The Completeness and Accuracy of Hepatoma Coding for Medical Procedure Based on ICD-9 CM at Public Hospital in Padang

2022 ◽  
Vol 2 (1) ◽  
pp. 22-25
Author(s):  
Sayati Mandia
Keyword(s):  
Medical Record ◽  
Public Hospital ◽  
Discharge Summary ◽  
Medical Procedure ◽  
Inaccurate Information ◽  
Procedure Code ◽  
History Of ◽  
Quantitative Descriptive ◽  
Item Data ◽  
Code Procedure

Background: Hepatoma  or  hepatocellular  carcinoma  (KHS)  is  a  primary  malignant  tumor  of  the  liver originating from hepatocytes and the 3rd cause of death from cancer in the world. The history of a hepatoma patient can be seen based on the patient's medical record. The filling of medical record is done by doctors, nurses and medical record personel. However, in medical record  filling, incompleteness  is often found and cause inaccurate information. Accuracy coding important for financial of hospital.Methods: Type  of  research  is  quantitative  descriptive,  which  is  to  determine  the  completeness  and accuracy of  the  medical  records  for  hepatoma  cases and procedure code using criteria  for  document  quantitative  analysis in a public hospital, Padang. The study  design  used  a  retrospective  analytical  approach. The variables in the study were completeness of discharge summary and accuracy of hepatoma procedure based on ICD-9 CM. The population in this study were inpatient medical record documents for Hepatoma cases at a public hospital, Padang from June to August 2019, which were 45 medical record documents (discharge summary form) of hepatoma inpatients.Results: From 45 hepatoma patient medical record documents, filling of item name, medical record number, date of admission, indication of the patient being treated, history, physical examination, diagnostic examination, procedures, medications given, medicines used at home, PPBS doctor's signature, DPJP doctor's hand is complete 100% . Highest incompleteness of filling was found  at code ICD (47%) and address item (43%). From 45 discharge summary , accuracy procedure code at hepatome case shows 100 % accurate in ultrasonoggrafi abdomen and ultrasonografi thorax. While that EKG 98% accurate and 95 % rontgen thorax.Conclusions: In general, item data of discahrege summary for hepatoma medical record are completenes; highest incompleteness of filling was found  at code ICD (47%) and address item (43%); Accuracy of code procedure more than 90% in each code procedure.

scholarly journals The Completeness and accuracy of clinical coding for diagnosis and medical procedure on the INA-CBGs claim amounts at a hospital in South Jakarta

2018 ◽  
Vol 9 (1) ◽  
pp. 14-18
Author(s):  
Cicih Opitasari ◽  
Atik Nurwahyuni
Keyword(s):  
Medical Record ◽  
Standard Procedure ◽  
Discharge Summary ◽  
Health Science ◽  
Medical Procedure ◽  
Science Journal ◽  
Clinical Coding ◽  
Depth Interview ◽  
Hospital Revenue ◽  
Record Review

