Cover PK 1

BAB III
HASIL KEGIATAN DAN PEMBAHASAN
A. Sistem Muskoloskeletal
1. Kode Diagnosa
Hasil Kegiatan dan Pembahasan
No No. Tgl Masuk Tgl Keluar Anamnesa Dx

RM
1 053917 11/29/2016 11/30/2016 Nyeri lutut dan Artrosis
sulit berjalan
No. Leadterm Arthrosis

Arthosis (deformans)
Volume 3 Hal. 65
(degenerative) M19.9
1 Volume 1 Hal. 568 M 19.96 Artrosis of knee joint
Kode Akhir M 19.96

RM
2 242616 4/28/2017 4/29/2017 Nyeri pada kaki Rupture Tendon
Extensor
No. Leadterm Rupture

Rupture
- tendon (traumatic) — see also
Volume 3 Hal. 562 Injury, muscle
- - nontraumatic M66.5
2 - - - extensor M66.2
M 66.2 Rupture of extensor
Volume 1 Hal. 586
tendons
Kode Akhir M 66.2
No No. RM Tgl Tgl Anamnesa Dx

Masuk Keluar
3 227569 3/12/2017 3/15/2017 Luka pada Fascititis
telapak kaki Necrotizing
7
8
No. Leadterm Fasciitis

Fasciitis
Volume 3 Hal. 272
-Necrotozing M72.6
3 Volume 1 Hal. 589 M 72.6 Necrotizing fasciitis
Kode Akhir M 72.6
No No. RM Tgl Tgl Keluar Anamnesa Dx

Masuk
4 193694 5/4/2017 5/5/2017 Sakit punggung scoliosis
No. Leadterm Scoliosis

Scoliosis (aquired) (postural)
Volume 3 Hal. 568
M41.9
4
Volume 1 Hal. 577 M 41.9 Scoliosis,unspecified
Kode Akhir M 41.9

Masuk
5 227887 8/1/2017 10/1/2017 Jari Bengkok Deformity
No. Leadterm Deformity

Deformity
Volume 3 Hal. 180
-finger (aquired) M20.0
5 Volume 1 Hal. 569 M 20.0 Deformity of finger
Kode Akhir M 20.0

Masuk
6 237057 2/27/2017 3/2/2017 Luka pada Fascititis
telapak kaki Necrotizing
No. Leadterm Fasciitis

Fasciitis
Volume 3 Hal. 272
-Necrotozing M72.6
6 Volume 1 Hal. 589 M 72.6 Necrotizing fasciitis
Kode Akhir M 72.6
9
No. No. Tgl Masuk Tgl Keluar Anamnesa Dx

RM
7. 215149 17/05/2017 18/05/2017 nyeri Displacement
punggung. intervertebral
disk
No. Leadterm Displacement

7. Volume 3 Hal 231 Displacement
- intervertebal disk NEC M51.2
Volume 1 Hal 581 M51.2 Other specified
intervertebral disc
displacement
Kode Akhir M51.2
No. No. RM Tgl Masuk Tgl Keluar Ananmnesa Dx

8. 139026 20/02/2017 22/02/2017 nyeri Spondylosis
punggung,
mati rasa dan
kesemutan.
No. Leadterm Spondylosis

8. Volume 3 Hal 585 Spondylosis M47.9
Volume 1 Hal 580 M47.9 Spondylosis,
unspecified
Kode Akhir M47.9
No. No. RM Tgl Masuk Tgl Keluar Anamnesa Dx

9. 204950 11/04/2017 13/04/2017 rasa tidak Myalgia
nyaman pada
otot, nyeri,
kejang.
No. Leadterm Myalgia

9. Volume 3 Hal 429 Myalgia (intercostal) M79.1
Volume 1 Hal 591 M79.1 Myalgia
Kode Akhir M79.1

10. 121582 12/03/2017 15/03/2017 nyeri saat Sciatica
berjalan
10
No. Leadterm Sciatica

10. Volume 3 Hal 566 Sciatica (infective) M54.3
Volume 1 Hal 582 M54.3 Sciatica
Kode Akhir M54.3

11. 132669 11/01/2017 14/01/2017 nyeri dari Sindrom
leher, bahu cervicobrachial
sampai ke
ujung jari
No. Leadterm Syndrome

11. Volume 3 Hal 602 Syndrome
- cervicobrachial (diffuse) M53.1
Volume 1 Hal 582 M53.1 Cervicobrachial
syndrome
Kode Akhir M53.1

12. 210833 10/04/2017 13/04/2017 lelah, Lupus
bengkak sistemik
pada sendi.
No. Leadterm Lupus

12. Volume 3 Hal 403 Lupus
- erythematosus
- - systemic M32.9
Volume 1 Hal 574 M32.9 Systemic lupus
erythematosus, unspecified

13. 159245 22/03/2017 25/03/2017 mati rasa di Cervicalgia
bagian
belakang
kepala.
No. Leadterm Cervicalgia

13. Volume 3 Hal 102 Cervicalgia M54.2
Volume 1 Hal 582 M54.2 Cervicalgia
Kode Akhir M54.2
11
No. No. RM Tgl Masuk Tgl Keluar Ananmnesa Dx

14. 210478 02/01/2017 04/01/2017 nyeri, mati Radiculopathy
rasa, dan
kesemutan.
No. Leadterm Radiculopathy

14. Volume 3 Hal 549 Radiculopathy (see also
Radiculitit) M54.1
Volume 1 Hal 582 M54.16 Radiculopathy of
lumbar region
Kode Akhir M54.16

15. 210478 13/03/2017 15/03/2017 benjolan di Ganglion
pergelanga
tangan.
No. Leadterm Ganglion

15. Volume 3 Hal 294 Ganglion (compound)
(diffuse) (joint) (tendon
(steath)) M67.4
Volume 1 Hal 587 M67.4 Ganglion
Kode Akhir M67.4

16. 139731 14/01/2017 19/01/2017 nyeri pada Fracture
tulang. malunion
No. Leadterm Fracture

16. Volume 3 Hal 288 Fracture
- malunion M84.0
Volume 1 Hal 593 M84.0 Malunion of fracture
Kode Akhir M84.0

17. 150921 17/01/2017 19/01/2017 nyeri, kaku, Arthritis
bengkak.
No. Leadterm Arthritis

17. Volume 3 Hal 61 Arthritis
Volume 1 Hal 565 M13.9 Arthritis, Unspecified
Kode Akhir M13.9
12

18. 213324 21/03/2017 24/03/2017 Nyeri otot Myositis
No. Leadterm Myositis

18. Volume 3 Hal 433 Myositis
Volume 1 Hal 584 M60.9
Kode Akhir M60.9

19. 175786 05/01/2017 07/01/2017 nyeri di Arthritis
kaki. pada fibula
No. Leadterm Arthritis

