Review for External Cause Coding of Injury Case on Medical Record Inpatient of Orthopedic Specialist Surgery in RSKB Banjarmasin Siaga in 2013

Abstract

Backgrounds: External cause code is a secondary code is used to encode diagnose the cause of the occurrence Banjarmasin Siaga Special Surgery Hospital. Objectives: orthopedic specialist surgery in RSKB Banjarmasin Siaga in 2013. Methods: This research used descriptive method with case study approach. The samples are 92 inpatient orthopedic specialist surgery with injury cases medical records from January to April 2013. Data collection techniques that had been used were observation and interviews. The research instruments are check list, interview guides, and observation guideline. This research was analyzed using univariate analysis. Results: There has been no Operational Standard Procedures of external cause coding but Operational Standard Procedures coding and disease indexing already exist, but not yet appropriate with the implementation. Completeness of external cause diagnosis writing is 82% and 18% did not completely written. External causes injury to the orthopedic specialist surgery cause by land transportation accidents is 43%, other transportation are the absence of procedures for external cause coding, the lack on media used, unsuitable human resources that needed, unreadable, incomplete, and unsuitable diagnosis with the rules, and the absence diagnosis coding audit.