Abstrak Latar belakang: Kelengkapan resume dan ketidaktepatan koding masih menjadi penyebab terbesar pengembalian berkas klaim dari BPJS. Penelitian ini bertujuan untuk melakukan analisis kelengkapan dan ketepatan koding diagnosis dan prosedur terhadap besaran klaim di satu rumah sakit (RS) Pemerintah di Jakarta Selatan. Metode: Penelitian observasional yang dilakukan dengan penelusuran rekam medis (RM) bulan November 2017 dan wawancara mendalam terhadap 7 informan yang terdiri dari manajemen, koder, dokter penanggung jawab pasien (DPJP) dan verifikator RS. Ketepatan koding didapatkan dengan membandingkan pengkodean oleh koder RS dan koder standar. Analisis data dilakukan dengan analisis konten. Hasil: Dari 105 sampel rekam medis didapatkan angka ketidaklengkapan resume terbanyak pada pemeriksaan penunjang (12,2%), ketidaksesuaian pengisian pada diagnosis sekunder mencapai 68,6% dan ketidaktepatan koding paling tinggi pada diagnosis utama (21,9%). Rerata klaim INA-CBGs yang dihasilkan koder RS lebih rendah dari koder standar dengan selisih klaim sebesar 4%. Hal tersebut disebabkan adanya ketidakpatuhan dokter dan tidak semua dokter mendapatkan pelatihan pengkodean. Proses pencatatan RM masih banyak didelegasikan kepada residen. Pemeriksaan resume oleh verifikator dan pengkodean oleh koder masih kurang pemahaman tentang diagnosis dalam konsep INA-CBGs. Kesimpulan: Ketidaklengkapan resume dan ketidaktepatan koding di RS menyebabkan klaim INA-CBGs yang diterima lebih rendah rata-rata 4% sehingga dapat mengurangi pendapatan RS. (Health Science Journal of Indonesia 2018;9(1):14-8) Kata kunci: Ketidaktepatan koding, diagnosis dan prosedur, klaim rendah Abstract Background: Coding inaccuracy and inadequate physician documentation are still the major problem of BPJS claims that resulting potential loss of hospital finance. This study aims to analyze the completeness and accuracy of diagnosis and procedure coding on the INA-CBGs claim amounts at one government hospital in South Jakarta. Methods: This observational study was conducted through medical record review during the period of November 2017 and in-depth interview involved 7 informants consist of hospital management, coders, responsible physicians and hospital verifiers. Re-coding was carried out by standar coder and the results were compared with hospital coders outcome. Content analysis was used to analyze the data. Results: The review of 105 medical record found incomplete documentation for supporting medical examination variable (12.2%), inconsistency documentation of secondary diagnoses were the highest, at 68.6% and the most frequent for inaccurate coding was primary diagnoses at 21.9%. The claims generated by hospital coders are lower than standard coder by an average 4%. The indepth interview revealed low physicians compliance on the documentation standard procedure and lack of coding training for physician. The process of the documentation practice was still delegated to the resident physicians. The discharge summary review by verifier and coding by the coders was still lack of understanding of the diagnosis in the INA-CBGs concept. Conclusion: Incomplete discharge summary and inaccurate coding of diagnosis and procedure generate loss of hospital revenue by an average 4%. (Health Science Journal of Indonesia 2018;9(1):14-8) Keywords: Inaccuracy of clinical coding, diagnosis and procedure, lower claim

scholarly journals GAMBARAN KLINIS DAN RADIOLOGIS MENURUT KELLGREN AND LAWRENCE PADA PENDERITA OSTEOARTHRITIS GENU YANG BEROBAT JALAN DI POLOKLINIK ORTOPEDI RSU ANUTAPURA PALU TAHUN 2018

2019 ◽  
Vol 2 (1) ◽  
Author(s):  
Mukramin Amran
Keyword(s):  
Physical Examination ◽  
Clinical Picture ◽  
Joint Pain ◽  
Public Hospital ◽  
Joint Stiffness ◽  
Descriptive Research ◽  
History Of ◽  
Kellgren And Lawrence ◽  
Grade 3 ◽  
Patient’S History

Osteoarthritis (OA) is a progressive and degenerative chronic musculoskeletal disease caused by thinning of the cartilage in the joint due to bone rubbing against each other. History of the patient's history, clinical picture of the physical examination and the results of the radiological examination are basic things to diagnose OA. Patient's complaints include joint pain which is a major complaint that brings the patient to the doctor, joint stiffness, crepitation, joint swelling, and changes in gait. Gait changes due to pain are found on a physical examination even though radiologically is still at an initial level. In addition it can be found that crepitus, swollen joints are often asymmetrical. The aim of this study was to determine clinical and radiological features by counselor and Lawrence of outpatient genotypes osteoarthritis patients in the rsu anutapura hammer orthopedic polyclinic in 2018. Descriptive research methods were conducted on 27 people with genital osteoarthritis who were treated at the orthopedic clinic in Anutapura Palu Public Hospital 2018. Consecutive sampling was used and data collection through interviews and observations in the form of pain, joint stiffness, crepitus, joint swelling and gait changes and radiological examinations based on Kellgren and Lawrence criteria. Data analysis using SPSS 25 with frequency distribution test. The results of the study were (1) based on the clinical picture in genu osteoarthritis patients pain (100%), pain accompanied by gait changes (70.37%), pain accompanied by joint stiffness (51.4%), pain accompanied by joint swelling (44, 4%), and pain with crepitus (37.0%). (2) based on radiology in patients with osteoarthritis genu with the highest grade 3 and 4 respectively (33.3%), grade 2 (29.6%), grade 1 (3.7%) and in grade 0 not found. Conclusion: found joint pain and a small portion of pain accompanied by crepitus, radiologists found in most grades 3 and 4 while grade 0 was not found.