19. Volume 3 Hal 61 Arthritis, arthritic (acute)
(chronic) (subacute) M13.9
Volume 1 Hal 565 M13.96 Arthritis, unspecified
of fibula
Kode Akhir M13.96

RM
20. 210904 21/02/2017 24/02/2017 nyeri punggung, (low
kaki baal. back
pain)
LBP
No. Leadterm Pain

20. Volume 3 Hal 496 Pain
- low back M54.5
Volume 1 Hal 583 M54.5 Low back pain
Kode Akhir M54.5
2. Kode Tindakan

No. No. RM Tgl Masuk Tgl Keluar Tx
1. 229863 10/04/2017 14/04/2017 Excision tendon
of hand
13
No. Leadterm Excision

1. Alfabetical Hal 320 Excision
Index - tendon
- - hand 82.21
Tabular List Hal 201 82.21 Excision of lesion of
tendon sheath of hand
Kode Akhir 82.21

2. 243467 20/03/2017 24/03/2017 Injection
No. Leadterm Injection

2. Alfabetical Hal 351 Injection
Index - Ligament (joint)
(therapeutic substance)
81.92
Tabular List Hal 200 81.92 Injection of therapeutic
substance into joint or
ligament
Kode Akhir 81.92

3. 764520 02/02/2017 05/02/2017 Exercise
No. Leadterm Exercise

3. Alfabetical Hal 324 Exercise
Index - Active
musculoskeletal 93.12
Tabular List Hal 239 93.12 Other active
musculoskeletal exercise
Kode Akhir 93.12
No No.RM Tgl. Masuk Tgl. Keluar Tx

4. 208922 02/06/2016 05/06/2016 Biopsy of radius
No Leadterm Biopsy
4. Alfabetic Index Hal. 277 Biopsy
-bone
--radius 77.43
14

5. 172172 19/04/2017 21/04/2017 Open reduction
without fixation
of tibia
No. Leadterm Reduction

5. Alfabetical Hal 400 Reduction
Index - fracture
- - leg
- - - open 79.26
Tabular List Hal 192 79.26 Open reduction of
fracture without internal
fixtation of tibia
Kode Akhir 79.26
B. Sistem Respirasi
1. Kode Diagnosa
No. Tgl
No. Tgl Keluar Anamnesa Dx
RM Masuk
1. 242890 3/5/2017 8/5/2017 Panas Bronchopneumonia
No. Leadterm Pneumonia

Pnemonia
Volume 3 Hal. 517
-bronco
1.
Volume 1 Hal. 463 J 18.0 Bronchopneumonia
Kode Akhir J 18.0
No.
No. Tgl Masuk Tgl Keluar Anamnesa Dx
RM
2. 235768 23/2/2017 23/2/2017 Sesak nafas Asthma
15
No. Leadterm Asthma

Asthma,asthmatic (bronchial)
Volume 3 Hal. 67
(catarrh) (spasmodic) J45.9
2. J 45.9 asthma, unspecified
Volume 1 Hal. 473
asthmatic bronchitis NOS
Kode Akhir J 45.9

RM
3. 240160 31/3/2017 3/4/2017 mimisan, Tonsilitis
muntah -
No. Leadterm Tonsilitis

Tonsilitis, (acute) (follicular)
(gangrenous) (infective) (lingual)
Volume 3 Hal. 622
(septic) (subacute) (ulcerative)
3. J03.9
J 03.9 Acute Tonsilitis,
Volume 1 Hal. 458
Unspecified
Kode Akhir J 03.9

RM
4. 229797 24/11/2016 29/11/2016 Nyeri nelen, Faringitis akut
demam, sulit
menelan
No. Leadterm Pharyngitis

Pharyngitis (acute) (catarrhal)
(gangrenous) (infective)
Volume 3 Hal. 511
(subacute) (suppurative)
4. (ulcerative) J02.9
J 02.9 Acute pharyngitis,
Volume 1 Hal. 456
unspecified
Kode Akhir J 02.9

RM
5. 228321 7/11/2016 11/11/2016 Sulit Menelan Abses
- Peritonsil
sinistra
16
No. Leadterm Abscess

Abscess
Volume 3 Hal. 20
-peritonsilar J36
5. Volume 1 Hal. 468 J 36 Peritonsilar Abscess
Kode Akhir J 36

6. 214218 10/5/2017 12/5/2017 Batuk Bronchitis
No. Leadterm Bronchitis

Bronchitis
-acute or subacute (with
Volume 3 Hal. 83 bronchospasm or obstruction)
6. J20.9
Volume 1 Hal. 464 J 20.9 Acute Bronchhitis

Kode Akhir J 20.9

RM
7. 229374 19/11/2016 25/11/2016 Sesak Respyrasi
Failure
No. Leadterm Failure

Failure
Volume 3 Hal. 271
-respiratory J96.9
7. J 96.9 Respiratory failure,
Volume 1 Hal. 481
unspecified
Kode Akhir J 96.9
Tanggal Tanggal
No. No RM Anamnesa Dx
Masuk Keluar
8. 202247 21/03/2017 24/02/2017 Sesak nafas ISPA
17
No
Leadterm Infection
.
Volume 3 Hal. 355 Infection
-respiratory (tract) NEC
- - upper (acute) NEC J06.9
8.
Volume 1 Hal. 459 J06.9 Acute upper respiratory infection,
unspecified.
Kode Akhir J06.9
Tanggal Tanggal
No. No RM Anamnesa Dx
Masuk Keluar
9. 202362 03/03/2017 04/03/2017 sesak napas Efusi Pleura
sejak 1 bulan
yang lalu,
lemas, muntah
(+), BAB cair
No
Leadterm Effusion
.
Volume 3 Hal. 248 Effusion
- Pleura, pleurisy, pleuritic,
pleuropericardial J90
9.
Volume 1 Hal. 479 J90 Pleural effusion, not elsewhere
classified
Kode Akhir J90

10. 202275 24/02/2017 25/02/2017 sesak napas Pneumonia
selama 1 syncytial
bulan virus
No. Leadterm Pneumonia

10. Volume 3 Hal 519 Pneumonia
- respiratory syncytial
virus J12.1
Volume 1 Hal 461 J12.1 Respiratory syncytial
virus pneumonia
Kode Akhir J12.1
18

11. 837865 21/04/2017 23/04/2017 Pasien datang Abses
dengan keluhan para
bengkak di pharingeal
leher.
No. Leadterm Abscess

11. Volume 3 Hal 20 Abscess
- parapharyngeal J39.0
Volume 1 Hal 470 J39.0 Retropharyngeal and
paeaphaeyngeal abscess
Kode Akhir J39.0
No No.RM Tgl. Masuk Tgl. Keluar Anamnesa Dx

