GAMBARAN KETEPATAN PENGODEAN PENYEBAB KEMATIAN PADA SERTIFIKAT MEDIS PENYEBAB KEMATIAN KASUS PERINATAL DI RSIA TIARA CIKUPA

Octa Rina Sari; Laela Indawati; Noor Yulia; Lily Widjaja

doi:10.59003/nhj.v3i3.957

Authors

Octa Rina Sari Universitas Esa Unggul
Laela Indawati Universitas Esa Unggul
Noor Yulia Universitas Esa Unggul
Lily Widjaja Universitas Esa Unggul

DOI:

https://doi.org/10.59003/nhj.v3i3.957

Keywords:

underlying cause of death, ICD-10

Abstract

The basic cause of death is used as an evaluation of a health service, knowing the general health status, reporting mortality and prevention of deadly diseases and preparing for medical needs in the future. The purpose of this research is to know the description of the accuracy of the coding accuracy of the cause of death on the perinatal case death certificate at RSIA Tiara. The research method used in this research is a descriptive mix method where a mix of quantitative and qualitative is by describing and explaining the accuracy of the UCoD coding on medical certificates causing death in perinatal cases. The population in this study were all medical records of babies who died in 2020, 2021 and 2022, totaling 32 medical records. The sample used in this study was a saturated sample where all populations were sampled, namely 32 medical records. The results of the presentation of the accuracy of the coding on the medical certification cause of death were as much as 69% while those that were not correct were as many as 31%. It is preferable to code all diagnoses in the prenatal case death certificate using the guideline and rules P1,P2,P3,P4 to give the correct code. Factors causing inaccuracy in codification of the underlying cause of death on the death certificate, the doctor's writing on the infant's medical resume in the final diagnosis section using cursive letters creates obstacles for the coding officer in determining the correct code. There is no special SPO for coding prenatal cases. Lack of human resources with a background in medical records.

Downloads

Download data is not yet available.

References

Badan Batlingbangkes. (2010). Surat Keterangan Kematian.

Manual Rekam Medis, 1 (2006).

Peraturan Menteri Kesehatan Republik Indonesia Nomor 39 Tahun 2016, 1 (2016).

Depkes RI, Pub. L. No. 21, Depkes RI 1 (2022).

Indawati, L. (2017). Identifikasi Unsur 5M Dalam Ketidaktepatan Pemberian Kode Penyakit Dan Tindakan (Systematic Review). Indonesian of Health Information Management Journal (INOHIM), 5(2), 59–64.

Ningrum, R. P., & Widjaja, L. (2016). Hubungan Kelengkapan Sertifikat Medis Penyebab Kematian Terhadap Ketepatan Kode Diagnosa Penyebab Kematian Pasien di Rumah Sakit Sumber Waras Jakarta Tahun 2016. Indonesian of Health Information Management Journal (INOHIM), 4(2), 58–62.

Pemerintah Indonesia, Pemerintah Indonesia 1 (2009).

Peraturan Menteri Kesehatan Republik Indonesia Nomor 39 Tahun 2016, 1 (2016).

Siswati. (2018). Manajemen Unit Kerja II (Vol. 1).

Supriyadi, A. (2018). Tinjauan Ketepatan Kode Diagnosis Utama Penyebab Dasar Kematian Berdasarkan ICD-10. Jurnal Perekam Medis dan Informasi Kesehatan, 1(1), 1–6.

WHO. (2016). International statistical classification of diseases and related health problems. World Health Organization.

Widjaya, L., & Rumana, N. A. (2014). Faktor-Faktor Yang Mempengaruhi Keakurasian Koding Ibu Melahirkan dan Bayi di Beberapa Rumah Sakit Tahun 2014. Indonesian of Health Information Management Journal (INOHIM), 2(2), 114–122.