scholarly journals Upaya Pencegahan Perbedaan Diagnosis Klinis Dan Diagnosis Asuransi Dengan Diberlakukan Program Jaminan Kesehatan Nasional (JKN) Dalam Pelayanan Bpjs Kesehatan Studi Di Rsud Kota Semarang

2016 ◽  
Vol 4 (2) ◽  
pp. 84-90
Author(s):  
Faik Agiwahyuanto ◽  
Sudiro Sudiro ◽  
Inge Hartini
Keyword(s):  
Qualitative Study ◽  
Social Security ◽  
Medical Treatment ◽  
Emergency Room ◽  
Medical Record ◽  
Clinical Pathway ◽  
Public Hospital ◽  
Medical Service ◽  
Hospital Director ◽  
Social Security Agency

Percentage of clinical and insurance diagnosis differences at Semarang City Public Hospital tended to increase. If this condition remained, it would lead to upcoding (fraud). The aim of this study was to explain a process of clinical and insurance diagnosis at a hospital in the implementation of Healthcare and Social Security Agency (Health BPJS). This was a qualitative study. Main informants consisted of doctors at an emergency room, surgeons, and internists. Informants for triangulation purpose consisted of a Hospital Director, a hospital verifier, and a head of Medical Record Unit. Data were analysed using content analysis.The results of this research showed that there were any differences in clinical and insurance diagnosis at Semarang City Public Hospital. The cause of these differences was due to differences in diagnosis and medical treatment between medical service standard of doctors at the hospital and a standard of INA-CBGs. To prevent the differences of clinical and insurance diagnosis, the Semarang City Public Hospital had formed an internal verifier team of the hospital and a Clinical Micro System team. A medical committee had a role to minimise the occurrence of upcoding by multiplying kinds of Clinical Pathway as a reference for doctors in diagnosing and determining kinds of treatments for patients.The differences of clinical and insurance diagnosis must be equated to prevent the occurrence of upcoding and disadvantage of the hospital. Efforts to prevent these differences are by adding officers, training coding, making and multiplying algorithm of clinical pathway, forming a team of Clinical Micro System, and monitoring and evaluating medical services.

scholarly journals An Unusual Suspect for a Traumatic Arteriovenous Fistula in the Left Vertebral Artery

2020 ◽  
Vol 44 (1) ◽  
pp. 28-31
Author(s):  
Cassey Y. Noh
Keyword(s):  
Vertebral Artery ◽  
Arteriovenous Fistula ◽  
Genetic Disorders ◽  
Invasive Procedure ◽  
Left Vertebral Artery ◽  
Medical Procedure ◽  
Doppler Waveform ◽  
Spectral Doppler ◽  
Vascular Laboratory ◽  
History Of

This case study discusses an unusual vertebral arteriovenous fistula of a patient with no history of an invasive medical procedure or underlying genetic disorders. The patient is a 54-year-old female with a history of tinnitus for 6 months behind the left ear prior to coming to the vascular laboratory. There was a connection between the left vertebral artery and the vertebral vein, which showed a mosaic pattern with a high velocity. The spectral Doppler waveform in the vertebral vein post the unintended anastomosis showed an arterialized venous Doppler waveform, confirming that the area of the interest was indeed an arteriovenous fistula. The image of the screening computed tomography performed on the same day did not show this connection or dilated venous system, possibly because of the small size of the fistula. A published literature suggests hyperextension as a possible suspect. There are a few test modalities that can identify an arteriovenous fistula, but ultrasound maybe the most desirable due to the fact that it does not involve an invasive procedure or a contrast dye. It is very important for a sonographer to learn the advanced information such as how to identify a true arteriovenous fistula with the analysis of Doppler waveform in the vein post the anastomosis. In doing so, it will increase the sonographer’s knowledge as well as promoting the field of ultrasound overall.