12. 202461 01/08/2016 05/08/2016 Pilek,Nyeri Acute
kepala (+), sinusitis
nyeri pd
pangkal
hidung (+),
demam (+)
No Leadterm Sinusitis
12. Volume 3 Hal 580 Sinusitis acute J01.9
Volume 1 Hal 457 J01.9 Acute sinusitis, unspecified
Kode Akhir J01.9

13. 200857 20/01/2017 22/01/2017 Pasien datang Tonsilitis
dengan keluhan hiperthropy
nyeri saat
menelan.
No. Leadterm Hypertrophy

13. Volume 3 Hal 336 Hypertrophy
- tonsils (faucial)
(infecive) (lingual)
(lympoid) J35.1
Volume 1 Hal 467 J35.1 Hypertrophy of tonsils
Kode Akhir J35.1
19
Tanggal Tanggal
No No RM Anamnesa Dx
Masuk Keluar
14.` 202295 18/04/2017 19/04/2017 Polip nasal
cavity
No Leadterm Polyp
Volume 3 Hal. 524 Polyp, polypus
- nasal
14. - - cavity J33.0
Volume 1 Hal. 467 J33.0 Polyp of nasal cavity
Kode Akhir J33.0
No No.RM Tgl. Masuk Tgl. Keluar Anamnesa Dx

15. 168643 02/05/2017 05/05/2017 - Chronic
obstructive
pulmonary
disease
No Leadterm Disease
15. Volume 3 193 Disease
-airway, obstructive
J44.9
Volume 1 524 J44.9 Chronic
obstructive pulmonary
disease, unspecified
Kode Akhir J44.9

16. 202757 14/02/2017 16/02/2017 nyeri saat Tonsillitis
menelan - Chronic
No. Leadterm Tonsilitis

16. Volume 3 Hal 622 Tonsillitis
- Chronic J35.0
Volume 1 Hal 467 J35.0 Chronic Tonsillitis
Kode Akhir J35.0

17. 202954 28/04/2017 29/04/2017 sesak napas, Edema
batuk berdahak. paru
20
No. Leadterm Edema

17. Volume 3 Hal 246 Edema
- lung (acute) J81
Volume 1 Hal 478 J81 Pulmonary oedema
Kode Akhir J81

18. 240908 22/03/2017 25/03/17 sesak napas, Fibrosis
batuk kering, lung
kelelahan.
No. Leadterm Fibrosis

18. Volume 3 Hal 278 Fibrosis
- lung (atrophic)
(capillary) (chronic)
(confluent) (massive)
(perialveolar)
(peribronchial) J84.1
Volume 1 Hal 478 J84.1 Other intersitial
pulmonary diseases with
fibrosis
Kode Akhir J84.1
Tanggal Tanggal
Masuk Keluar
19. 00209823 09/03/2017 13/03/2017 Rinitis
kronis
No Leadterm Rhinitis
Volume 3 Hal. 557 Rhinitis (catarrhal) (fibrinous)
(membranous)
19. - Chronic J31.0
Volume 1 Hal. 466 J31.0 Chronic rhinitis
Kode Akhir J31.0
Tanggal Tanggal
Masuk Keluar
20. 190831 11/03/2017 13/03/2017 Pneumothorax
acute
21
No Leadterm Pneumothorax
Volume 3 Hal. 520 Pneumothorax

- Acute J93.8
20.
Volume 1 Hal. 480 J93.8 Other pneumothorax
Kode Akhir J93.8
Karena pada penelitian ditemukan banyak anamnesa pada Dokumen Rekam Medis
(DRM) yang tidak lengkap dan tidak bisa dibaca oleh peneliti, maka kolom
anamnesa tidak semuanya dapat ditulis dan yang tidak lengkap diberi tanda (-) pada
kolom anamnesa.
2. Kode Tindakan

1. 200876 15/03/2016 17/03/2016 Laryngoscopy
No Leadterm Laryngoscopy
1. Alfabetic Index Hal. 364 Laryngoscopy
(suspension) 31.42
Tabular List Hal. 69 31.42 Laryngoscopy
and other tracheoscopy
Kode Akhir 31.42

2. 227634 29/02/2017 01/03/2017 Tonsillectomy
No. Leadterm Tonsillectomy

2. Alfabetical Hal 447 Tonsillectomy 28.2
Index
Tabular List Hal 66 28.2 Tonsillectomy without
adenoidectomy
Kode Akhir 28.2

3. 202355 01/04/2016 04/04/2016 Pharyngoscopy
22
No Leadterm Pharyngoscopy
3. Alfabetic Index Hal. 389 Pharyngoscopy 29.11
Tabular List Hal. 66 29.11 Pharyngoscopy
Kode Akhir 29.11

4. 191448 25/03/2017 27/05/2017 Augmentation
rhinoplasty
No. Leadterm Rhinoplasty
4. Alfabetical Hal 431 Rhinoplasty

Index Augmentation (with graft)
(with synthetic implant) 21.85
Tabular List Hal 57 21.85 Augmnetation
rhinoplasty
Kode Akhir 21.85

5. 172389 20/02/2017 22/02/2017 Pneumonectomy
No Leadterm Pneumonectomy
5. Alfabetic Index Hal. 391 Pneumonectomy(comp
lete) 32.5
Tabular List Hal. 71 32.5 Complete
pneumonectomy
C. Sistem Kardiovaskuler
3. Kode Diagnosa
Tgl
No No. RM Tgl Keluar Anamnesa Dx
Masuk
1 241520 16/4/2017 19/4/2017 Nyeri Perut, atherosclerotic
mual, muntah, heart disease
pusing (ASHD)
23
No. Leadterm Atherosclerotic

Arteriosclerosis
Volume 3 Hal. 61
-Heart (disease)
1 I 25.1 atherosclerotic heart
Volume 1 Hal. 425
disease
Kode Akhir I 25.1
Tgl
Masuk
2 242152 23/4/2017 29/4/2017 Lemas, Pusing Hypertensi
No. Leadterm Hypertensi

Hypertension (accelerated)
(benign) (essential) (idiopathic)
Volume 3 Hal. 332
(malignant) (primary) (systemic)
2 I10
I 10 Essensial (Primary)
Volume 1 Hal. 421
Hypertension
Kode Akhir I 10
Tgl
Masuk
Sesak Napas, Coronary Artery
3 235907 5/2/2017 7/2/2017
Pusing, Mual Disease (CAD)
No. Leadterm Disease

3. Volume 3 Hal 207 Disease
- coronary (artery) I25.1
Volume 1 Hal 426 I25.1 Artherosclerotic heart
disease
Kode Akhir I25.1
No No. RM Tgl Masuk Tgl Keluar Anamnesa Dx

Jantung
ventricular
4. 243490 9/5/2017 10/5/2017 brdebar lebih
tachycardia
cepat
No. Leadterm Tachycardia

Tachycardia
Volume 3 Hal. 613
-venticurar
4. Volume 1 Hal. 435 I 47.2 ventricular tachycardia
Kode Akhir I 47.2
24

