vii ABSTRAK
Ana Lailin Mustofiah, 2020. “Hubungan Kelengkapan Dokumen Rekam Medis Dengan Keakuratan Kode Diagnosis Penyakit Pada Pasien Rawat Inap Di Rs Permata Bunda Kota Malang”. Pembimbing: dr. Endang Sri Dewi Hastuti S., M.QIH.
Dalam melakukan proses pengisian kelengkapan dokumen rekam medis dan proses pemberian kode diagnosis penyakit RS Permata Bunda Kota Malang masih belum sesuai standar. Analisa pada 10 dokumen rekam medis rawat inap yang ditemukan 3 berkas rekam medis yang terisi lengkap, dengan angka kelengkapan dokumen 30%
serta 2 dokumen kodenya akurat dengan angka keakuratan 20%. Penelitian dengan judul “Hubungan Kelengkapan Dokumen Rekam Medis Dengan Keakuratan Kode Diagnosis Penyakit Pada Pasien Rawat Inap Di Rs Permata Bunda Kota Malang”
bertujuan untuk menganalisis hubungan kelengkapan dokumen rekam medis dengan keakuratan kode diagnosis penyakit. Jenis penelitian adalah survey analitik dengan pendekatan cross sectional. Sampel dalam penelitian berjumlah 90 dokumen rekam medis rawat inap dengan teknik simple random sampling cara undian. Analisis data didapatkan kelengkapan dokumen rekam medis presentase sebanyak 62% dengan jumlah dokumen rekam medis sebanyak 56 dokumen. Sedangkan dokumen rekam medis tidak lengkap menunjukkan presentase 38% dengan jumlah dokumen rekam medis sebanyak 34 dokumen. Keakuratan kode diagnosis penyakit, presentase sebanyak 71% dan jumlah dokumen rekam medis sebanyak 64 dokumen. Sedangkan diagnosis penyakit tidak akurat menunjukkan presentase 29% dengan jumlah dokumen rekam medis sebanyak 26 dokumen. Hasil uji Chi Square nilai Asymp Sig sebesar 0,000. Hal ini dapat diketahui p=0,000, sehingga p<0,05 maka H0 ditolak dan H1 diterima. Sehingga dapat diartikan bahwa ada hubungan antara kelengkapan dokumen rekam medis dengan keakuratan kode diagnosis penyakit pada pasien rawat inap di RS Permata Bunda Kota Malang.
Kata kunci: rekam medis, kelengkapan, keakuratan
viii ABSTRACT
Ana Lailin Mustofiah, 2020. “The Correlaton Of The Completeness Of Medical Record Documents With The Accuracy Of Inpatient Disease Diagnosis Code at Permata Bunda Hospital, Malang”. Lecture: dr. Endang Sri Dewi Hastuti S., M.QIH.
In carrying out the process of completing the medical record documents and the process of giving the diagnosis code for RS Permata Bunda Hospital Malang, itsn’t standard yet. Analysis of 10 inpatient medical record documents that were found 3 files of medical records that were completely, which has 30% complete documents and 2 documents which has 20% accuracy with accurate code. The research with the title
"The Correlation of Completeness of Medical Record Documents with the Accuracy of Disease Diagnosis Codes in Inpatients at Rs Permata Bunda Malang City" aims to analyze the relationship between the completeness of medical record documents with the accuracy of disease diagnosis codes. This type of research is an analytic survey with cross sectional approach. The samples in this study were 90 inpatient medical record documents with a simple random sampling technique in the lottery method.
Analysis of the data obtained the completeness of medical record documents as much as 62% with a total of 56 medical record documents. While incomplete medical record documents has a percentage of 38% with a total of 34 medical record documents. The accuracy of the disease diagnosis code, has percentage of 71% and the number of medical record documents as much as 64 documents. While inaccurate disease diagnosis has a percentage of 29% with the number of medical record documents as many as 26 documents. the results of Chi Square test with Asymp Sig's value of 0,000.
It can be seen that p = 0,000, so that p <0.05 then H0 is rejected and H1 is accepted. So it can be interpreted that there is a relationship between the completeness of medical record documents with the accuracy of the disease diagnosis code for inpatients at Permata Bunda Hospital Malang.
Keywords: medical record, completeness, accuracy