Management of medical record in installation of inpatient Regional Public Hospital Batara Guru Belopa

2020 ◽  
Vol 30 ◽  
pp. 481-483
Author(s):  
Musriati ◽  
Indar ◽  
Muhammad Tahir Abdullah ◽  
Rahman Kadir
Keyword(s):  
Medical Record ◽  
Public Hospital

scholarly journals Pre hospital indicators in assessing the quality of care for patients with acute coronary syndrome

2015 ◽  
Vol 36 (3) ◽  
pp. 49-55
Author(s):  
Gláucia de Souza Omori Maier ◽  
Eleine Aparecida Penha Martins ◽  
Mara Solange Gomes Dellaroza
Keyword(s):  
Acute Coronary Syndrome ◽  
Quality Of Care ◽  
Medical Record ◽  
Heart Attack ◽  
Tertiary Hospital ◽  
Coronary Syndrome ◽  
History Of ◽  
Assess Quality ◽  
Record Review

Objective: to assess quality indicators related to the pre-hospital time for patients with acute coronary syndrome.Method: collection took place at a tertiary hospital in Paraná between 2012 and 2013, through interviews and a medical record review. 94 patients participated, 52.1% male, 78.7% who were over 50 years old, 46.9% studied until the fourth grade, 60.6% were diagnosed with acute myocardial infarction.Results: the outcomes were the time between the onset of symptoms and the decision to seek help with an average of 1022min ± 343.13, door-to-door 805min ± 181.78; and reperfusion, 455min ± 364.8. The choice to seek out care within 60 min occurred in patients who were having a heart attack, and longer than 60 min in those with a history of heart attack or prior catheterization.Conclusion: We concluded that the pre-hospital indicators studied interfered with the quality of care.

scholarly journals Profile of Ectopic Pregnancy at Kathmandu Model Hospital

2016 ◽  
Vol 10 (2) ◽  
pp. 10-13
Author(s):  
HK Pradhan ◽  
G Dangal ◽  
A Karki ◽  
R Shrestha ◽  
K Bhattachan
Keyword(s):  
Risk Factors ◽  
Ectopic Pregnancy ◽  
Discharge Summary ◽  
Reproductive Age ◽  
Emergency Laparotomy ◽  
Average Hospital ◽  
Pain Abdomen ◽  
Number Of Patients ◽  
History Of ◽  
Age Range

Aims: The study was done to analyze the epidemiology, diagnosis and treatment aspect of patients with ectopic pregnancy at Kathmandu Model Hospital.Methods: This was a retrospective study of patients with ectopic pregnancy who received treatment at Kathmandu Model Hospital from January 2008 to September 2015. Data were analyzed from patient records and discharge summary. Delivery number was obtained from maternity record.Results: There were 61 cases of ectopic pregnancy with the hospital incidence of 1.46%. Highest number of patients 20 (32.79%) were in the age range of 28-32 years. Most of the patients were nullipara 22 (36.06%) or with parity two 20 (32.79%). Some risk factors were found in 29 (47.54%) cases. The commonest risk factor was pelvic inflammatory disease in 12 (19.67%). All presented with pain abdomen, 48 (78.68%) had per vaginal bleeding, 17 (27.87%) presented in shock. Cervival excitation was present in 38 (62.29%). Urine for pregnancy test was positive in all and 37 (60.66%) had ultrasonography. Ten (16.39%) patients underwent emergency laparoscopic surgery and 40 (65.57%) had emergency laparotomy. Salpingectomy was required in 53 (86.89%) cases. The average hospital stay was 5 days.Conclusions: The study showed that ectopic pregnancy could occur at any reproductive age without obvious risk factors. Although not all patients gave history of amenorrhoea, pain abdomen was present in all.

scholarly journals Gambaran Pasien yang Menggunakan Suplemen Kalsium di Poliklinik Sub Spesialis Bedah Onkologi RSUD Ulin Banjarmasin

2021 ◽  
Vol 8 (1) ◽  
pp. 7
Author(s):  
Adella Adella ◽  
Noor Cahaya ◽  
Siti Rahmah
Keyword(s):  
Medical Record ◽  
Hormonal Therapy ◽  
Public Hospital ◽  
Ace Inhibitor ◽  
Research Result ◽  
Data Retrieval ◽  
Megestrol Acetate ◽  
Calcium Supplements ◽  
H2 Blocker ◽  
Goserelin Acetate

