Accuracy and Conformity of Coding Diagnosis Case of Road Care Patients on Medical Records Using Hospital Management Information System

Abstract

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.