Synchronization of Codification of Unspecified Schizophrenia Againts Back-Referral System of Mirit Public Health Center

Background: The disease classification system is a grouping of diseases following the International Statistical Classification of Diseases and Related Health Problems Tenth Revisions ICD-10. The coding application must be in accordance with ICD-10 to obtain a valid code in disease indexing, national, international reporting of morbidity and mortality, analysis of health care costs, and epidemiological and clinical research. The diagnosis of schizoaffective disorder is made if schizophrenia and affective disorder are symptoms based on the ICD-10 diagnostic criteria. This study aims to determine the synchronization of the codification of unspecified schizophrenia and determine the factors that influence it against the back-referral system at the Mirit Health Center. Method: This research is qualitative research with a descriptive approach. Respondents were four officers, i.e. one doctor, one medical record officer, one person holding a mental program, one pharmacy officer. The number of observed medical record documents was 96 data with research indicators of accuracy and completeness of the diagnosis code in patients referred from First Level Health Facilities (FKTP) to Advanced Health Facilities (FKTL). Result: The results showed 30 referrals, with nine referrals having the accuracy of the patient referral diagnosis code. The back-referral program (PRB) for mental illness at the Mirit Health Center, in collaboration with Mbah Marsio's mental health rehabilitation center, was carried out well. However, the implementation of the Chronic Disease Management program (Prolanis) for mental health was still not good. Conclusion: There are many unsynchronized codifications. It is recommended to conduct an evaluation where they communicate with each other about the patient's condition to supervise the implementation of Referback Patients, especially to specialists who write the back-referral form.

Download Full-text

Accuracy and Validity Outpatient Diagnosis Code Base On ICD-10 at Imogiri I Health Center Bantul Yogyakarta

Proceeding International Conference on Medical Record ◽

10.47387/icmr.v2i1.151 ◽

2022 ◽

Vol 2 (1) ◽

pp. 26-31

Author(s):

Hendra Rohman

Keyword(s):

Health Center ◽

Medical Record ◽

Total Sample ◽

Accurate Diagnosis ◽

Diagnosis Code ◽

Validation Data ◽

Diagnosis Codes ◽

Code Base ◽

Icd 10

Background: Analysis of accuracy and validity fill code diagnosis on medical record document is very important because if diagnosis code is not appropriate with ICD-10, will cause decline in quality services health center, generated data have this validation data level is low, because accuracy code very important for health center such as index process and statistical report, as basis for making outpatient morbidity report and top ten diseases reports, as well as influencing policies will be taken by primary health center management. This study aims to analyze accuracy and validity diagnosis disease code based on ICD-10 fourth quarter in 2020 Imogiri I Health Center Bantul.Methods: Descriptive qualitative approach, case study design. Subject is a doctor, nurse, head record medical and staff. Object is outpatients medical record document in Imogiri I Health Center Bantul. Total sample 99 medical record file. Obtaining data from this study through interviews and observations.Results: Number of complete accurate diagnosis codes is 60 (60,6%), incomplete accurate diagnosis codes is 26 (26.3%) and inaccurate diagnosis codes is 13 (13.1%). Inaccuracies include errors in determining code, errors in determining 4th character ICD-10 code, not adding 4th and 5th characters, not including external cause, and multiple diseases.Conclusions: Inaccuracy factors are not competence medical record staff, incomplete diagnosis writing and no training, no evaluation or coding audit has been carried out, and standard operational procedure is not socialized.