Masuk
5 237765 15/3/2017 16/3/2017 Benjolan di Varicocelle
buah zakar
No. Leadterm Varicocelle

Varicocelle (thrombosed)
Volume 3 Hal. 648
(scrotum) I86.1
5 I 86.1 Scrotal Varices
Volume 1 Hal. 451
(Varicocele)
Kode Akhir I 86.1
Tgl
Masuk
6. 241153 11/4/2017 15/4/2017 Sesak,nafas Gagal Jantung
berbunyi

Failure
Volume 3 Hal. 269 -congestive (see also
6. failure,heart,congestive) I50.0
Volume 1 Hal. 473 I 50.0
Kode Akhir I 50.0 Congestive heart failure

7. 231460 11/02/2017 14/02/2017 lemas, muntah Cardiomegaly
, batuk
No. Leadterm Cardiomegaly

7. Volume 3 Hal 97 Cardiomegaly (see also
Hypertrophy, cardiac) I51.7
Volume 1 Hal 438 I51.7 Cardiomegaly
Kode Akhir I51.7
Tgl
Masuk
Cerebral
Kejang,sakit
8. 241630 17/4/2017 21/4/2017 infaction
kepala
trombosis
25
No. Leadterm Occlusion

Occlusion
-artery
--cerebral
Volume 3 Hal. 619
---posterior
8. ----with infarcition (due to) 163.5
-----thrombosis I63.3
I 63.3 Cerebral infarction
Volume 1 Hal. 440
trombosis of cerebral arteries
Kode Akhir I 63.3
Tgl
Masuk
Nyeri rahang,
9. 240168 1/4/2017 3/4/2017 Nyeri pada kulit Arteritis
kepala
No. Leadterm Arteritis

Volume 3 Hal. 61 Arteritis I77.6
9 Volume 1 Hal. 446 I 77.6 Arteritis, unspecified
Kode Akhir I 77.6
Tgl
Masuk
Penurunan
10. 102654 27/3/17 30/3/17 Stroke
Kesdaran
No. Leadterm Stroke

10. Volume 3 Hal 596 Stroke (apopletic) (brain) (paralytic)
I64
Volume 1 Hal 440 I64 Stroke not specified as
haemorrhage or infarction
Kode Akhir I64
Tgl
Masuk
Pola nafas tidak Pulmonary
11. 188669 2/2/2016 4/3/2017
teratur heart disease
26

- Pulmonary
- - heart I27.9
Volume 1 Hal 427 I27.9 Pulmonary heart disease,
unspecified
Kode Akhir I27.9
Tgl
Masuk
12. 216721 15/4/2016 16/4/2016 sesak nafas Heart disease

Disease
Volume 3 Hal. 208
-heart (organic) I51.9
12. Volume 1 Hal. 438 I 51.9 Heart disease, unspecified
Kode Akhir I 51.9

13. 236676 17/04/2017 20/04/2017 Stenocardia
No. Leadterm Stenocardia

13. Volume 3 Hal 589 Stenocardia I20.8
Volume 1 Hal 422 I20.8 Other forms of angina
pectoris
Kode Akhir I20.8
Tgl
Masuk
nyeri dada,
14. 196372 7/9/2016 9/9/2016 cardiomyopathy
sesak nafas
No. Leadterm Cardiomyopathy

14. Volume 3 Hal 97 Cardiomyopathy
- dilated I42.0
Volume 1 Hal 432 I42.0 Dilated cardiomyopathy
Kode Akhir I42.0

15. 213587 22/11/2016 23/11/2016 penurunan Hypertensi
kesadaran. esential
27
No. Leadterm Hypertension

15. Volume 3 Hal 332 Hypertension (accelerated)
(benign) (essential) (idiopatic)
(malignant) (primary)
(systemic) I10
Volume 1 Hal 421 I10 Essential (primary)
hypertension
Kode Akhir I10

16. 043642 6/12/2016 7/12/2016 Pasien kejang Fibrilation
muntah . atrial
No. Leadterm Fibrilation

16. Volume 3 Hal 276 Fibrilation
- atrial or auricular
(established) I48
Volume 1 Hal 435 I48 Atrial fibrilation and flutter
Kode Akhir I48
Tgl
Masuk
17 211829 26/1/2017 27/1/2017 sembelit Hemorrhoids
No. Leadterm Hemorrhoids

17. Volume 3 Hal 316 Hemorrhoids
- internal
- - bleeding, prolapsed,
strangulated or
ulcerated I84.1
Volume 1 Hal 450 I84.1 Internal haemorrhoids
with other complications
Kode Akhir I84.1

pembengkakan
18. 128697 27/6/2016 27/6/2016 lymphadenitis
leher
28
No. Leadterm Lymphadenitis

Volume 3 Hal. 404 Lymphadenitis I88.9
I 88.9 Nonspecific lymphadenitis,
18. Volume 1 Hal. 452
unspecified
Kode Akhir I 88.9

Acute myocardial
19 211526 5/3/2016 6/3/2016 Nyeri dada
infarction, (AMI)
No. Leadterm Infarct

19. Volume 3 Hal 347 Infarct
- myocardium (acute or
with a stated duration of
weeks or less) I21.9
Volume 1 Hal 424 I21.9 Acute myocardial
infarction, unspecified
Kode Akhir I21.9

20. 226879 02/03/2016 05/03/2016 nyeri dada, Rheumatic
jantung heart
berdebar- disease
debar, sesak (RHD)
napas.

- heart
- - rheumatic (chroni) (inactive)
(old) (quiscent) (with chorea)
I09.9
Volume 1 Hal 420 I09.9 Rheumatic heart disease,
unspecified
Kode Akhir I09.9
29
2. Kode Tindakan

1. 128833 12/03/2017 14/03/2017 Aorticopumonary
window
operation
No. Leadterm Operation

1. Alfabetical Hal 376 Operation
Index - aorticopulmonary
window 39.59
Tabular List Hal 102 39.59 Other repair vessel
Kode Akhir 39.59

2. 215986 27/10/2016 29/10/2016 Electrocardiogram
(EKG)
No Leadterm Electrocardiogram
2. Alfabetic Index 308 EKG –see also
electrocardiogram
308 Electrocardiogram
89.52
Tabular List 234 89.52
Electrocardiogram
Kode Akhir 89.52

3. 214730 03/11/2016 06/11/2016 Replacement
30
No. Leadterm Replacement

3. Alfabetical Hal 422 Replacement
Index - cardioverter/defibrillator
(total system) 37.94
Tabular List Hal 93 37.94 Implantation or
replacement of automatic
caridoverter/defibrillator, total
system
Kode Akhir 37.94

4. 232734 14/07/2016 15/05/2016 Echography
No Leadterm Echograpy
4. Alfabetic Index 308 Echograpy 88.72
Tabular List 230 88.72 Diagnostic
ultrasound of heart
Kode Akhir 88.72

