Ketepatan Kodifikasi Klinis Berdasarkan ICD-10 di Puskesmas dan Rumah Sakit di Indonesia: Sebuah Studi Literatur

Abstract

The disease classification system is a grouping of similar diseases based on the International Statistical Classification of Diseases and Related Health Problem Tenth Revisions (ICD-10). The coding application must comply with ICD-10 to get the correct code so that it reflects the actual health condition. This study aimed to identify the level of accuracy of clinical classification and its influence factors at primary health facilities and referral health facilities (hospitals) in Indonesia. This study used a systematic literature review to a number of published research articles in 2009-2019. Literatures were obtained from 3 online databases, 19 journals, Google Scholar, and online proceedings. The total number of literatures obtained was 458 articles and 45 articles met the research criteria. Most of the articles show that the accuracy rate of diagnosis code at primary health center is 26 – 45% and in hospital is 21 – 81%. The previous studies also show that the availability of adequate standard operating procedure and facilities, as well as the coding audit are also a determining factor for the code accuracy. It is necessary to increase the accuracy of the diagnosis code to support a quality health reporting system. Efforts to improve should not only be on some factors but must be carried out thoroughly in all aspects.