Download Full-text

The prevalence of pre-existing mental health, drug and alcohol conditions in major trauma patients

Australian Health Review ◽

10.1071/ah16050 ◽

2017 ◽

Vol 41 (3) ◽

pp. 283 ◽

Cited By ~ 6

Author(s):

Tu Q. Nguyen ◽

Pamela M. Simpson ◽

Belinda J. Gabbe

Keyword(s):

Mental Health ◽

Medical Record ◽

Major Trauma ◽

Health Conditions ◽

Trauma Patients ◽

Discharge Data ◽

Mental Health Conditions ◽

Icd 10 ◽

Record Review ◽

Drug And Alcohol

Objective Capturing information about mental health, drug and alcohol conditions in injury datasets is important for improving understanding of injury risk and outcome. This study describes the prevalence of pre-existing mental health, drug and alcohol conditions in major trauma patients based on routine discharge data coding. Methods Data were extracted from the population-based Victorian State Trauma Registry (July 2005 to June 2013, n = 16 096). Results Seventeen percent of major trauma patients had at least one mental health condition compared with the Australian population prevalence of 21%. The prevalence of mental health conditions was similar to the Australian population prevalence in men (19% v. 18%), but lower in women (14% v. 25%) and across all age groups. Mental health conditions were more prevalent in intentional self-harm cases (56.3%) compared with unintentional (13.8%) or other intentional (31.2%) cases. Substance use disorders were more prevalent in major trauma patients than the general population (15% v. 5%), higher in men than women (17% v. 10%) and was highest in young people aged 25–34 years (24%). Conclusions Under-reporting of mental health conditions in hospital discharge data appears likely, reducing the capacity to characterise the injury population. Further validation is needed. What is known about the topic? Medical record review, routine hospital discharge data and self-report have been used by studies previously to characterise mental health, drug and alcohol conditions in injured populations, with medical record review considered the most accurate and reliance on self-report measures being considered at risk of recall bias. The use of routinely collected data sources provides an efficient and standardised method of characterising pre-existing conditions, but may underestimate the true prevalence of conditions. What does this paper add? No study to date has explored the prevalence of Abbreviated Injury Scale and International Classification of Diseases and Health Related Problems, Tenth Revision, Australian Modification (ICD-10-a.m)-coded mental health, alcohol and drug conditions in seriously injured populations. The results of this study show the incidence of mental health conditions appeared to be under-reported in major trauma patients, suggesting limitations in the use of ICD-10-a.m. to measure mental health comorbidities. What are the implications for practitioners? In order to achieve improvements in measuring mental health, drug and alcohol comorbidities, we suggest the use of a series of different diagnostic systems to be used in conjunction with ICD-10-a.m., such as medical record review and self-reporting as well as linkage to other datasets. When applied simultaneously, diagnosis and outcomes of mental health may be compared and validated across diagnostic systems and deviations in diagnoses could be more readily accounted for.

Download Full-text

Diagnosis Code Accuracy Analysis Of Acute Gastroenteritis Disease Based on Medical Record Document in Balung Hospital Jember

Journal of Agromedicine and Medical Sciences ◽

10.19184/ams.v2i2.2775 ◽

1970 ◽

Vol 2 (2) ◽

pp. 12

Author(s):

Rinda Nurul Karimah ◽

Dony Setiawan ◽

Puput Septining Nurmalia

Keyword(s):

Medical Record ◽

Acute Gastroenteritis ◽

Medical Records ◽

Disease Diagnosis ◽

Accuracy Analysis ◽

Diagnosis Code ◽

Diagnosis Codes ◽

Icd 10

Accuracy analysis of replenishment diagnosis codes on the document medical records is very important because if the diagnosis code is not right or not in accordance with the ICD-10, it can cause a decline in the quality of care in hospitals as well as the influence of data, information reporting, and accuracy rates of INA-CBG's that are currently used as a method of payment for patient care. The purpose of this study was to analyze the accuracy of diagnosis codes acute gastroenteritis disease in hospitalized patients by medical record documents in the first quarter of 2015 in the Balung Hospital Jember. This research used qualitative data. Acquisition of data from this study through interviews and observations. Results obtained from the observation of medical record documents at the inpatient unit in the first quarter 2015 in Balung Hospital Jember, there are some numbers determining the accuracy of disease diagnosis codes as many as 17 medical record documents with acute gastroenteritis illness and the determination of improper diagnosis codes as many as 63 medical records document acute gastroenteritis illness. After analyzing, the cause of the problem is the accuracy of the diagnosis that affects the accuracy of writing code, beside it has never been disseminated to physicians and medical records personnel related to the management of medical records. Therefore, it is necessary to carry out activities that can improve the accuracy of disease diagnosis code and quality of human resources, among others, include doctors and medical records personnel in training and socialization related to the management of medical records. Key Words : Diagnosis codes , medical record, acute gastroenteritis

