Adam, Naila Zhafirah Putri (2025) TINJAUAN KETEPATAN KODIFIKASI DIAGNOSIS TUBERKULOSIS BERDASARKAN ICD-10 DI RSUD WALED KABUPATEN CIREBON TAHUN 2024. Diploma thesis, POLITEKNIK KESEHATAN TASIKMALAYA.
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Abstract
Latar Belakang : Ketepatan dalam pengkodean diagnosis pada dokumen rekam medis memegang peranan penting karena akan berdampak terhadap keakuratan data epidemiologis, kelancaran proses klaim asuransi, validitas pelaporan, serta mutu layanan rumah sakit. Tuberkulosis sebagai salah satu penyakit menular yang menjadi perhatian global, memerlukan pengkodean diagnosis yang sesuai dengan standar ICD-10. Tujuan penelitian ini adalah untuk mengetahui ketepatan kodifikasi diagnosis Tuberkulosis berdasarkan ICD-10 di RSUD Waled Kabupaten Cirebon. Metodologi Penelitian : Metode yang digunakan dalam penelitian ini adalah metode deskriptif kuantitatif dengan pendekatan retrospektif. Metode pengumpulan sampel menggunakan Simple Random Sampling pada populasi penelitian yang berupa dokumen rekam medis pasien Tuberkulosis di RSUD Waled Kabupaten Cirebon pada semester 1 tahun 2024. Hasil : Hasil penelitian menunjukkan bahwa tingkat ketepatan pengkodean diagnosis tuberkulosis sebesar 59% (44 dokumen), sedangkan tingkat ketidaktepatan mencapai 41% (31 dokumen). Ketidaktepatan tersebut disebabkan oleh kesalahan dalam menentukan blok ICD-10 dan subkategori keempat pada kode diagnosis. Kesimpulan : Pelaksanaan kodifikasi di unit rawat inap RSUD Waled dilakukan secara hybrid berdasarkan Standar Operasional Prosedur yang ditetapkan sejak tahun 2019. Hasil evaluasi pada periode Januari–Juni 2024 menunjukkan bahwa tingkat ketepatan kodifikasi diagnosis Tuberkulosis mencapai 59%, dengan ketidaktepatan terutama disebabkan oleh kesalahan dalam penentuan blok dan subkategori kode Kata Kunci : Ketepatan, Kodifikasi, Tuberkulosis Daftar Pustaka : 44 (2016-2024) Background : The accuracy of diagnostic coding in medical records plays a crucial role, as it directly impacts the reliability of epidemiological data, the efficiency of insurance claims, the validity of reporting, and the overall quality of hospital services. Tuberculosis, as a globally concerning infectious disease, requires diagnostic coding that aligns with the standards of the ICD-10. Errors in codification can impact reporting and medical decision-making. This study aims to determine the relationship between the completeness of supporting examinations and the accuracy of Tuberculosis diagnosis coding based on ICD-10 at Waled Hospital Cirebon Regency. Methods : This study employs descriptive-quantitative method with a retrospective approach. The sampling method used is Simple Random Sampling, targeting a population consisting of medical records of Tuberculosis patients at Waled Hospital Cirebon Regency during semester 1, 2024. Result : The results indicated that 59% (44 records) of the diagnosis codes were accurate, while 41% (31 records) were inaccurate. The inaccuracies were primarily due to errors in determining the ICD-10 block and the fourth subcategory of the diagnostic code. Conclusions : The coding process in the inpatient unit of RSUD Waled is implemented using a hybrid system based on the Standard Operating Procedure for Assigning Diagnosis and Procedure Codes, which has been in effect since 2019. Evaluation results for the period of January to June 2024 indicate that the accuracy rate of Tuberculosis diagnosis coding reached 59%, with the primary cause of inaccuracy being errors in selecting the correct code block and subcategory. Keyword : Accuracy, Code, Tuberculosis Bibliography : 44 (2016-2024)
| Item Type: | Thesis (Diploma) | ||||||||||||||||
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| Uncontrolled Keywords: | Ketepatan, Kodifikasi, Tuberkulosis, ICD-10. ktirmik2025,rmikcrb | ||||||||||||||||
| Subjects: | L Education > L Education (General) R Medicine > R Medicine (General) |
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| Divisions: | Jurusan RMIK > D3 Rekam Medis & Informasi Kesehatan | ||||||||||||||||
| Depositing User: | CRBR NAILA ZHAFIRAH PUTRI ADAM | ||||||||||||||||
| Date Deposited: | 07 Jul 2025 05:50 | ||||||||||||||||
| Last Modified: | 07 Jul 2025 05:50 | ||||||||||||||||
| URI: | http://repo.poltekkestasikmalaya.ac.id/id/eprint/6207 |
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