Factors Affecting the Quality of Diagnosis Coding and Medical Record at Dr. Moewardi Hospital, Surakarta
Abstract
Background: Diagnosis coding is atool for identifying and grouping diseases, disorders, symptoms, and other disease-related outcomes, such as poisoning, adverse effect of drugs and chemicals, injury. Diagnosis code can be used in policy making and costing medical care. Doctors, nurses, coding personnel, and medical record quality, may affect the quality of diagnosis coding. This study aimed to investigate factors that affects the quality of diagnosis coding at Dr. Moewardi Hospital, Surakarta.
Subjects and Method: This was an analytic observational using cross sectional design. This study was conducted at Dr. Moewardi Hospital, Surakarta, Indonesia. A total of 250 inpatient medical record document at Dr. Moewardi Hospital were selected for the study bystratified random sampling.The data was analyzed by structural equation modeling (SEM).
Results:Sub-specialistic doctor (b = 1.13; 95%CI = 0.06 to 0.33; p = 0.039),civil servant doctor(b = 0.84; 95%CI = 0.06 to 1.62; p =0.034),nurse working ≥ 5 years (b = 1.77; 95% CI = 1.13 to 2.42; p<0.001), significantly increased the quality of medical record. Coding personnel aged ≥40 years (b= 1.70; 95%CI = 0.64 to 2.77; p = 0.002), coding personnelworking ≥5 years (b = 1.70; 95%CI= 0.98 to 2.42; p 0.001), and coding personnel has ≥ 5 times training(b = 2.62; 95% CI = 1.40 to 3.83; p <0.001), significantly increased the quality of diagnosis coding.
Conclusion: Sub-specialistic doctor, civil servant doctor, nurse working ≥5 years, significantly increased the quality of medical record. Coding personnel aged ≥40 years, coding personnel working ≥5 years, and coding personnel has ≥ 5 times training, significantly increased the quality of diagnosis coding.
Keywords: Quality of diagnosis coding, quality of medical record, doctor, nurse, coding personnel.
Correspondence: Warsi Maryati. School of Medical Records and Health, APIKES Citra Medika, Surakarta. Email: warsi_maryati@yahoo.com
Journal of Health Policy and Management (2016), 1(2): 61-70
https://doi.org/10.26911/thejhpm.2016.01.02.01
References
Abiyasa MT, Ernawati D, dan Kresnowati L (2012). hubungan antara spesifitas penulisan diagnosis terhadap akurasi kode pada rm 1 dokumen rawat inap rumah sakit bhayangkara semarang. Jurnal Visikes. 11(2): 99-104.
Arifianto E, Kresnowati L, dan Ernawati D (2011). keakuratan kode diagnosa utama dokumen rekam medis pada kasus partus dengan sectio cesarean di rumah sakit panti wilasa citarum. Jurnal Visikes. 10(2): 84-88.
Astuti RD, Riyoko, dan Lena D (2007). Tinjauan akurasi kode diagnosis utama pasien rawat inap berdasarkan icd-10 bangsal dahlia di rsud sukoharjo triwulan iv tahun (2007). Jurnal Rekam Medis. 2(1): 25-30.
Berger RP, Parks S, Fromkin J, Rubin P, dan Pecora PJ (2015). Assessing the accuracy of the international classifycation of diseases codes to identify abusive head trauma: a feasibility study. BMJ Journal. 21(0): 133-137.
ChengP, Gilchrist A, Robinson KM, dan Paul L (2009). The risk and consequences of clinical miscoding due to inadequate medical documentation: a case study of the impact on health services funding.HIMJ. 38(1): 35-46.
Cummings E, Maher R, Showell CM, Croft T, Tolman J, Vickers J, Stirling C, Robinson A, dan Turner P (2011). Hospital coding of Dementia: is it accurate. Health Information Mana-gement Journal. 40(3): 5-11.
Dalal S dan Roy B (2009). Reliability of clinical coding of hip facture surgery: implycations for payment by results. Inernational Journal Care Injured. 40 (1): 738-741.
Dariyo A (2003). Psikologi perkembangan dewasa muda. Jakarta: PT. Gramedia Widiasarana Indonesia.
Djafar F, Pasinringi S, Sudirman I (2011). Faktor insentif, kepemimpinan, kondisi lingkungan kerja dan kesempatan promosi yang berpengaruh terhadap kepuasan kerja dokter spesialis di rsup dr. wahidin sudirohusodo. Public Health Journal, 14(5): 60-64.
Fardiansyah A (2014). Analisis hubungan beban kerja dan lama masa kerja dengan stres pada perawat di puskesmas blooto kota mojokerto. Jurnal Medica Majapahit, 6 (2); 96-107.
Farida (2011). Kepemimpinanefektif dan motivasi kerja dalam penerapan komunikasi terapeutik perawat. Jurnal Ners. 6 (1); 31-41.
Farzandipour M, Sheikhtaheri A dan Sadoughi F (2010). Effective factors on accuracy of principal diagnosis coding based on international classification of diseases, the 10th revision (icd-10). International Journal of Information Management. 30: 78–84.
Ghazanfar F, Chuanmin S, Khan MM dan Bashir M (2011). A study of relationship between satisfaction with compensation and work motivation. International Journal of Business and Social Science. 2(1): 120-131.
Hatta G (2013). Pedoman manajemen informasi kesehatan di sarana pelayanan kesehatan. Jakarta: Universitas Indonesia Press.
