Accuracy Review Diagnose Codefication on Labor Case Based ICD-10 Book at RSU Tangerang District

Abstract

Diagnose decoding has to by the rules of ICD-
10. So, the coder officer need to have knowledge in
determines diagnosis code. Based on preliminary
studied, review was doing for twenty files to have the
image level codefication accuracy. There was 55%
files that not accurate, meanwhile 45% had entirely
accurate code. The purpose of this research was to
know accuracy review diagnose codefication on labor
case based icd-10 book at RSU Kabupaten Tangerang.
The research was using descriptive analysis by using
interviewal methode and observation. The subject
on the research was codefication officer and labor
patient medical record files as the object of research.
The research instrument was using interviewal book
and check list sheet. The result of this research was
all coder officer had same education level which
is DIII medical recorder and health information.
Operational procedure standard related to diagnose
code determine wasn’t all done. Doctor diagnose
writing was main obstacle when doing codefication
process. The results of researchers’ interviews with
informants related to writing diagnoses, there was
often diagnoses with abbreviations that did not
match the list of abbreviations set by the hospital,
and also the writing of doctors which was sometimes
difficult to read. Subjective observations made by
researchers, there was 69.77% or 60 medical records
of labor cases that could be read by researchers and
30.23% or 26 medical records of labor cases that
was difficult to be read by researchers . Accuracy
diagnose codefication on labor case by 86 samples
of 38 files (44,19%) accurately code and as 48 files
(55,81%) by in accurate code, there weren’t coded as
17 files (35,42%) in between.