ANALYSIS OF ACCURACY OF DIAGNOSIS CODES BASED ON ICD-10 OUTPUT PATIENTS AT SENTOLO I KULON PROGO HEALTH CENTER

Abstract

The diagnosis code is the code for the disease diagnosis determined based on the ICD-10. The diagnosis code is used for report generation, if the code is not correct then the resulting information has low data validity. Based on the results of a preliminary study at the Sentolo I  Kulon Progo Health Center  on December 7, 2021, from 11 samples of medical records, 5 (45.4%) medical records were obtained with the correct code and 6 (54.6%) medical records with the incorrect code. This study aims to determine the coding procedure, the percentage of accuracy and inaccuracy, as well as the factors causing the inaccuracy of the outpatient diagnosis code at the Sentolo I Kulon Progo Health Center. This study uses a descriptive method with a qualitative approach and a cross sectional research design. The population of the subjects in this study were 11 midwives, 9 general nurses, 1 dental nurse, and 1 triangulation of sources, namely medical recorders. The object population in this study is the medical records of outpatients in the period from September to November 2021, which is 6,354 medical records. The sample subjects in this study were 2 midwives, 2 general nurses, and 1 dental nurse and the object sample was 98 outpatient medical records. The results showed that the diagnosis coding activity was carried out by midwives and nurses who provided services at the polyclinic. The correct diagnosis code was 47 medical records with a percentage of 47.9% and the incorrect code was 51 medical records with a percentage of 52.1%. The inaccuracy of giving the diagnosis code was due to the man factor, namely human resources that did not meet the competence of medical recorders, some officers had never attended training related to diagnosis coding, and had not been evaluated related to diagnosis coding, the money factor, namely there was no budget for diagnosis coding training, material factors. namely the less optimal use of the ICD-10 book, the machine factor, namely SIMPUS there is still a code that only reaches the 3rd character so it is less specific, the method factor is the lack of socialization of SOPs related to the diagnosis coding system, while for environmental factors, the puskesmas already have adequate ventilation. according to the standards of the Ministry of Health.