Review Ketepatan Kode Diagnosis Dan Pending Klaim Rekam Medis Pasien Covid-19 Tahun 2021
Abstrak
rekam medis yang lengkap dan pemberian kode klinis yang akurat mencerminkan kualitas pendokumentasian rekam medis. Tahun 2021, jumlah pending klaim asuransi untuk pasien covid-19 mencapai 41% dikarenakan pendokumentasian rekam medis tidak lengkap dan kode pasien covid-19 tidak akurat. penelitian ini bertyjuan untk mengukur kualitas kelengkapan rekam medis dan pending klaim asuransi serta ketepatan kode diagnosis pasien covid-19. penelitian ini menggunakan pendekatan mix-methode dengan pendekatan ekplanatory sekuensial. Data sekunder dianalisis dengan software statistik Stata Versi 13. Hasil penelitian ini dengan melakukan studi dokumen pada total sampling sebesar 889 kasus pada rekam medis pasien covid-19 pada tahun 2021 didapatkan hasil berdasarkan cakupan jenis kelamin laki-laki sebesar 571 (64,45%) dan perempuan 315 (35,55%), berdasarkan status probabel 24 kasus (2,71%), status suspek 214 kasus (24,15%) dan terkonfirmasi positif 648 kasus (73,14%). selanjutnya pengukuran ketepatan pemberian code covid-19 masih terdapat 3 jenis klasifikasi, kode B34.2 sebanyak 377 kasus (42.55%), kode U07.1 sebesar 295 kasus (33,30%) dan kode Z20.8 sebesar 215 kasus (24.14%). jika diukur berdasarkan pemberian kode covid-19 terbaru sesuai kaidah pengodean, terdapat 591 kasus tidak tepat (66.70%) dan 295 kode tepat (33,30%). Terdapat 222 rekam medis pending klaim karena item tanda tangan pada resume medis tidak lengkap, selajutnya hasil wawancara dengan kepala ICM bahwa penggunaan kode U07.1 baru diterapkan per september 2021, sehingga terdapat 3 kode covid-19 yang digunakan, selain itu factor penghambat klaim tepat waktu karena kurang lengkap pada item tanda tangan dan nama lengkap dokter di resume medis.
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