summary of patient care and is an indicator of medical record completeness. Incomplete medical resumes can hinder diagnosis coding, including in cases of delivery by severe eclampsia, which is a delivery method with an increasing trend globally. Incomplete medical resumes and inaccurate diagnosis coding in these cases result in INA-CBG tariff discrepancies, potentially costing the hospital money. Therefore, the cooperation of all health workers, especially medical recorders, is needed to ensure the quality of complete and accurate medical records to support the efficiency of health services. Methods: Quantitative research with a cross-sectional approach. Samples were taken using simple random sampling technique from medical records of patients with severe preeclampsia indications at Sumber Hurip Hospital Cirebon totaling 115 medical record files. Data analysis was performed using the chi-square test to see the relationship between variables using SPSS. Result: Based on the results of the chi square test significance value (p) of 0,000, indicating that the p-value is less than 0,05 then the null hypothesis (H₀) is rejected,There is a significant relationship between the completeness of medical records and the accuracy of diagnosis coding for delivery with severe preeclampsia indication in Sumber Hurip Hospital. Conclusion: Comprehensive medical record documentation plays a critical role in ensuring accurate disease coding. Incomplete records may result in coding inaccuracies, which can negatively impact INA-CBGs reimbursement claims and compromise the overall quality of hospital health information systems.
| Item Type: | Thesis (Diploma) | ||||||||||||||||
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| Uncontrolled Keywords: | Kelengkapan, Keakuratan, Resume Medis, Preeklampsia Berat. ktirmik2025,rmikcrb | ||||||||||||||||
| Subjects: | L Education > L Education (General) R Medicine > R Medicine (General) R Medicine > RG Gynecology and obstetrics |
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| Divisions: | Jurusan RMIK > D3 Rekam Medis & Informasi Kesehatan | ||||||||||||||||
| Depositing User: | CRBR Nadzwa Nahdatun Niessa | ||||||||||||||||
| Date Deposited: | 31 Jul 2025 01:07 | ||||||||||||||||
| Last Modified: | 31 Jul 2025 02:29 | ||||||||||||||||
| URI: | http://repo.poltekkestasikmalaya.ac.id/id/eprint/6866 |
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