Hsia DC, Krushat WM, Fagan AB, Tebutt JA, dan Kusserow RP. (2009). Accuracy of diagnostic coding for medicare patients under the prospective-payment system. N Engl J Med. 318: 352-355.
Hurriyati R (2005). Bauran pemasaran dan loyalitas konsumen. Bandung: Alfabeta.
Ifalahma D (2013). Hubungan pengetahuan coder dengan keakuratan kode diagnosis pasien rawat inap jami
nan kesehatan masyarakat berdasarkan icd-10 di rsud simo boyolali. Jurnal INFOKES. 3(2): 14-26.
Karimah RN, Setiawan D dan Nurmalia PS (2016). Analisis ketepatan kode diagnosis penyakit gastroenteritis acute berdasarkan dokumen rekam medis di rumah sakit balung jember. Journal of Agromedicine and Medical Sciences. 2(2): 12-17.
Kemenkes RI (2006). Pedoman pengelolaan rekam medis rumah sakit indonesia. Jakarta: Kemenkes RI.
Lihawa C, Noermijati dan Al Rasyid H (2016). Pengaruh motivasi kerja terhadap kinerja dokter dalam kelengkapan pengisian rekam medis dengan di moderasi karakteristik individu (studi di rumah sakit islam unisma malang). Jurnal Aplikasi Ma
najemen. 14(2): 300-308.
Muljani N (2012). Kompensasi sebagai motivator untuk meningkatkan kinerja karyawan. Jurnal Manajemen & Kewirausahaan. 4(2): 13-20.
Pujihastuti A dan Sudra RI (2014). Hubungan kelengkapan informasi dengan keakuratan kode diagnosis dan tindakan pada dokumen rekam medis rawat inap. Jurnal Manajemen Informasi Kesehatan Indonesia. 3(1): 60-64.
Pujihastuti A dan Sudra RI (2014). Hubungan kelengkapan informasi dengan keakuratan kode diagnosis dan tindakan pada dokumen rekam medis rawat inap. Jurnal Manajemen Informasi Kesehatan Indonesia. 3(1): 60-64.
Rahayu H, Ernawati D dan Kresnowati L (2011).Akurasi kode diagnosis utama pada rm 1 dokumen rekam medis ruang karmel dan karakteristik petugas koding rawat inap rumah sakit mardi rahayu kudus periode desember 2009.Jurnal Visikes. 10(1): 1-5.
Randy KC, Vivienne WML dan Tang TLP (2012). Retaining and motivating employees compensation preferences in hongkong and china. Personnel Review. 31(4): 402-431.
Rivai V (2003). Kepemimpinan dan perilaku organisasi. Jakarta: Raja Grafindo Persada.
Rohman H, Hariyono W dan Rosyidah (2011). Kebijakan pengisian diagnosis utama dan keakuratan kode diagnosis pada rekam medis di rumah sakit pku muhammadiyah yogyakarta. Jurnal KESMAS. 5(2): 162-232.
Rustiana ER dan Cahyati WH (2012). Stress kerja dengan pemilihan strategi coping. Jurnal KESMAS. 7(2): 149-155.
Sarwastutik (2013). Tinjauan keakuratan kode diagnosis pada dokumen rekam medis pasien rawat inap dengan kondisi utama typhoid fever berdasarkan icd-x di rsu pku muhammadiyah delanggu. Jurnal INFOKES. 3(2): 8-13.
Seruni FDA dan Sugiarsi S (2015). Problem solving cycle swot keakuratan kode diagnosis kasus obstetri pada lembar masuk dan keluar (rm 1a) pasien rawat inap di rsuddr. sayidiman magetan. Jurnal Manajemen Informasi Kesehatan Indonesia. 3(2): 5-13.
Siagian (2008). Manajemen sumber daya manusia. Jakarta: Bumi Aksara.
Sudra RI dan Pujihastuti A (2016). Pengaruh penulisan dianosis dan pengetahuan petugas rekam medis tentang terminologi medis terhadap keakuratan kode diagnosis. Jurnal Manajemen Informasi Kesehatan Indonesia. 4(1): 67-72.
Sugiyanto Z (2006). Analisis perilaku dokter dalam mengisi kelengkapan data rekam medis lembar resume rawat inap di rs ungaran.Jurnal Kesehatan, 12(3): 115-159.
Suma’mur S (2014). Kesehatan kerja dalam perpektif hiperkes dan keselamatan kerja. Jakarta: Erlangga.
Supratti dan Ashriady (2016). Pendokumentasian standar asuhan keperawatan di rumah sakit umum daerah mamuju, indonesia. Jurnal Kesehatan Manarang. 2(1): 43-50.
Thigpen JL, Pharm, DillonC, Forster KB, Henault L, Quinn EK, Tripodis Y, BergerPB, Hylek EM dan Limdi NA (2015). Validity of international classifycation of disease codes to identify ischemic stroke and intracranial hemorrhage among individuals with associated diagnosis of atrial fibrillation. Circ Cardiovasc Qual Out comes. 8(1): 8–14.
World Health Organization (2010). International satistical classification of diseases and related health problems tenth revision volume 1, 2 dan 3. Geneva: WHO.
Yulianto H dan Santoso E (2015). Persepsi dan ekspektasi dokter terhadap jasa medis di rs pku muhammadiyah nanggulan. Jurnal Kesehatan. 33 (1); 147 152.