Download Full-text

Tinjauan Sistem Penyelenggaraan Rekam Medis Menurut Standart Akreditasi Puskesmas di Puskesmas Pangakalan Berandan Tahun 2020

Jurnal Ilmiah Perekam dan Informasi Kesehatan Imelda (JIPIKI) ◽

10.52943/jipiki.v6i2.587 ◽

2021 ◽

Vol 6 (2) ◽

pp. 108-118

Author(s):

Esraida Simanjuntak ◽

Fajar Insani

Keyword(s):

Health Center ◽

Medical Record ◽

Medical Records ◽

Clinical Information ◽

Record Management ◽

Registration Process ◽

Accreditation Standards ◽

Icd 10 ◽

Research Population ◽

Access Rights

Puskesmas are required to maintain medical records containing data and information on patient care. Implementation according to accreditation standards, namely criteria 3.2 Registration Process and 3.8 Administration of medical records which are divided into 3.8.1 Coding, 3.8.2 Medical Record Access Rights 3.8.3 Clinical Information Filling and 3.8.4 Storage. The purpose of the study was to find out the implementation of the medical record management system according to the Puskesmas accreditation standards at the Pangkalan Berandan Health Center in 2020. This type of research was qualitative with a Phenomenology approach. The place of research was conducted at the Pangkalan Berandan Health Center. Time of study in July 2020. Research population is all medical record officers at the Pangkalan Berandan Health Center. The research sample is 5 officers. The research instrument was interview guide and check list sheet for observation. The results of the study revealed that the outpatient registration process had been carried out according to criteria 3.2 but there was no inpatient numbering of medical records. Coding was not carried out according to criteria 3.8.1, namely the absence of coding SOPs carried out by doctors using ICD 10, Medical Record Access Rights were carried out according to criteria 3.8. 2 but the implementation is not fully carried out in accordance with the SOP, the lending process is not recorded in the expedition book, Assembling is in accordance with criteria 3.8.3 but recording corrections are carried out using stip-ex and the storage process has been carried out according to criteria 3.8.4 but retention is not carried out according to the guidelines legislation. It is recommended for registration to give medical record numbers to inpatients, coding to make SOPs and given coding training, access rights to medical records to record loans in expedition books, assembling to be given socialization in terms of correcting recording of medical record files and storing tracers as well as in the retention process. given socialization about the implementation of retention.

Download Full-text

Correlation Between Medical Information Completeness and Accuracy of The Diagnosis Code for Upper Respiratory Tract Infection and Hypertension Based on ICD-10 in Medical Record at Cibening Health Center

Muhammadiyah Medical Journal ◽

10.24853/mmj.2.1.1-6 ◽

2021 ◽

Vol 2 (1) ◽

pp. 1

Author(s):

Ahmad Muchlis ◽

Rifa Aulia Ramadhanty

Keyword(s):

