HUBUNGAN KELENGKAPAN INFORMASI MEDIS DENGAN KEAKURATAN KODETUBERCULOSIS PARUBERDASARKAN ICD-10 PADA DOKUMEN REKAM MEDIS RAWAT INAP DI BBKPM SURAKARTA
Keywords:
Code Accuracy, Pulmonary Tuberculosis Diagnosis, ICD-10Abstract
ABSTRAK
BBKPM Surakarta merupakanbalaibesarkesehatanparumasyarakat di Surakarta. Tuberculosis Paru berada pada urutan keempat dan kelima dalam 10 besar penyakit pasien rawat inap tahun 2017. Berdasarkan survei pendahuluanterdapat 80% dokumen tidak lengkapdan 60% dokumen tidak akurat. Tujuan penelitian ini untuk mengetahui hubungan kelengkapan informasi medis terhadap keakuratan kode Tuberculosis Parudi BBKPM Surakarta.
Jenis penelitian ini adalah analitik dengan metode observasi dan wawancara dengan menggunakan pendekatan retrospektif. Jumlah populasi yaitu 66 dokumen rekam medis pasien rawat inap dengandiagnosis Tuberculosis Paru tahun 2017. Teknik pengambilansampelpenelitianmenggunakantekniksampeljenuh.Analisis data dilakukandengananalisis univariate dan analisis bivariate, sedangkanuntukanalisis bivariate diperolehdariperhitungan uji chi -squaredengan menggunakanaplikasi SPSS.
Persentase akurasi kode diagnosis Tuberculosis Paru di BBKPM Surakarta 2017 menunjukkan angka keakuratan 52% (34 dokumen) dan ketidakakuratan 48% (32 dokumen). Kelengkapan informasi medis terdapat 8% (5 dokumen) lengkap dan 92% (61 dokumen) tidak lengkap. Berdasarkan hasil perhitungan SPSS nilai p=0,592 > 0,05, artinya H0 diterima dan Ha ditolak, dengan demikian tidak ada hubungan antara kelengkapan informasi medis dengan keakuratan kode Tuberculosis Paru berdasarkan ICD-10 di BBKPM Surakarta tahun 2017.
Kata Kunci : Akurasi Kode, Diagnosis Tuberculosis Paru, ICD-10
ABSTRACT
BBKPM Surakarta is a community center for lung health in Surakarta. Pulmonary tuberculosis is in the fourth and fifth place in the top 10 inpatient diseases in 2017. Based on the preliminary survey there were 80% of incomplete documents and 60% of documents were inaccurate. The purpose of this study was to determine the relationship between the completeness of medical information on the accuracy of the pulmonary tuberculosis code in BBKPM Surakarta.
This type of research is analytical with observation and interview methods using a retrospective approach. The population is 66 inpatient medical record documents with a diagnosis of Lung Tuberculosis in 2017. The research sampling technique uses saturated sample techniques. Data analysis was performed by univariate analysis and bivariate analysis, while bivariate analysis was obtained from the chi-square test using the SPSS application.
The percentage of accuracy of diagnosis code for pulmonary tuberculosis in BBKPM Surakarta 2017 shows the accuracy rate of 52% (34 documents) and inaccuracies of 48% (32 documents). Completeness of medical information is 8% (5 documents) complete and 92% (61 documents) are incomplete. Based on the results of the SPSS calculation the value of p = 0.592> 0.05, means that H0 is accepted and Ha is rejected, thus there is no relationship between completeness of medical information with the accuracy of the pulmonary Tuberculosis code based on ICD-10 in BBKPM Surakarta in 2017
Keywords: Code Accuracy, Pulmonary Tuberculosis Diagnosis, ICD-10