Classification and Codefication of Diagnosis of Infection, Parasites, Neoplasm, Injury, Poisoning, and External Causes at Embung Fatimah Hospital
DOI:
https://doi.org/10.25311/keskom.Vol11.Iss2.2263Abstract
Medical records play an important role in supporting quality health services, one of which is through accurate diagnosis classification and coding. This study aims to analyze the classification and coding of diagnoses of infection, parasites, neoplasms, injuries, poisoning, and external causes for the period of January 2025 at Embung Fatimah Hospital. The type of research used is quantitative research with a descriptive observational research design., conducted on January 20 - February 5, 2025. Data collection techniques were carried out through direct observation and documentation studies from the medical records unit. The number of samples analyzed was 40 out of 391 outpatient diagnosis data. The analysis technique used was descriptive analysis to identify and classify diagnoses. Of the 391 data it was found that, code S (injury) was the most common, with 180 cases, followed by code D (neoplasm), with 132 cases. The ten most common diseases include Vulnus Lacerasi (S31.4), Thalassemia (D56), and Superficial Injury of Head (S00). It was recommended that hospitals conduct routine audits of medical documents to ensure the accuracy of diagnoses.
Downloads
References
[1] Permenkes RI, “Peraturan Menteri Kesehatan Nomor 3 Tahun 2020 tentang Klasifikasi dan Perizinan Rumah Sakit,” 2020
[2] Permenkes No 24 Tahun, “Peraturan Menteri Kesehatan Republik Indonesia Nomor 24 Tahun 2022 Tentang Rekam Medis,” Kementerian Kesehatan Republik Indonesia, No. 24, P. 21, 2022.
[3] Pemerintah Republik Indonesia, “Undang-Undang Republik Indonesia Nomor 17 Tahun 2023 Tentang Kesehatan,” Nomor 17, 2023
[4] Kepmenkes, “Sandard Profesi Perekam Medsi Dan Informasi Kesehatan,” Vol. 21, No. 1, Pp. 1–9, 2020.
[5] Hatta, Pedoman Manajemen Informasi Kesehatan Di Sarana Pelayanan Kesehatan, 2nd Ed. Jakarta: Universitas Indonesia Press, 2013.
[6] Depkes Ri, “Pedoman Penyelenggaraan Dan Prosedur Rekam Medis Rumah Sakit Di Indonesia,” 2006
[7] F. R. Mangentang, “Kelengkapan resume medis dan kesesuaian penulisan diagnosis berdasarkan ICD-10 sebelum dan sesudah JKN di RSU Bahteramas,” Jurnal ARSI (Administrasi Rumah Sakit Indonesia), vol. 1, no. 3, p. 4, 2015.
[8] R. I. Depkes, “Buku Panduan Penentuan Kode Penyebab Kematian Menurut ICD-10,” Jakarta: Badan Penelitian Dan Pengembangan Kesehatan, Depkes RI, 2008.
[9] H. M. Ulfa, H. Octaria, and T. P. Sari, “Analisis Ketepatan Kode Diagnosa Penyakit Antara Rumah Sakit Dan BPJS Menggunakan ICD-10 Untuk Penagihan Klaim di Rumah Sakit Kelas C Sekota Pekanbaru Tahun 2016,” Indonesian of Health Information Management Journal (INOHIM), vol. 5, no. 2, pp. 119–124, 2017.
[10] C. R. D. Sipayung and K. Khairani, “Tinjauan Kompetensi Coder Terhadap Keakuratan Dan Ketepatan Pengkodean Menggunakan ICD 10 Di Rumah Sakit Imelda Pekerja Indonesia Medan,” Jurnal Kesehatan Sejahtera, vol. 1, no. 2, pp. 79–89, 2024.
[11] W. Kurnianingsih, “Hubungan Pengetahuan Coder dengan Keakuratan Kode Diagnosis Pasien Rawat Jalan BPJS berdasarkan ICD–10 Di Rumah Sakit Nirmala Suri Sukoharjo,” Jurnal Manajemen Informasi dan Administrasi Kesehatan, vol. 3, no. 1, pp. 18–24, 2020.
[12] Annisa Safitri Azzahro and Chyntia Vicky Alvionita, “Analisis Ketepatan Kode Diagnosis Kasus Persalinan Pada Pasien Rawat Inap Di Rumah Sakit Dkt Sidoarjo Tahun 2022,” Jurnal Rekam Medis dan Informasi Kesehatan Indonesia, vol. 3, no. 1, pp. 01–08, Dec. 2023, doi: 10.62951/jurmiki.v3i1.40.
[13] E. Mutiara, “Algoritma Klasifikasi Naive Bayes Berbasis Particle Swarm Optimization Untuk Prediksi Penyakit Tuberculosis (Tb). Swabumi, 8 (1), 46–58,” 2020.
[14] I. Mathar, Manajemen informasi kesehatan: Pengelolaan dokumen rekam medis. Deepublish, 2018.
Downloads
Submitted
Accepted
Published
How to Cite
Issue
Section
License
Copyright (c) 2025 Jurnal kesehatan komunitas (Journal of community health)
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
Copyright @2017. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License (http://creativecommons.org/licenses/by-nc-sa/4.0/) which permits unrestricted non-commercial used, distribution and reproduction in any medium
