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

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

Study of Incompleteness Medical Records of Inpatient in Appendicitis Cases at Dr. Reksodiwiryo Hospital Padang

2022 ◽  
Vol 2 (1) ◽  
pp. 39-44
Author(s):  
Nurhasanah Nasution
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Research Method ◽  
Digestive Surgery ◽  
Diagnostic Codes ◽  
Diagnosis Codes ◽  
Service Information ◽  
Incomplete Filling ◽  
Existing Data

Background: Incomplete filling of medical record files for inpatients at Dr. Reksodiwiryo hospital medical records will be describe health services and the quality of medical record services. Medical record quality services include the completeness of medical record files, accuracy in providing diagnosis and diagnosis codes, as well as speed in providing service information. The requirements for quality medical records must be accurate, complete, reliable, valid, timely, usable, common, comparable, guaranteed, and easy.Methods: This research method is a descriptive with a retrospective approach or looking at existing data. This study was carried out in September 2021. The population was 70 files cases of inpatient digestive surgery. Samples were taken from 27 files of inpatients with appendicitis cases.Results: From the research that has been done, the highest percentage of incomplete identification components is found on the gender item about 81.48%, the highest percentage of incomplete important report components is obtained on the medical resume and informed consent items about 11.1%. The highest percentage of incomplete authentication components was obtained in the nursing degree about 96.3%. The highest percentage of the components of the recording method was obtained by 59.3%, there are several blank sections about 16 files. The percentage of incomplete diagnostic codes and procedures is 100%  Conclusions: the researcher suggested that the hospital can have an Operational Standart on filling out the completeness of medical records files

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

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.

scholarly journals 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

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.

Pengaruh Kompetensi Coder terhadap Keakuratan dan Ketepatan Pengkodean Menggunakan ICD 10 di Rumah Sakit X Pekanbaru Tahun 2016

2018 ◽  
Vol 1 (1) ◽  
pp. 31-43
Author(s):  
Nur Maimun ◽  
Jihan Natassa ◽  
Wen Via Trisna ◽  
Yeye Supriatin
Keyword(s):  
Medical Record ◽  
Human Error ◽  
Medical Personnel ◽  
Quality Of Data ◽  
Accuracy And Precision ◽  
Result Show ◽  
Study Implementation ◽  
Icd 10 ◽  
The Cost

The accuracy in administering the diagnosis code was the important matter for medical recorder, quality of data was the most important thing for health information management of medical recorder. This study aims to know the coder competency for accuracy and precision of using ICD 10 at X Hospital in Pekanbaru. This study was a qualitative method with case study implementation from five informan. The result show that medical personnel (doctor) have never received a training about coding, doctors writing that hard and difficult to read, failure for making diagnoses code or procedures, doctor used an usual abbreviations that are not standard, theres still an officer who are not understand about the nomenclature and mastering anatomy phatology, facilities and infrastructure were supported for accuracy and precision of the existing code. The errors of coding always happen because there is a human error. The accuracy and precision in coding very influence against the cost of INA CBGs, medical and the committee did most of the work in the case of severity level III, while medical record had a role in monitoring or evaluation of coding implementation. If there are resumes that is not clearly case mix team check file needed medical record the result the diagnoses or coding for conformity. Keywords: coder competency, accuracy and precision of coding, ICD 10

Accuracy Analysis of Fringe Projection Systems Based on Blue Light Technology

2014 ◽  
Vol 615 ◽  
pp. 9-14 ◽  
Author(s):  
Claudio Bernal ◽  
Beatriz de Agustina ◽  
Marta María Marín ◽  
Ana Maria Camacho
Keyword(s):  
Blue Light ◽  
Point Clouds ◽  
Fringe Projection ◽  
Accuracy Analysis ◽  
Scanning Procedure ◽  
Structured Light Scanner ◽  
Cloud Of Points ◽  
3D Digitizing

Some manufacturers of 3D digitizing systems are developing and market more accurate, fastest and affordable systems of fringe projection based on blue light technology. The aim of the present work is the determination of the quality and accuracy of the data provided by the LED structured light scanner Comet L3D (Steinbichler). The quality and accuracy of the cloud of points produced by the scanner is determined by measuring a number of gauge blocks of different sizes. The accuracy range of the scanner has been established through multiple digitizations showing the dependence on different factors such as the characteristics of the object and scanning procedure. Although many factors influence, accuracies announced by manufacturer have been achieved under optimal conditions and it has been noted that the quality of the point clouds (density, noise, dispersion of points) provided by this system is higher than that obtained with laser technology devices.

scholarly journals Use of ICD-10 Codes for Identification of Injection Drug Use–Associated Infective Endocarditis Is Nonspecific and Obscures Critical Findings on Impact of Medications for Opioid Use Disorder

