ACCURACY OF WRITING THE DIAGNOSIS AND ACCURACY OF THE CEREBRAL INFARCTION CODE INPATIENT PATIENTS AT HOSPITAL X

Abstract

Issue: The implementation of the clinical classification system and the coding of health-related diseases must be in accordance with the correct medical terminology. The results of the initial survey of 10 medical resumes of inpatient cerebral infarction cases showed that 4 (40%) had the right diagnosis code and 6 (60%) did not have the right diagnosis code. The inaccuracy of the diagnosis code is due to the writing of the diagnosis of the disease not in accordance with medical terminology and there is no communication between the coder and the doctor. This can affect the quality of data, information and reports as well as the accuracy of rates for general patients and INA-CBG's rates used as a method of payment for BPJS patients so that it can have an impact on the decline in the quality of hospital services. Objective: To determine the accuracy of medical terminology and the accuracy of inpatient cerebral infarction coding at X House in 2023. Methods: This type of research is observational research with descriptive design. The population and samples in this study were 84 medical resume sheets of inpatient cases in 2023. The research data used secondary data using a checklist sheet instrument, then processed univariately using frequency distribution. Results: From 84 sheets of medical resumes of inpatient cerebral infarction cases, there were 56 (67%) complete and 28 (33%) incomplete medical terminology writing, and the accuracy of the diagnosis code 47 (56%) was accurate and 37 (44%) was inaccurate. It is hoped that the hospital will socialize the Diagnosis Writing policy that has been determined by management so that medical personnel write diagnoses in accordance with the terminology in ICD-10 as stated in the Standard Abbreviation Manual for Hospital X and include coders in coding training.