FAKTOR PENYEBAB KETIDAKTEPATAN KODE DIAGNOSA SEBAGAI SYARAT PENGAJUAN KLAIM PASIEN RAWAT INAP PESERTA BADAN PENYELENGGARA JAMINAN SOSIAL KESEHATAN DI RUMAH SAKIT UMUM SURYA HUSADHA DENPASAR

Abstract

Background: Writing a complete diagnosis can produce the right coding because the diagnosis is written in a complete, clear, specific, and consistent manner. Writing clear, complete, and consistent diagnoses can produce quality data (Hatta, 2008). Based on observations made for 1 month from 23 January to 23 February 2023, 39 claim files were returned by the Health Social Security Administering Body due to inaccuracies in the diagnosis code.. This was caused by the doctor's notes that were not clearly legible in 24 (61.5%) claim files and the use of abbreviations in patient diagnoses in 15 (38.5%) claim files, while the purpose of this study was to find out the relationship between doctor's notes that were not clearly legible and the use of abbreviations for patient diagnoses for inaccuracies in the diagnosis code as a condition for filing claims for inpatient patients participating in the Health Social Security Administration at Surya Husadha General Hospital.

Methods: The design in this study used a quantitative analytic descriptive research design and porpusive sampling research type, and the sample in this study were all inpatient claim files returned by Health Social Security Administering Body claims for inaccuracies in the diagnosis code totaling 39 claim files. Doctor's notes were illegible in 24 (61.5%) claim files and the use of abbreviations in patient diagnoses in 15 (38.5%) claim files.

Result: From the results of this study it was found that there was a relationship between illegible doctor's notes and inaccuracy of the diagnostic code with a p value of 0.001 <0.05 and the use of abbreviations in patient diagnoses for inaccuracy of patient diagnosis codes with a p value of 0.003 <0.05.