Tinjauan Keakuratan Kode Diagnosis Birth Asphyxia di RSUD 45 Kuningan Tahun 2024

MUHAMMAD, HEGEL KEMAL KHARISMA (2025) Tinjauan Keakuratan Kode Diagnosis Birth Asphyxia di RSUD 45 Kuningan Tahun 2024. Diploma thesis, POLTEKKES KEMENKES TASIKMALAYA.

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Abstract

Latar Belakang: Birth Asphyxia merupakan penyebab utama kematian neonatal di dunia, termasuk di Indonesia. Diagnosis yang akurat dan pengkodean yang tepat berdasarkan ICD-10 sangat penting untuk analisis epidemiologi dan pelayanan kesehatan. RSUD 45 Kuningan sebagai rumah sakit rujukan utama belum melakukan kajian mendalam mengenai keakuratan kode diagnosis Birth Asphyxia. Metode Penelitian: Penelitian ini menggunakan metode deskriptif kuantitatif dengan teknik total sampling terhadap 80 dokumen rekam medis pasien rawat inap kasus Birth Asphyxia di RSUD 45 Kuningan. Hasil Penelitian: Proses kodefikasi di RSUD 45 Kuningan masih dilakukan secara manual pada unit rawat inap, sementara unit rawat jalan sudah menggunakan sistem elektronik. Dari 80 data rekam medis yang diteliti, 74 kode diagnosis (92,5%) akurat dan 6 kode diagnosis (7,5%) tidak akurat. Simpulan: Proses pengkodean diagnosis kasus Birth Asphyxia di RSUD 45 Kuningan secara umum menunjukkan hasil yang baik. Dari 80 sampel dokumen rekam medis yang diteliti, sebanyak 74 dokumen (92,5%) dikategorikan akurat dan 6 dokumen (7,5%) tidak akurat Background: Birth Asphyxia is a leading cause of neonatal mortality worldwide, including in Indonesia. Accurate diagnosis and proper coding based on ICD-10 are crucial for epidemiological analysis and healthcare services. RSUD 45 Kuningan, as a primary referral hospital, has not yet conducted an in-depth study on the accuracy of Birth Asphyxia diagnosis codes. Research Method: This study employed a descriptive quantitative method with a total sampling technique, analyzing 80 inpatient medical records of Birth Asphyxia cases at RSUD 45 Kuningan. Research Results: The coding process at RSUD 45 Kuningan is still performed manually for inpatient services, while outpatient services have adopted an electronic system. Out of 80 medical records reviewed, 74 diagnosis codes (92.5%) were accurate, and 6 diagnosis codes (7.5%) were inaccurate. Conclusion: The coding process for Birth Asphyxia diagnoses at RSUD 45 Kuningan generally shows good results. Of the 80 medical record samples analyzed, 74 records (92.5%) were categorized as accurate and 6 records (7.5%) as inaccurate.

Item Type: Thesis (Diploma)
Contributors:
ContributionContributorsNIDN/NIDKEmail
UNSPECIFIEDARYANI, BHAKTIUNSPECIFIEDbhaktiaryani13@gmail.com
Uncontrolled Keywords: Keakuratan kode diagnosis, Birth Asphyxia, Rekam medis. ktirmik2025,rmikcrb
Subjects: L Education > L Education (General)
T Technology > T Technology (General)
Divisions: Jurusan RMIK > D3 Rekam Medis & Informasi Kesehatan
Depositing User: CRBR HEGEL KEMAL KHARISMA MUHAMMAD
Date Deposited: 04 Jul 2025 07:59
Last Modified: 04 Jul 2025 07:59
URI: http://repo.poltekkestasikmalaya.ac.id/id/eprint/5922

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