Factors Affecting the Innaccuracy of Outpatient Disease Diagnosis Coding in General Surgery and Neurosurgery Polyclinics, Hospital X, Badung Regency

Abstract

The purpose of this research was to investigate the correlation of coder's comprehension, audit implementation, medical record the completeness, SOP implementation, as well as facilities and infrastructure completeness with the innaccuracy of outpatient diagnosis coding in General Surgery and Neurosurgery Polyclinics, Hospital X, Badung Regency. This research was quantitative analytic research with cross sectional study design. A total of 8 coders were sampled and as many as 200 medical records were selected for the determination of coding innaccuracy. The results showed that most medical records are inaccurately coded. The bivariate test using spearman's rho indicated that there was a correlation between the coder's comprehension (sig. = 0.000), audit implementation (sig. = 0.003), medical record completeness (sig. = 0.000), SOP implementation (sig. = 0.004), as well as facilities and infrastructure completeness (sig. = 0.000) with the innaccuracy of outpatient disease diagnosis coding. Tujuan penelitian ini adalah untuk mengetahui hubungan pemahaman koder, pelaksanaan audit, kelengkapan rekam medis, pelaksanaan SOP, dan kelengkapan sarana dan prasarana dengan ketidakakuratan pengkodean diagnosis penyakit pasien rawat jalan di Poli Bedah Umum & PoliBedah Saraf, Rumah Sakit X, Kabupaten Badung. Penelitian ini merupakan penelitian analitik kuantitatif dengan rancangan penelitian cross sectional. Sebanyak 8 orang koder dijadikan sebagai sampel dan sebanyak 200 rekam medis dipilih untuk penentuan ketidakakuratan pengkodean diagnosis penyakit. Hasil penelitian menunjukkan bahwa sebagian besar rekam medis terkode secara tidak akurat. Uji bivariat menggunakan spearman's rho menunjukkan bahwa terdapat hubungan antara pemahaman koder (nilai sig. = 0,000), pelaksanaan audit (nilai sig. = 0,003), kelengkapan rekam medis (nilai sig. = 0,000), pelaksanaan SOP (nilai sig. = 0,004), dan kelengkapan sarana dan prasarana (nilai sig. = 0,000) dengan ketidakakuratan pengkodean diagnosis penyakit pasien.