5. 225878 04/03/2017 05 Echocardiography
/03/2017
No Leadterm Echocardiography
5. Alfabetic Index 449 Echocardiography – see
ultrasonography
Ultrasonography
-heart 88.72
Tabular List 254 88.72 diagnostic
ultrasound of
Kode Akhir 88.72
Karena pada pencarian kode tindakan di Rumah Sakit Umum Daerah Cideres,
peneliti hanya dapat menemukan tindakan yang bercampuran antara non operatif
dan operatif, maka peneliti menulis sesuai apa yang didapat ditempat praktiknya.
31
D. Sistem Digestive
1. Kode Diagnosa

1. 235768 23/2/2017 25/2/2017 Nyeri Ulu ati Gastritis
No. Leadterm Gastritis

Volume 3 Hal. 295 Gastritis
1. -acute (erosive) K29.1
Volume 1 Hal. 502 K 29.1 Other Acute Gastritis
Kode Akhir K 29.1

Sering merasa Ulcerative
2. 241636 17/4/2017 22/4/2017
lapar Colitis
No. Leadterm Colitis

Volume 3 Hal. 111 Colitis
2. -ulcerative (crhonic) K51.9
Volume 1 Hal. 502 K 51.9 Ulcerative colitis,
unspecified
Kode Akhir K 51.9

3. 238884 5/4/2017 6/4/2017 Benjolan pada Hernia
lipat paha kaki Inguinalis (HIL)
No. Leadterm Hernia

3 Volume 3 Hal. 319 Hernia
-inguinal (direct) (external) (funicular)
(indirect) (internal) (oblique) (scrotal)
(sliding) K40.9
Volume 1 Hal. 505 K 40.9 unspecified inguinal hernia
Kode Akhir K 40.9

32

4. 236786 16/2/2017 22/2/2017 Perut nyeri Ileus paralitik
No. Leadterm Ileus

Volume 3 Hal. 341 Ileus
4. -paralytic K56.0
Volume 1 Hal. 511 K 56.0 Paralytic Ileus
Kode Akhir K 56.0

5. 239309 21/3/2017 24/3/2017 Nyeri pada perut Pancreatitis
No. Leadterm Pancreatitis

Volume 3 Hal. 498 Pancreatitis
5. -acute K85.9
Volume 1 Hal. 526 K 85.9 Acute Pancreatitis,
Unspecied
Kode Akhir K 85.9

6. 235062 26/1/2017 31/1/2017 Panas, Mata Hepatitis
kuning, pusing
No. Leadterm Hepatitis

Volume 3 Hal. 317 Hepatitis
6. -toxic (see also Disease, liver,
toxic) K71.6
Volume 1 Hal. 519 K 71.6 Toxic liver diases with
hepatitis
Kode Akhir K 71.6

7. 118792 21/2/2017 24/2/2017 Nyeri perut, Appendicitis
mual, muntah Akut
33
No. Leadterm Appendicitis

Volume Hal. 59 Appendicitis
3 -with—continued
7. - - peritonitis, generalized K35.2
Volume Hal. 504 K 35.2 Acute Appendicitis with
1 generalized peritonitis
Kode Akhir K 35.2

8. 140155 24/3/2017 28/3/2017 Mual, muntah, Peritonitis
mencret
No. Leadterm Peritonitis

Volume Hal. 508 Peritonitis (adhesive) (fibrinous)
8. 3 (with effusion) K65.9
Volume Hal. K 65.9 Peritonitis, Unspecified
1 517
Kode Akhir K 65.9

9. 242152 23/4/2017 29/4/2017 Mual, nyeri perut Ileus Obs
No. Leadterm Ileus

Volume 3 Hal. 341 Ileus
9. -obstructive NEC K56.6
Volume 1 Hal. 512 K 56.6 Ileus Obstruction
Kode Akhir K 56.6

10. 140155 24/3/2017 28/3/2017 Mual, muntah, Adhesi
mencret, demam
No. Leadterm Adhesions

Volume 3 Hal. 34 Adhesions K66.0
10. Volume 1 Hal. 517 K 66.0 Peritoneal Adhesions
Kode Akhir K 66.0
34

11. 237991 3/7/2017 3/9/2017 Demam Cellulitis
No. Leadterm cellulitis

Volume 3 Hal. 101 Cellulitis
11. -mouth (floor) K12.2
Volume 1 Hal. 496 K 12.2 Cellulitis and abses mouth
Kode Akhir K 12.2

RM
12. 229374 19/11/16 25/11/16 Mual Liver

Volume Hal. 101 Disease
3 -liver
12. --inflammatory K75.9
Volume Hal. 522 K 75.9 inflamatory liver disease,
1 unspecified
Kode Akhir K 75.9

13. 230454 22/11/2016 25/11/2016 sesak napas, Stomatitis
demam 3 hari,
No. Leadterm Stomatitis

Volume 3 Hal 592 Stomatitis (denture)
13. (ulceratice) K12.1
Volume 1 Hal 496 K12.1 Other form of stomatitis
Kode Akhir K12.1
No. No. RM Tgl Tgl Anamnesa Dx

Masuk Keluar
14. 830956 10/05/17 15/05/17 BAB Dyspepsia
cair,muntah
(+)
35
No. Leadterm Dyspespia

Volume 3 Hal 241 Dyspepsia(allergic)
14. (congenital)(gastrointestinal)
(occupational) (reflex) K30
Volume 1 Hal 502 K30 Dyspepsia
Kode Akhir K30

RM
15. 225461 02/02/2017 05/02/2017 sakit kepala, Failure Hepatic
demam selama 2
hari naik turun,
muntah (+), BAB
sperti dempuk,
timbul ruam-
ruam merah

15. Volume 3 Hal 270 Failure
- hepatic K72.9
Volume 1 Hal 520 K72.9 Hepatic failure,
unspecified
Kode Akhir K72.9

16. 211730 05/04/2017 08/04/2017 mual dan Esopagitis
muntah, batuk
berdahak.
No. Leadterm Esophagitis

16. Volume 3 Hal 264 Esophagitis (acute) (alkaline)
(chemical) (chronic) (infection)
(necrotic) (peptic)
(postoperative) K20
Volume 1 Hal 499 K20 Oesophagitis
Kode Akhir K20
36

17. 241787 24/01/2017 27/01/2017 nyeri pada Gastro-
ulu hati, oesophageal
suara serak, reflux
kesulitan disease
menelan. (GERD)
No. Leadterm Reflux

17. Volume 3 Hal 552 Reflux
- esophageal K21.9
Volume 1 Hal 499 K21.9 Gastro-oesophageal
reflux disease without
oesophagitis
Kode Akhir K21.9

18. 203565 12/04/2017 14/04/2017 kelelahan, Cirrhosis
bengkak di
pergelangan
kaki, demam
(+), sesak napas.
No. Leadterm Cirrhosis

