ACCURACY AND CONFORMITY OF CODING DIAGNOSIS CASE OF ROAD CARE PATIENTS ON MEDICAL RECORDS USING HOSPITAL MANAGEMENT INFORMATION SYSTEM

RSPAU Dr. Suhardi Hardjolukito Yogyakarta was conducting coding the diagnosis in eye patients outpatients at medical records and information management system hospital. However, the initial data collection was still found inaccuracies in the diagnostic code in existing medical record documents and hospital management information systems. This study�s purpose was to shortly describe the accuracy and appropriateness of coding diagnoses cases of eye patients outpatients at the medical records with hospital amendment information system at RSPAU Dr. Suhardi Hardjolukito. This research is a qualitative descriptive study with a case study design. Location of research at RSPAU Dr. Suhardi Hardjolukito Yogyakarta. The data collection process was carried out in March-August 2019. In this study, informants were medical record coordinators, outpatient reporting officers, clinic administrators, and eye clinic nurses. The object of this research is a decree, SPO, and medical record files. In this study, the population takes as many as 91 medical records of outpatient eye cases, collecting data using interviews, the checklist of observations, and checklist documentation study. The data validity technique used triangulation of sources, namely medical record coordinators and coding experts. The results showed standard procedures operational on Coding and Indexing disease, but it does not yet include the coding activity on the hospital management information system. The accuracy of diagnosis codes outpatient eye cases in the medical record document by 42%, being right on the hospital management information system only by 9%. The highest conformity of the outpatient eye case diagnosis code is in Category E; namely, one or both of the codes in the medical record file or hospital management information system is not documented or is not filled in by 37%. The main contributing factor for the inaccuracy and mismatch of the diagnostic code lies in the method aspect.

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