2020 ◽  
Vol 7 (10) ◽  
Author(s):  
Laura R Marks ◽  
Nathanial S Nolan ◽  
Linda Jiang ◽  
Dharushana Muthulingam ◽  
Stephen Y Liang ◽  
...  
Keyword(s):  
Infective Endocarditis ◽  
Drug Use ◽  
Injection Drug Use ◽  
Opioid Use Disorder ◽  
Injection Drug ◽  
Diagnosis Code ◽  
Opioid Use ◽  
Diagnosis Codes ◽  
All Cause Mortality ◽  
Icd 10

Abstract Background No International Classification of Diseases, 10th revision (ICD-10), diagnosis code exists for injection drug use–associated infective endocarditis (IDU-IE). Instead, public health researchers regularly use combinations of nonspecific ICD-10 codes to identify IDU-IE; however, the accuracy of these codes has not been evaluated. Methods We compared commonly used ICD-10 diagnosis codes for IDU-IE with a prospectively collected patient cohort diagnosed with IDU-IE at Barnes-Jewish Hospital to determine the accuracy of ICD-10 diagnosis codes used in IDU-IE research. Results ICD-10 diagnosis codes historically used to identify IDU-IE were inaccurate, missing 36.0% and misclassifying 56.4% of patients prospectively identified in this cohort. Use of these nonspecific ICD-10 diagnosis codes resulted in substantial biases against the benefit of medications for opioid use disorder (MOUD) with relation to both AMA discharge and all-cause mortality. Specifically, when data from all patients with ICD-10 code combinations suggestive of IDU-IE were used, MOUD was associated with an increased risk of AMA discharge (relative risk [RR], 1.12; 95% CI, 0.48–2.64). In contrast, when only patients confirmed by chart review as having IDU-IE were analyzed, MOUD was protective (RR, 0.49; 95% CI, 0.19–1.22). Use of MOUD was associated with a protective effect in time to all-cause mortality in Kaplan-Meier analysis only when confirmed IDU-IE cases were analyzed (P = .007). Conclusions Studies using nonspecific ICD-10 diagnosis codes for IDU-IE should be interpreted with caution. In the setting of an ongoing overdose crisis and a syndemic of infectious complications, a specific ICD-10 diagnosis code for IDU-IE is urgently needed.

scholarly journals TINJAUAN PELAKSANAAN PENGODEAN DIAGNOSIS PENYAKIT PADA PASIEN RAWAT JALAN DI RSUD TUGUREJO PROVINSI JAWA TENGAH

2019 ◽  
Vol 6 (2) ◽  
pp. 139-147
Author(s):  
Qisthi Qurrota A’yuni ◽  
Kori Puspita Ningsih
Keyword(s):  
Medical Record ◽  
Medical Records ◽  
Standard Operating Procedure ◽  
Disease Diagnosis ◽  
Cross Sectional ◽  
Accreditation Standard ◽  
Central Java ◽  
Procedure Guidelines ◽  
Five Elements ◽  
Diagnosis Coding

Background: The implementation of diagnosis coding in the Medical Record Unit at a health institution plays an important role in the administration of medical records at the hospital because it describes the quality management of medical records. In order to maintain the quality, it is crucial to accomplish the accreditation standard, especially at ICM. 13 related coding. Objective: This study aimed to understand the procedures of implementation, compliance disease diagnosis code execution in an outpatient based on accreditation standards KARS 2012, the percentage and the resistance of diagnosis coding implementation in outpatients. Methods: This research was a descriptive qualitative approach with cross sectional design. The subjects were medical records staff with Diploma 3 medical record education background, outpatients coding officer, reporting coordinator, the head of clinic space and a clinic nurse. The data collectin techniques used were observation, documentation and interview studies. Testing the validity of the data use triangulate of source and triangulate of techniq. Results: The coding was done by the medical records staffs and nurses, coding reference were in the form of policies, guidelines and standard operating procedure, guidelines used by nurses in coding was assistive book. Tugurejo Hospital Accreditation in Central Java province had fulfilled the five elements of ICM. 13 and passed the accreditation of type B-level plenary meeting. The percentage of outpatient coding implementation reached 78.6%, consisting of JKN amounted to 75.4% and 3.2% were non JKN. The barriers of coding implementation consists of five elements such as man, method, material, machine and money. Conclusion: In general the implementation of the coding in JKN outpatient has already done optimally, but for non JKN has not been optimal because of the inhibiting factors such as man, method, material, machine and money. Keywords: Coding, disease diagnosis, outpatient

scholarly journals Improvement of patient safety through implementation of electronic medical records

2017 ◽  
Vol 1 (4) ◽  
pp. 111-112
Author(s):  
Elahe Gozali ◽  
Marjan Ghazisaiedi ◽  
Malihe Sadeghi ◽  
Reza Safdari
Keyword(s):  
Patient Safety ◽  
Medical Record ◽  
Electronic Medical Record ◽  
Electronic Medical Records ◽  
Medical Records ◽  
Access To Health Care ◽  
Clinical Care ◽  
Drug Management ◽  
Bar Code