18. Volume 3 Hal 108 Cirrhosis (hepatic) K74.6
Volume 1 Hal 521 K74.6 Other and unspecified
cirrhosis of liver
Kode Akhir K74.6

19. 231466 03/11/2016 05/11/2016 BAB berdarah, Melena
lemas (+), sakit
kepala, dada
terasa nyeri.
No. Leadterm Melena

19. Volume 3 Hal 420 Melena K92.1
Volume 1 Hal 529 K92.1 Melaena
Kode Akhir K92.1
37

20. 225466 16/09/2016 18/09/2016 keluar darah Pendarahan
aat BAB, anus
nyeri saat
BAB.
No. Leadterm Hemmorrhage

20. Volume 3 Hal 311 Hemorrhage
- anus (sphinter) K62.5
Volume 1 Hal 515 K62.5 Haemorrhage of anus
and rectum
Kode Akhir K62.5
2. Kode Tindakan

1. 118792 21/2/2017 24/2/2017 Appendectomy
No. Leadterm Appendectomy

1. Alfabetical Hal 270 Appendectomy (with
Index drainage) 47.09
Tabular List Hal 126 47.09 Other appendectomy
Kode Akhir 47.09

2. 238884 5/4/2017 6/4/2017 Pro herniotomy
No. Leadterm Pro herniotomy

2. Alfabetic Index 417 Pro herniotomy
Repair
-hernia
--femoral
---bilateral 53.39
Tabular List 140 53.39 Other bilateral
femoral herniorrhapy
Kode Akhir 53.39
38

3. 213314 20/04/2017 23/04/2017 Bilateral repair
of inguinal
hernia
No. Leadterm Repair

3. Alfabetical Hal 417 Repair
Index - Inguinal
- - bilateral 53.10
Tabular List Hal 140 53.10 Bilateral repair of
inguinal hernia, not otherwise
specified
Kode Akhir 53.10

4. 191244 12/02/2017 15/02/2017 Esophagogastroduodenoscpoy
(EGD)
No. Leadterm Esophagogastroduodenoscpoy

4. Alfabetical Hal 312 Esophagogastroduodenoscpoy
Index - with closed biopsy 45.16
Tabular Hal 119 45.16
List Esophagogastroduodenoscpoy
[EGD] with closed biopsy
Kode Akhir 45.16

5. 117543 17/10/2016 22/10/2016 Hemorrhoidectomy
No. Leadterm Hemorrhoidectomy

5. Alfabetic Index Hal. 338 Hemorrhoidectomy
49.46
Tabular List Hal . 130 49.46 Excision of
hemorrhoid
Kode Akhir 49.46
Karena pada pencarian kode tindakan di Rumah Sakit Umum Daerah Cideres,
peneliti hanya dapat menemukan tindakan yang bercampuran antara non operatif
dan operatif, maka peneliti menulis sesuai apa yang didapat ditempat praktiknya.
39
E. Sistem Endokrin
1. Kode Diagnosa
1. 199606 12/5/2017 14/5/2017 pusing, mual (+), hypoglycemia
jantung
No. Leadterm hypoglycemia

Hypoglycemia
Volume 3 Hal. 337
(spontaneous) E16.2
1.
Volume 1 Hal. 255 E 16.2 Hypoglicaemia, unspecified
Kode Akhir E 16.2

2. 242565 28/4/2017 29/4/2017 Nyeri ulu ati, sesak Diabetes
dada Melitus (DM)
type II
No. Leadterm Diabetes

Volume 3 Hal 201 Diabetes
2. - non-insulin-dependent E11.-
Volume 1 Hal 253 E11.1 Non-insulin-dependent
diabetes mellitus with ketoacidosis
Kode Akhir E11.1

3. 200985 4/5//2016 6/5/2016 muncul benjolan di gondok
leher, sulit
bernapas
No. Leadterm Goiter

Volume 3 Hal 300 Goiter (plunging) (substernal)
3. E04.9
Volume 1 Hal 250 E04.9 Nontoxic goitre, unspecified
Kode Akhir E04.9
40

4. 96618 7/4/2016 8/4/2016 sering mersa lapar, DM
berat badan turun.

4. Volume 3 Hal 200 - Diabetes (mellitus) E14.-
Volume 1 Hal 254 E14.9 Unspecified diabetes mellitus
without complication
Kode Akhir E14.9

5. 205891 3/4/2016 6/4/2016 sering terasa lapar, DM type I
mual (+), muntah
(+), sakit perut.

5. Volume 3 Hal 201 - Diabetes
- - insulin-dependent E10.-
Volume 1 Hal 253 E10.9 Insulin-dependent diabetes
mellitus without complication
Kode Akhir E10.9

6. 204223 10/3/2016 13/3/2016 berkeringat banyak, thyrotoxicosis
jantung berdebar-
debar.
No. Leadterm Thyrotoxicosis

6. Volume 3 Hal 621 Thyrotoxicosis (recurrent) E05.9
Volume 1 Hal 250 E05.9 Thyrotoxicosis,
Unspecified
Kode Akhir E05.9

jantung berdegup
kencang
41
No. Leadterm Hypoglycemia

7. Volume 3 Hal 337 Hypoglycemi (spontaneous) E16.2
Volume 1 Hal 255 E16.2 Hypoglycaemia, unspecified
Kode Akhir E16.2

8. 207670 19/6/2016 22/6/2016 muncul benjolan di gondok
leher, sulit
bernapas
No. Leadterm Goiter

8. Volume 3 Hal 300 Goiter (plunging) (substernal)
E04.9
Volume 1 Hal 250 E04.9 Nontoxic goitre, unspecified
Kode Akhir E04.9

jantung berdegup
kencang
No. Leadterm Hypoglycemia

9. Volume 3 Hal 337 Hypoglycemi (spontaneous) E16.2
Volume 1 Hal 255 E16.2 Hypoglycaemia, unspecified
Kode Akhir E16.2

10. 209301 17/3/2017 18/3/2017 nyeri di kaki, otot Hypoparathyroidism
di lengan berkedut,
pusing.
No. Leadterm Hypoparathyroidism

10. Volume 3 Hal 337 Hypoparathyroidism E20.9
Volume 1 Hal 256 E20.9 Hypoparathyroidism
Kode Akhir E20.9

11. 210038 11/3/2017 12/3/2017 sering terasa lapar, DM type I
mual (+), muntah
(+), sakit perut
42

11. Volume 3 Hal 201 - Diabetes
- - insulin-dependent E10.-
Volume 1 Hal 253 E10.9 Insulin-dependent diabetes
mellitus without complication
Kode Akhir E10.9

12. 210485 5/3/2016 6/3/2016 berkeringat banyak, thyrotoxicosis
jantung berdebar-
debar.
No. Leadterm Thyrotoxicosis

12. Volume 3 Hal 621 Thyrotoxicosis (recurrent) E05.9
Volume 1 Hal 250 E05.9 Thyrotoxicosis,
Unspecified
Kode Akhir E05.9

13. 211107 8/7/2016 10/7/2016 diare, mulut terasa Dehidrasi
kerng, mengigil
No. Leadterm Thyroiditis

13. Volume 3 Hal 621 Thyroiditis E06.9
Volume 1 Hal 251 E06.9 Thyroiditis, unspecified
Kode Akhir E06.9

14. 211319 26/7/2016 27/7/2016 sering mersa lapar, DM
berat badan turun.