Suplemen kalsium banyak digunakan oleh pasien yang menderita kanker dengan terapi hormonal di poliklinik sub spesialis bedah onkologi RSUD Ulin Banjarmasin. Penelitian ini bertujuan mendeskripsikan karakteristik berupa umur dan jenis kelamin pasien yang menerima suplemen kalsium, jenis kanker, obat lain yang diberikan bersama pemberian kalsium, jenis suplemen kalsium, frekuensi pemberian kalsium, lama pemberian kalsium dan penggunaan suplemen kalsium dari lama pemberian kalsium dan obat terapi hormonal yang digunakan di poliklinik sub spesialis bedah onkologi RSUD Ulin Banjarmasin. eksperimental deskriptif  adalah jenis penelitiannya serta pengambilan datanya dengan retrospektif menggunakan sumber cacatan medik pada tahun 2018. Data Populasi digunakan dengan kriteria inklusi adalah pasien kanker usia >18 tahun, menerima suplemen kalsium dan kriteria eksklusi yaitu penderita kanker dengan informasi catatan medik yang kurang lengkap/tak ditemukan. Total jumlah populasi yang digunakan adalah 55 pasien. Hasil dan kesimpulan penelitian didapatkan karakteristik berdasarkan usia pada rentang 26-35 tahun (1,81%), 36-45 tahun (10,91%), 46-65 tahun (43,64%), 56-65 tahun (40,00%) dan >65 tahun (3,64%); jenis kelamin perempuan (100%); jenis kanker berupa kanker payudara (98,18%) dan kanker tiroid (1,82%); obat lain yang diberikan bersama pemberian kalsium adalah obat golongan hormonal, kemoterapi sitotoksik, analgesik, H2 Blocker, ACE Inhibitor, Antihistamin, Bifosfonat, Analog vitamin D serta multivitamin lainnya; jenis suplemen kalsium yang didapat yaitu kalsium karbonat (100%); frekuensi pemberian kalsium 1x sehari 500 mg (100%); lama pemberian kalsium selama 7 hari (1,82%), 15 hari (1,82%), 20 hari (1,82%), 21 hari (1,82%), 30 hari (92,72%) dan penggunaan suplemen kalsium dari lama pemberian kalsium dan obat terapi hormonal yang digunakan adalah 7, 15, 20 dan 21 hari dengan jumlah pasien masing-masing 1 pasien terapi hormonal yang digunakan yaitu letrozole dan 30 hari dengan jumlah pasien 51 terapi hormonal yang digunakan yaitu letrozole, anasrozole, tamoxifen, goserelin acetate, megestrol acetate, dan levothyroxine. Kata Kunci: Suplemen, Kalsium, Onkologi, Hormonal, Kanker Calcium supplements are widely used by patients who suffer cancer with hormonal therapy at oncology surgery sub specialist polyclinic at Ulin Regional Public Hospital Banjarmasin. The research aims to describe the characteristics of the age and gender of patiens who receive calcium supplements, types of cancer, other drugs given with calcium, types of calcium supplements, frequency of calcium administration, duration of calcium administration and the use of calcium supplements from the duration of calcium administration and hormonal therapy drugs used at oncology surgery sub specialist polyclinic at Ulin Regional Public Hospital Banjarmasin. The research type is non-experimental descriptive and the data retrieval is taken restropective by using medical record as the source in 2018. The population data used with inclusion criteria are patients who suffer cancer with the age of > 18 years old, consumed calcium supplements and the exclusion criteria are patients with incomplete / not found medical record. The total population used are 55 patients. The research result and conclusion shows that the characteristics based on age is between 26-35 years old (1,81%), 36-45 years old (10,91%), 46-65 years old (43,64%), 56-65 years old (40,00%) and > 65 years old (3,64%); female (100%); types of cancer in the form of breast cancer (98,18%) and thyroid cancer (1,82%); other drugs given with calcium are hormonal medicine groups, cytotoxic chemotherapy, analgesic, H2 Blocker, ACE Inhibitor, Antihistamine, Bisphosphonates, Vitamin analogues D and other multivitamins; types of calcium supplements obtained is calcium carbonate (100%); frequency of calcium administration is 1 x 500 mg (100%) each day and duration of calcium administration is 7 days (1,82%), 15 days (1,82%), 20 days (1,82%), 21 days (1,82%), 30 days (92,72%) and the use of calcium supplements from the duration of calcium administration and hormonal therapy drugs used were 7,15,20 and 21 days with 1 patient each of hormonal therapy used letrozole and 30 days with 51 patients using hormonal therapy letrozole, anasrozole, tamoxifen, goserelin acetate, megestrol acetate, dan levothyroxine.

