Analisis Kemampuan PMIK Terhadap Kelengkapan dan Ketepatan Kode Diagnosis Kasus Persalinan di Rumah Sakit

Abstract

AbstractThe childbirth code according to WHO consists of mother's condition, method, and outcome of delivery. The labor code is used as the basis for making morbidity and mortality reports. The preliminary studies found incompleteness and inaccuracy of labor codes. The research analyzed the ability of PMIK in coding childbirth cases. The research method was a mixed method with a sequential explanatory model. Data collection used documentation studies and interviews. The subjects of the study were the coding officer. The study sample was 95 medical records of childbirth cases in 2021 with a simple random sampling technique. The coding officers in the hospital totaled 5 (five) people with a background of Diploma in Medical Record and Health Information.  The age of the coding officer was between 23 to 28 years old and work experience was one to eight years. There are 5 (five) major maternal diagnoses or conditions, namely long labor, PROM, preeclampsia, pre-term or post-term delivery, and oligohydramnios with a total code completeness of 94.74% and code accuracy of 53.68%. The delivery method based on studies was spontaneous delivery, delivery with breech presentation, and SC with completeness of the code of 92.63% and code accuracy of 1.05%. The delivery result code was not written by the officer so that the completeness and accuracy of the code were 0%. Factors caused incompleteness and inaccuracy of the code were coding officers have never attended training, coding procedures in hospitals have not been in accordance with WHO rules in ICD-10 Volume 2, and the codes have never been evaluated or monitored by hospitals. The conclusion that PMIK has not used the ICD-10 rule according to Volume 2 regarding the outcome of delivery of 0%, the percentage of code completeness, and the percentage of code accuracy were still not optimal.Keyword: maternity case, code completeness, code accuracy, PMIKAbstrakKodefikasi persalinan menurut WHO terdiri atas kode kondisi ibu, metode dan hasil persalinan. Kode persalinan digunakan sebagai dasar pembuatan laporan morbiditas dan mortalitas. Hasil studi pendahuluan ditemukan ketidaklengkapan dan ketidakakuratan kode persalinan. Tujuan penelitian ini untuk menganalisis kemampuan PMIK dalam mengkode kasus persalinan. Metode penelitian yaitu mixed method dengan model sequential explanatory. Pengumpulan data menggunakan studi dokumentasi dan wawancara. Subjek penelitian yaitu petugas koding dan kepala instalasi rekam medis. Sampel penelitian adalah 95 rekam medis kasus persalinan tahun 2021 dengan teknik pengambilan sampel simple random sampling. Petugas koding di rumah sakit berjumlah 5 (lima) orang dengan latar belakang lulusan DIII Rekam Medis. Usia petugas koding antara 23 hingga 28 tahun dengan masa kerja satu hingga delapan tahun. Terdapat 5 (lima) besar diagnosis atau kondisi ibu yaitu long labor, KPD, preeklampsia, pre-term atau post-term delivery, dan oligohidramnion dengan kelengkapan kode total sebesar 94,74% dan ketepatan kode 53,68%. Metode persalinan terdiri dari persalinan spontan, persalinan dengan kondisi janin sungsang, dan cesarean section dengan kelengkapan kode yaitu 92,63% dan ketepatan kode sebesar 1.05%. Kode hasil persalinan tidak dituliskan oleh petugas sehingga kelengkapan dan ketepatan kode adalah 0%. Faktor penyebab ketidaklengkapan dan ketidaktepatan kode yaitu petugas koding belum pernah mengikuti pelatihan, prosedur pengkodean di rumah sakit belum sesuai dengan aturan WHO dalam ICD-10 Volume 2, dan belum pernah dilaksanakan evaluasi maupun monitoring koding. Kesimpulan bahwa PMIK belum menggunakan aturan ICD-10 sesuai Volume 2 tentang hasil persalinan (outcome of delivery) 0%, persentase kelengkapan kode, dan persentase ketepatan kode masih belum optimal.Kata Kunci: kasus persalinan, kelengkapan kode, ketepatan kode, PMIK