14. Volume 3 Hal 200 - Diabetes (mellitus) E14.-
Volume 1 Hal 254 E14.9 Unspecified diabetes mellitus
without complication
Kode Akhir E14.9

15. 204899 15/3/2016 16/3/2016 - Graves disease
43
No. Leadterm Graves’ disease

15. Volume 3 Hal. 303 Graves’ disease E05.0
Volume 1 Hal. 272 E05.0 Thyrotoxicosis with diffuse
goitre
Kode Akhir E05.0

16 204229 2/6/2016 2/6/2016 Nyeri ulu ati, sesak NIDDM
dada

Volume 3 Hal 201 Diabetes
16. - non-insulin-dependent E11.-
Volume 1 Hal 253 E11.1 Non-insulin-dependent
diabetes mellitus with ketoacidosis
Kode Akhir E11.1

17. 126392 11/12/2016 13/12/2016 lemas, sulit Hypopituitarism
BAB. (juvenile)
No. Leadterm Hypopituitarism

17. Volume 3 Hal 337 Hypopituitarism (juvenile)
E23.0
Volume 1 Hal 257 E23.0 Hypopituitarism
Kode Akhir E23.0

18. 238833 11/05/2017 15/05/2017 mual (+), Hyperparathyroi
muntah (+), dism
BAK sering.
No. Leadterm Hyperparathyroidism

18. Volume 3 Hal 330 Hyperparathyroidism E21.3
Volume 1 Hal 256 E21.3 Hyperparathyroidism,
unspecified
Kode Akhir E21.3
44

19. 229351 20/04/2017 23/04/201 nyeri di kaki, Hypoparathyroi
7 otot di lengan dism
berkedut,
pusing.
No. Leadterm Hypoparathyroidism

19. Volume 3 Hal 337 Hypoparathyroidism E20.9
Volume 1 Hal 256 E20.9 Hypoparathyroidism
Kode Akhir E20.9

20. 231247 13/03/2017 15/03/2017 bengkak, demam DM gangrene
(+), riwayat DM
(+).

20. Volume 3 Hal 200 - Diabetes (mellitus)
E14.-
Volume 1 Hal 254 E14.5 Unspecified diabetes
mellitus with peripheral
circulatory complications
Kode Akhir E14.5
2. Kode Tindakan
Berdasarkan hasil kegiatan penelitian dan pembahasan, tidak
ditemukan tindakan pada sistem Endokrin di RSUD Cideres Kabupaten
Majalengka.
F. Sistem Urinaria
1. Kode Diagnosa

1. 233167 28/3/17 31/3/17 Sulit BAK Calculus ginjal
45
No. Leadterm Calculus

Calculus
- Kidney (impaction) (multiple)
Volume 3 Hal. 90
(pelvis) (recurrent) (staghorn)
1. N20.0
Volume 1 Hal. 613 N 20.0 Calculus of Kidney
Kode Akhir N 20.0

2. 235247 2/9/2017 2/11/2017 Nyeri pinggang Hydroneprosis
No. Leadterm Hydroneprosis

Hydroneprosis (atrophle) (early)
Volume 3 Hal. 327 (fungtionless) (intermittent)
(primary) (secondary) NEC N13.3
2.
Volume 1 Hal. 609 N 13.3 Hydroneprosis, Unspecified
Kode Akhir N 13.3

3. 235247 2/9/2017 2/11/2017 Nyeri pinggang Uretherolithiasis
No. Leadterm Uretherolithiasis

Uretherolithiasis (with colic or
Volume 3 Hal. 645
infection N21.1
3. Volume 1 Hal. 613 N 21.1 Calculus in Urethra
Kode Akhir N 21.1

4. 222796 3/3/2017 3/10/2017 Nyeri perut, Colic Renal
pinggang
No. Leadterm Colic

Colic
Volume 3 Hal. 110
- Renal N23
4. Volume 1 Hal. 613 N 23 Renal colic, unspecified
Kode Akhir N 23
46

5. 238245 3/7/2017 3/10/2017 BAK merah Cystitis
seperti teh
No. Leadterm Cystitis

Cystitis (exudative) (hemorrhagie)
Volume 3 Hal. 170
(septic) (supporative) N30.9
5. Volume 1 Hal. 616 N 30.9 cystitis, unspecified
Kode Akhir N 30.9

6. 202168 6/2/2017 7/2/2017 mencret, sesak CKD
napas (+),
muntah (+).

Disease
Volume 3 Hal. 211 - Kidney
- - cronic N18.9
6. N 18.9 Cronic Kidney disease,
Volume 1 Hal. 612
unspecified
Kode Akhir N 18.9

7. 202983 30/1/2016 1/4/2016 sakit saat BAK Calculus
urinary

Calculus
Volume 3 Hal. 91 - Urinary (duct) (impacted)
(passage) (tract) N20.9
7. N 20.9 Urinary Calculus,
Volume 1 Hal. 613
unspecified
Kode Akhir N 20.9

8. 202512 24/4/2016 26/4/2016 Sulit BAK calculus kidney
47

Calculus
- Kidney (impacted)
Volume 3 Hal. 90 (multiple) (pelvis)
8. (recurrent) (staghorn)
N20.0
Volume 1 Hal. 613 N 20.0 Calculus of kidney
Kode Akhir N 20.0

9. 203111 7/2/2016 8/2/2016 Neprhritic
syndrom
No. Leadterm syndrome

Syndrome
Volume 3 Hal. 604 - Nepritic (see also
neprhitis) N05
9. N 05 Neprhitic syndrom,
Volume 1 Hal. 606
unspecified
Kode Akhir N 05

10. 198321 21/8/2016 24/8/2016 Neprhotic
syndrom
No. Leadterm Neprhotic

Neprhotic (congenital) (epstein’s)
Volume 3 Hal. 474
(syndrome) N04
10. N 04 Neprhitic syndrom,
Volume 1 Hal. 605
unspecified
Kode Akhir N 04

11. 200928 4/4/2016 4/4/2016 Nyeri perut, colic renal
pinggang
48
No. Leadterm Colic

Colic
Volume 3 Hal. 110
- Renal N23
11. Volume 1 Hal. 613 N 23 Renal colic, unspecified
Kode Akhir N 23

12. 203254 21/8/2016 22/8/2016 BAK merah Cystitis
seperti teh
No. Leadterm Cystitis

Cystitis (exudative) (hemorrhagie)
Volume 3 Hal. 170
(septic) (supporative) N30.9
12. Volume 1 Hal. 616 N 30.9 cystitis, unspecified
Kode Akhir N 30.9

13. 235247 2/9/2017 2/11/2017 Nyeri pinggang Hydroneprosis
No. Leadterm Hydroneprosis

Hydroneprosis (atrophle) (early)
Volume 3 Hal. 327 (fungtionless) (intermittent)
(primary) (secondary) NEC N13.3
13.
Volume 1 Hal. 609 N 13.3 Hydroneprosis, Unspecified
Kode Akhir N 13.3

14. 33045 5/1/2016 6/1/2016 mencret, sesak CKD
napas (+),
muntah (+).