scholarly journals Utilização do prontuário eletrônico do paciente pela equipe de enfermagem

2020 ◽  
Vol 14 ◽  
Author(s):  
Marielle Maria Oliveira Barros ◽  
Carolinne Kilcia Carvalho Sena Damasceno ◽  
Magda Coeli Vitorino Sales Coêlho ◽  
Juliana Macêdo Magalhães
Keyword(s):  
Medical Record ◽  
Electronic Medical Record ◽  
Nurse Practitioners ◽  
Cross Sectional Study ◽  
Length Of Service ◽  
Microsoft Excel ◽  
Cross Sectional ◽  
El Sistema ◽  
Quantitative Descriptive ◽  
Team Nursing

Objetivo: descrever a utilização do prontuário eletrônico do paciente pela equipe de enfermagem. Método: trata-se de um estudo quantitativo, descritivo, transversal, num hospital privado, com 89 técnicos de enfermagem e 11 enfermeiros. Utilizou-se um questionário para a coleta de dados, processando-os na planilha Microsoft Excel, exportando-os, posteriormente, para o programa IBM SPSS Statistics 20.2. Resultados: predominou-se a faixa etária dos 18 aos 29 anos nas duas classes profissionais e o tempo de serviço variou de 1 a 4 anos. Revela-se que a maioria dos participantes já havia realizado cursos na área da informática e, em relação ao sistema utilizado, afirmaram ser de fácil lembrança, manipulação e acesso, porém, a maior dificuldade relatada foi “o erro no sistema”. Conclusão: reforça-se, pelos resultados, a necessidade de investimentos em relação ao “erro no sistema” ou “falha na conexão”, visto que esse foi o maior problema relatados e está identificado na literatura como desvantagem do prontuário eletrônico. Descritores: Registros Eletrônicos de Saúde; Processos de Enfermagem; Profissionais de Enfermagem; Equipe de Enfermagem; Enfermagem; Informática em Enfermagem.AbstractObjective: to describe the use of the patient's electronic medical record by the nursing staff. Method: this is a quantitative, descriptive, cross-sectional study in a private hospital with 89 nursing technicians and 11 nurses. A data collection questionnaire was used and processed in the Microsoft Excel spreadsheet and then exported to the IBM SPSS Statistics 20.2 program. Results: the age group from 18 to 29 years predominated in both professional classes and the length of service ranged from one to four years. It is revealed that most participants had already taken courses in the area of informatics and, in relation to the system used, said to be easy to remember, manipulate and access, however, the biggest difficulty reported was “the error in the system”. Conclusion: the results reinforce the need for investments in relation to “system error” or “connection failure”, as this was the biggest problem reported and is identified in the literature as a disadvantage of the electronic medical record. Descriptors: Electronic Medical Records; Nursing Process; Nurse Practitioners; Nursing, Team; Nursing; Nursing Informatics. ResumenObjetivo: describir el uso del historial médico electrónico del paciente por parte del personal de enfermería. Método: este es un estudio cuantitativo, descriptivo, transversal en un hospital privado con 89 técnicos de enfermería y 11 enfermeros. Se utilizó y se procesó un cuestionario de recopilación de datos en la hoja de cálculo de Microsoft Excel y luego se exportó al programa IBM SPSS Statistics 20.2. Resultados: el grupo de edad de 18 a 29 años predominó en ambas clases profesionales y la duración del servicio varió de 1 a 4 años. Se revela que la mayoría de los participantes ya habían tomado cursos en el área de tecnología de la información y, en relación con el sistema utilizado, se dice que es fácil de recordar, manipular y acceder, sin embargo, la mayor dificultad reportada fue "el error en el sistema". Conclusión: los resultados refuerzan la necesidad de inversiones en relación con "error del sistema" o "falla de conexión", ya que este fue el mayor problema reportado y se identifica en la literatura como una desventaja del historial clínico electrónico. Descriptores: Registros Electrónicos de Salud; Proceso de Enfermería; Enfermeras Practicantes; Grupo de Enfermería; Enfermería; Informática Aplicada a la Enfermería.

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