Tract Infection ◽

Respiratory Tract ◽

Respiratory Tract Infection ◽

Medical Record ◽

Medical Records ◽

Medical Information ◽

Upper Respiratory Tract ◽

Diagnosis Code ◽

Icd 10 ◽

Upper Respiratory

Background: Completeness of patient medical information in medical records is one indicator in assessing the quality of health services. Complete and accurate medical records contribute to the accuracy of medical staff in making a diagnosis so that they can determine the correct diagnosis code according to the ICD-10 guidelines. A good medical record shows that a doctor or other medical staff has carried out their duties by the demands of their profession as stated in the Medical Practice Law No.29 of 2004. Purposes: To find out there is or not a correlation between the medical information completeness and the accuracy of the diagnosis code for upper respiratory tract infection and hypertension based on the ICD-10 in the medical record documents of outpatients at the Cibening Health Center in 2019. Method: The method used in this study is observational analytic with a cross-sectional study design. The population of this study was outpatient medical records with a diagnosis of upper respiratory tract infection and hypertension at the Cibening Health Center in 2019. The sampling technique used a simple random sampling technique with a sample size of 100. Results: Out of obtained 71 complete medical record (71%) filling in medical records, 64 medical records (64%) were accurate in giving ICD-10 codes, 63 medical records (88.7%) with complete medical information had accurate diagnosis codes in comparison with 8 medical records (11.3%) which were complete but inaccurate diagnosis code. Conclusion: With a p-value of 0.000, there is a significant correlation between the completeness of medical information and the accuracy of the diagnosis code for Upper Respiratory Tract Infection and Hypertension based on ICD-10.

Download Full-text

Level of agreement between medical record and ICD-10-AM coding of mental health, alcohol and drug conditions in trauma patients

Health Information Management Journal ◽

10.1177/1833358318769482 ◽

2018 ◽

Vol 48 (3) ◽

pp. 127-134 ◽

Cited By ~ 2

Author(s):

Tu Q Nguyen ◽

Pamela M Simpson ◽

Sandra C Braaf ◽

Peter A Cameron ◽

Rodney Judson ◽

...

Keyword(s):

Mental Health ◽

Medical Record ◽

Administrative Data ◽

Medical Records ◽

Policy Development ◽

Injured Patient ◽

Trauma Patients ◽

Co Morbidity ◽

Icd 10 ◽

Drug And Alcohol

Background: Despite the reliance on administrative data in epidemiological studies, there is little information on the completeness of co-morbidities in administrative data coded from medical records. Objective: The aim of this study was to quantify the agreement between the International Classification of Diseases, Tenth Revision, Australian Modification (ICD-10-AM) administrative coding of mental health, drug and alcohol co-morbidities and medical records in a severely injured patient population. Method: A random sample of patients ( n = 500) captured by the Victorian State Trauma Registry and definitively managed at the state’s adult major trauma services was selected for the study. Retrospective medical record review was conducted to collect data about documented co-morbidities. The agreement between ICD-10-AM data generated from routine hospital coding and medical record–based co-morbidities was determined using Cohen’s κ and prevalence-adjusted bias-adjusted kappa (PABAK) statistics. Results: The percentage of agreement between the medical record and ICD-10-AM coding for mental health, drug and alcohol co-morbidities was 72.8%, and the PABAK showed moderate agreement (PABAK = 0.46; 95% confidence interval (CI): 0.37, 0.54). There was no difference in agreement between unintentional injury patients (PABAK = 0.52; 95% CI: 0.42, 0.62) compared with intentional injury patients (PABAK = 0.36, 95% CI: 0.23, 0.49), and no change in agreement for patients admitted before (PABAK = 0.40; 95% CI: 0.30, 0.50) and after the introduction of mandatory co-morbidity coding (PABAK = 0.46; 95% CI: 0.37, 0.54). Conclusion: Despite documentation in the medical record, a large proportion of mental health, drug and alcohol conditions were not coded in ICD-10-AM. Acknowledgement of these limitations is needed when using ICD-10-AM coded co-morbidities in research studies and health policy development. Implications: This work has implications for researchers of drug and alcohol abuse; mental health; accidents and injuries; workers' compensation; health workforce; health services; and policy decisions for healthcare, emergency services, insurance industry, national productivity and welfare costings reliant on those research outcomes.

Download Full-text