Analisis Ketepatan Kode Diagnosis pada Pasien Rawat Inap dengan Jaminan Kesehatan Nasional di Rumah Sakit Fatima Tahun 2023

Analysis of the Accuracy of Diagnosis Codes in Inpatient Patients with National Health Guarantee at Fatima Hospital in 2023

Abstract

Introduction: Evaluation of the accuracy of diagnosis codes in inpatients with National Health Insurance at Fatima Hospital in 2023 is important to ensure quality health documentation and good management. The accuracy of giving a diagnosis code is the suitability of the diagnosis and disease code determined by the coder based on the rules and regulations of ICD-10. However, discrepancies in diagnoses and disease codes were still found. In 2022, Fatima Hospital conducted a review of medical records with a sample of 3761 and 132 medical records were found to have incorrect coding based on ICD-10.

Methods: This research design uses a descriptive research method with a qualitative approach, namely a method used to describe or describe a situation objectively. Retrospective analysis was carried out on medical record documents for inpatients with National Health Insurance at Fatima Hospital in 2023. Diagnosis codes were evaluated based on international standards to determine the level of accuracy.

Results: There were variations in the accuracy of diagnosis codes for inpatients at Fatima Hospital in 2023. Although some cases were in accordance with international standards, several other cases showed discrepancies or did not reflect the actual condition of the patient. Researchers conducted research on 2070 patient medical record files for the first quarter of 2023 at Fatima Hospital. From this data it was found that 94% The diagnosis code was accurate and 6% of the diagnosis code was inaccurate.

Discussion: These findings emphasize the importance of improving medical documentation and coding practices at Fatima Hospital. Staff training, implementation of clear recording guidelines, and utilization of sophisticated health information systems are among the proposed steps for improvement.

Keywords: accuracy of diagnosis codes, inpatients, national health insurance, fatima hospital, retrospective evaluation