REVIEW OF THE ACCURACY OF DISEASE DIAGNOSIS CODES TO SUPPORT THE EFFECTIVENESS OF ELECTRONIC MEDICAL RECORDS AT EDELWEISS HOSPITAL BANDUNG

Abstract

The level of accuracy of diagnosis coding in patients has an important role in the smooth running of health services. studies show the level of accuracy of diagnosis coding in electronic medical records (RME) is relatively high. The purpose of this study was to measure how much the level of accuracy and inaccuracy and the factors of accuracy and inaccuracy of diagnosis coding at Edelweiss Hospital Bandung. The type of research used in this article is qualitative analysis with descriptive methods. The sample used was the inpatient coding data file of Edelweiss Bandung Hospital as many as 90 samples. the results showed that the accuracy of diagnosis coding was 53.45% and the inaccuracy was 37.55%. the accuracy factor of this diagnosis code occurred due to increased accuracy and data quality, optimizing the use of ICD 10 and ICD 9 CM and reducing coding errors. The inaccuracy factor occurs due to the coder's inaccuracy in coding, lack of medical support information and lack of coder training and experience. The conclusion of this study is that from 90 samples of patient medical records at Edelweiss Bandung Hospital, the accuracy of the diagnosis code has not reached 100%, this happens because of the inaccuracy of the coder in reading the diagnosis code, lack of medical support information, and lack of medical support information and lack of training and experience of the coder in determining the patient's diagnosis code at Edelweiss Bandung Hospital.