EFEKTIVITAS PENERAPAN FORMULIR INCOMPLETE MEDICAL RECORD TERHADAP KELENGKAPAN INFORMASI MEDIS DALAM MENDUKUNG KEAKURATAN KODE DIAGNOSIS DIABETES MELLITUS DAN KEAKURATAN LAPORAN MORBIDITAS DI RSUD ARIFIN ACCHMAD PROVINSI RIAU

Abstract

ABSTRAK
Kelengkapan informasi medis sangat penting dalam menunjang keakuratan kode diagnosis dan keakuratan laporan morbiditas. Hasil observasi awal dari 56 rekam medis menunjukkan bahwa kelengkapan informasi medis diagnosis diabetes mellitus yang lengkap 33 rekam medis, kode diagnosis yang akurat 42, laporan morbiditas yang akurat 48. Penelitian ini bertujuan untuk mengetahui efektivitas formulir incomplete medical record terhadap kelengkapan informasi medis, keakuratan kode diagnosis diabetes mellitus dan keakuratan laporan morbiditas.
Rancangan penelitian yang digunakan adalah pre experimental designs dengan one group pretest-posttest design. Sampel yang digunakan untuk pretest dan posttest adalah 56 rekam medis rawat inap dengan diagnosis diabetes mellitus. Analisis data menggunakan uji wilcoxon t-test.
Hasil penelitian menunjukkan bahwa ada peningkatan setelah diterapkannya formulir incomplete medical record. Kelengkapan informasi medis sebelumnya 33 (58,9%) menjadi 53 (94,6%) hasil uji wilcoxon t-test p=-3.545, keakuratan kode diagnosis diabetes mellitus sebelumnya 42 (75%) menjadi 56 (100%) hasil uji wilcoxon t-test p=-3.742 dan keakuratan laporan morbiditas sebelumnya 48 (85,7%) menjadi 56 (100%) dengan hasil uji wilcoxon t-test p=-3.742
Kesimpulan: ada pengaruh signifikan kelengkapan informasi medis, keakuratan kode diagnosis diabetes mellitus dan keakuratan laporan morbiditas sebelum dan sesudah diterapkannya formulir incomplete medical record.
Kata Kunci: Informasi Medis, Keakuratan kode diabetes mellitus, Keakuratan laporan morbiditas, formulir incomplete medical record.
ABSTRACK
Completeness of medical information is very important in supporting the accuracy of the diagnosis code and the accuracy of the morbidity report. Preliminary observations from 56 medical records indicate that completeness of medical information diagnoses diabetes mellitus complete 33 medical records, accurate diagnosis code 42, accurate morbidity report 48. This study aims to determine the effectiveness of incomplete medical record forms on the completeness of medical information, code accuracy diagnosis of diabetes mellitus and the accuracy of morbidity reports.
The research design used was pre experimental designs with one group pretest-posttest design. The sample used for pretest and posttest was 56 inpatient medical records with a diagnosis of diabetes mellitus. Data analysis using Wilcoxon t-test.
The results showed that there was an increase after the implementation of incomplete medical record forms. Completeness of previous medical information 33 (58.9%) to 53 (94.6%) wilcoxon t-test results p = -3,545, accuracy of previous diabetes mellitus diagnosis code 42 (75%) to 56 (100%) wilcoxon test results t-test p = -3,742 and the accuracy of the previous morbidity report 48 (85.7%) to 56 (100%) with the results of the Wilcoxon t-test p = -3,742. Conclusion: there is a significant influence on the completeness of medical information, the accuracy of the diagnosis code for diabetes mellitus and the accuracy of the morbidity report before and after the incomplete medical record form is applied.
Keywords: Medical information, accuracy of diabetes mellitus code, accuracy of morbidity report, incomplete medical record form.