TINJAUAM PENULISAN DIAGNOSIS UTAMA DAN KETEPATAN KODE ICD-10PADA PASIEN UMUM DI RSUD KOTA SEMARANG TRIWULAN | TAHUN 2012 Retna Dwi VI Ayu): Dyan Emawate) )— Manasisws Fatutas Kesenatan UDINUS. ‘Stat Pengalsr Fatultas Kesentan UDINUS ABSTRACT Background: Puanc Hospital of Area of Semarang represent te pubic hospital 1ype © inbich have used JCD-10 as guidance coding. In the infil sunvey conducted by researchers loftne 50 cocuments meclcay recard ound 2s many as 47% of medical ;ecora aocument wen noting coge mat does nat match. to tat eng, researchers conaucted 2 stugy to cetermme te sever ar conrammy between me wrkng of the mam alagnasss and (CD-70 coamng an pubic patients at me nosptat \Metnod: The research use Me obsenvaton method win tie approech crossectonal with ne cescrpove analyac research type white popureton from this yesearch are 1323 mecica! ‘record documents fake care of to lage by Sample 93 document taken oy technique ‘ystemanc ranaom samping. Resul: Resut of writing main diagnosed code match at medical record documents teke care of foage counted 83% cocuments, and main glagnased not match counted 10,1286 eal! recard documents take care of lage. The cause of tne alscrepancy of me man ragnosis was writing the man dlagnosis was not specie and not pay attenton to dagnosis code sneet-sneet checks. In aogtin the packground coang clerk who nas never foioweD & traning Is one of me causes of te aiscrepancy of te main diagnes's. The conciusion obtained is that to get a dagnosis cade compllance fs not anly influenced by the wrtng af major-specinc agnosis, Out also Inmuenced the rattan omicer coaing 3s weN as the amner factors associated. Therefore, the Clerk fo the codhg shoul be given the oppartunty to ‘ateng ramng relaong @ his aides as oMcer coding. in agton ra te coamg cient should be mare active and conscientious in finding Informs! fourd major non-specific dtagnosis by ‘analyzing omer examination sheet sheets, oF you need fo ask ine goctor wno wrote the clagnosis Kaywards: usin Diagnosis, cage of aseases, ICD-10a. Dagnoss yang altenturan a. Kelengtapan Rexam Meds sseigtan cermat aka}. ‘Setelum pengkogean D. Menjsa| aissan unt lagnosis penyakt tenga irawat rekam edie ainaruskan & Menjad! fakta arahan atau mangkail data rekam meds pengobatan patien untuk menemukan 5. Macam — macam Diagnosis keturangan, keteluan atau nurut WHO ieanya esalanan. olen 8. Princiar Disgnasts arena. tty, Keengrapan 1 ‘Again diagnosis yang ream meds menmakan ‘tegatkan pasien seieian ersyaratan untuk menentukan oxy yang. tenitama agnosis, senungga ertanggung Jawan Neqssama antsta dotier dan menyebankan admission petugas koang —sangat pacien. erparan aia pangguraan b. Other Diagnosis ico. Again diagnosss sain D. Tenaga Meas pric! dlagnesis yang Kelengkapan diagnosis sangat ‘menggambarkan uatu Koni citemtuksn olen t2naga meds, mana pasien mencapaitan gain alm sangat pengooatan atau mana berantung pada owter okies memperimbangkan senagalpenentu diagnosis eputunan-keputunan —untu ikarena hanya profes! doktertan memasukkannya dalam yang mempurya ak dan pemerissaan leh larjut tanggung — jawab untuk ©. Campacanon manentukan agnosie pacian Suatu diagnosis tambahan Dokter yang merawat juga yang menggamoarman sutu Dertanggung jawap alas Konallel yang muncu! seteiah pengonatan pasien, narus cmulsinys obeervas! gan memiin xongisi wtama dan perawatan dl rumah sat yang ondis! tan yang sesua! dalan memgenganini —_perjalanan perioge perawatan. pasien atu asuhan meds c. Tenaga Rekam Medie yang) cutumkan oleh Petugs koging —senagat pasien ©, pemoen kogng nertanggung 6 Faktor — faktor Pengaruh jawat stse Kakurstan ode ‘Akuraal Kods Penyakit giagnosis yang sudan.GAIMAN cme