Introduction: Today, with the complexity of the process of conducting activities, the increase in diversity and the number of hospital services, and the increase in the expectations of clients - consistent with the fast technological advances - most of the hospitals in Iran have turned to mechanized systems to organize their daily activities and to register the patients' information and the care provided. One of these technologies is electronic medical records, which is known as a valuable system to evaluate patients' information in hospitals. The purpose of this paper was to examine the advantages of running electronic medical records in patient safety. Methods: This study is a review paper based on a structured review of papers published in the Google Scholar, SID, Magiran, Pubmed, and Science Direct databases (from 2007 to 2015) and the books on the benefits of implementing electronic medical records in patient safety and the related keywords. Results: Clinical information systems can have a significant effect on the quality of the outputs and patient safety. Various studies have indicated that the physicians with access to clinical guidelines and features such as computer reminders, doctors who did not have these features, presented more appropriate preventive care. Studies show that electronic medical records play a crucial role in improving the quality of patient health and safety services. Moreover, electronic medical record system is usually in connection with other technological tools: electronic drug management records,  electronic record of time and date of drug management are usually associated with bar code technology. Among the benefits of this system is the possibility to record clinical care by the treatment team, which would be especially beneficial for patient's bedside record. If the treatment personnel forgets to ask the patient a particular question, system reminds him/her. Furthermore, electronic medical record is able to remind the nurses of the patient's allergic reactions and medical history without the need for the patient to remind, which improves patient safety. Conclusion: Implementation of electronic medical records boosts up the quality of health services, patient safety, people's access to health care services, and the speed of patients treatment, leading to lower healthcare costs. Thus, considering the benefits mentioned and some other benefits of this kind, one can use this technology in clinical care provided to patients to come up with a safe and effective clinical care.

scholarly journals The efficient of beds used based on graphic Barber Johnson at Semen Padang Hospital in 2017

2019 ◽  
Vol 6 (12) ◽  
pp. 5071
Author(s):  
Sayati Mandia
Keyword(s):  
Statistical Analysis ◽  
Length Of Stay ◽  
Medical Record ◽  
Medical Records ◽  
Average Length ◽  
Sampling Technique ◽  
Occupancy Rate ◽  
Bed Occupancy ◽  
Average Length Of Stay

Background: Quality of hospital services can be seen from the bed usage. Statistical analysis of efficiency bed usage can be mesured based on inpatient medical records. To determine the efficiency requires four parameters namely bed occupancy rate (BOR), average length of stay (ALoS), turnover interval (TI), and bed turnover (BTR). parameters can be presented using Graphic Barber Johnson. This study aims to determine the efficiency of bed usage at Semen Padang Hospital in 2017.Methods: This research was conducted at Semen Padang Hospital, West Sumatera, Indonesia from January to December 2017. The study used a descriptive method with a qualitative approach. The data was collected from medical records department. The population is all abstraction data of in-patient medical record in 2017, 9796 medical record used total sampling technique. Data analysis was performed by calculating the values of ALoS, BOR, BTR, and TI. Data will be presented based on graphic Barber Johnson. Excel 2010 and graphic Barber Johnson method were applied for data analysis.Results: Number of daily inpatient censuses in 2017 are 31227 and number of service days are 31362. Number of beds 144. Statistical analysis results obtained total BOR 60%, BTR 67 times, TI 2 days and ALoS 3 days. The highest value of bed occupancy rate is 66% on August.Conclusions: Based on statistical, value of bed occupancy rate (60%) and turnover interval (2 days) are efficient at Semen Padang Hospital in 2017. Average length of stay (3 days) and bed turnover rate (67 times) are not efficient.

scholarly journals Penerapan Data Mining Untuk Pengelompokan Hasil Diagnosa Penyakit Pasien Pengguna BPJS Kesehatan (Studi Kasus Pada Rsud Undata Palu)

2019 ◽  
Vol 1 (1) ◽  
pp. 51 ◽  
Author(s):  
Amriana Amriana ◽  
Yuri Yudhaswana Joefrie ◽  
Farah Nabila Meidji
Keyword(s):  
Medical Record ◽  
Community Health Center ◽  
Disease Diagnosis ◽  
Patient Medical Record ◽  
International Classification Of Disease ◽  
Disease Information ◽  
C4.5 Algorithm ◽  
Icd 10 ◽  
Central Sulawesi

This research was conducted to process medical record data in RSUD Undata of central Sulawesi province, for some BPJS Kesehatan insurance member. Medical record contain information about identity and medical history by patient  in Hospital or community health center (Puskesmas). Medical records have disease information by patients encoded according to WHO standart. The code is called ICD (International Classification of Disease) and this research use C4.5 Algorithm as Classification method to process patient medical record which then uses address attributes, gender, age and disease diagnosis (ICD-10). Of the five attributes are groupings then processed into group of age, regional and icd. The result of this studi can find patterns of disease tendency that most suffered by people in a region.

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