Disease
- - cronic N18.9
14. N 18.9 Cronic Kidney disease,
Volume 1 Hal. 612
unspecified
Kode Akhir N 18.9
49

15. 203940 10/2/2016 13/2/2016 Nepritis tubolo
instertitial
No. Leadterm Nephritis

Nephritis
Volume 3 Hal. 473
- Tubolo interstitial (in) N12
15. N 12 Tubulo-interstitial nephritis, not
Volume 1 Hal. 608
specified as acute or chronic
Kode Akhir N 12

16. 204125 13/11/2016 15/11/2016 sesak napas, Gagal ginjal
lemas, dehidrasi,
nyeri di
punggung.

Failure
16. - - acute N17.9
Volume 1 Hal. 611 N 17.9 Acute renal failure, unspecified
Kode Akhir N 17.9

17. 204822 17/9/2016 18/9/2016 Nyeri saat BAK Calculus

Calculus
- Urinary (duct) (impacted) (passage)
Volume 3 Hal. 91
(tract)
17. - - lower NEC N21.9
N 21.9 Calculus of lower urinary tract,
Volume 1 Hal. 613
unspecified
Kode Akhir N 21.9

18. 112331 14/3/2016 14/3/2016 Neprotic
50
No. Leadterm Neprhotic

Neprhotic (congenital) (epstein’s)
Volume 3 Hal. 474
(syndrome) N04
18. Volume 1 Hal. 605 N 04 Neprhitic syndrom, unspecified
Kode Akhir N 04

19. 184127 11/2/2016 12/2/2016 Nepritis tubolo
instertitial
No. Leadterm Nephritis

Nephritis
Volume 3 Hal. 473
- Tubolo interstitial (in) N12
19. N 12 Tubulo-interstitial nephritis, not
Volume 1 Hal. 608
specified as acute or chronic
Kode Akhir N 12
No No RM Tgl Masuk Tgl Keluar Anamnesa Dx

20. 212837 11/03/2017 14/03/2017 nyeri saat BAK, Batu kandung
ada darah dalam kemih
urine

20. Volume 3 Hal 90 Calculus
- Bladder (diverticulum) (encysted)
(impacted) (urinary) N21.0
Volume 1 Hal 613 N21.0 Calculus in bladder
Kode Akhir N21.0
Karena pada penelitian ditemukan banyak anamnesa pada DRM yang tidak bisa
dibaca oleh peneliti, maka kolom anamnesa tidak semuanya dapat ditulis
2. Kode Diagnosa
Berdasarkan hasil kegiatan penelitian dan pembahasan, tidak
ditemukan tindakan pada sistem Endokrin di RSUD Cideres Kabupaten
Majalengka.

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BAB III

HASIL KEGIATAN DAN PEMBAHASAN

Hasil Kegiatan dan Pembahasan

No No. Tgl Masuk Tgl Keluar Anamnesa Dx

No. Leadterm Arthrosis

No No. Tgl Masuk Tgl Keluar Anamnesa Dx

No. Leadterm Rupture

No No. RM Tgl Tgl Anamnesa Dx

No. Leadterm Fasciitis

No No. RM Tgl Tgl Keluar Anamnesa Dx

No. Leadterm Scoliosis

No No. RM Tgl Tgl Keluar Anamnesa Dx

No. Leadterm Deformity

No No. RM Tgl Tgl Keluar Anamnesa Dx

No. Leadterm Fasciitis

No. No. Tgl Masuk Tgl Keluar Anamnesa Dx

No. Leadterm Displacement

No. No. RM Tgl Masuk Tgl Keluar Ananmnesa Dx

No. Leadterm Spondylosis

No. No. RM Tgl Masuk Tgl Keluar Anamnesa Dx

No. Leadterm Myalgia

No. No. RM Tgl Masuk Tgl Keluar Anamnesa Dx

No. Leadterm Sciatica

No. No. RM Tgl Masuk Tgl Keluar Anamnesa Dx

No. Leadterm Syndrome

No. No. RM Tgl Masuk Tgl Keluar Anamnesa Dx

No. Leadterm Lupus

No. No. RM Tgl Masuk Tgl Keluar Anamnesa Dx

No. Leadterm Cervicalgia

No. No. RM Tgl Masuk Tgl Keluar Ananmnesa Dx

No. Leadterm Radiculopathy

No. No. RM Tgl Masuk Tgl Keluar Anamnesa Dx

No. Leadterm Ganglion

No. No. RM Tgl Masuk Tgl Keluar Anamnesa Dx

No. Leadterm Fracture

No. No. RM Tgl Masuk Tgl Keluar Anamnesa Dx

No. Leadterm Arthritis

No. No. RM Tgl Masuk Tgl Keluar Anamnesa Dx

No. Leadterm Myositis

No. No. RM Tgl Masuk Tgl Keluar Anamnesa Dx

No. Leadterm Arthritis

No. No. Tgl Masuk Tgl Keluar Anamnesa Dx

No. Leadterm Pain

Hasil Kegiatan dan Pembahasan

No. Leadterm Excision

No. No. RM Tgl Masuk Tgl Keluar Tx

No. Leadterm Injection

No. No. RM Tgl Masuk Tgl Keluar Tx

No. Leadterm Exercise

No No.RM Tgl. Masuk Tgl. Keluar Tx

No. No. RM Tgl Masuk Tgl Keluar Tx

No. Leadterm Reduction

No. Leadterm Pneumonia

No. Leadterm Asthma

No. No. Tgl Masuk Tgl Keluar Anamnesa Dx

No. Leadterm Tonsilitis

No. No. Tgl Masuk Tgl Keluar Anamnesa Dx

No. Leadterm Pharyngitis

No. No. Tgl Masuk Tgl Keluar Anamnesa Dx

No. Leadterm Abscess

No. No. RM Tgl Masuk Tgl Keluar Anamnesa Dx

No. Leadterm Bronchitis

Volume 1 Hal. 464 J 20.9 Acute Bronchhitis