Suitability Term Of Medical Procedures Based On ICD-9-CMOf Medical Record Documents Non-PBI Inpatient Quarter I At Hasan Sadikin General Hospital Center 2015

Fahri Ramdan Hariri, Ida Wahyuni

Abstract

The Regulation of the Minister of Health of the Republic of Indonesia Number 27 Year 2014 on the Indonesian Systems Case Base Groups (INA-CBGS) Technical Guidelines that charging medical action terms, and action code refers to ICD-9cm. Based on preliminary studies in dr. Hasan Sadikin Central General Hospital, coders have difficulty in determining leadterm to define actions based on ICD-9-CM, giving rise to the assumption that resulted in inaccurate code determination. The study was conducted to determine the percentage level of medical procedures term conformity based on ICD -9-CM. This study is a descriptive study that seeks to look back by re-reviewing or review back the use of the medical action term on NON-PBI inpatient medicalrecord document in the first quarter of 2015. Data obtained through observation using observation sheet and interviews as supportive descriptives. The results showed that the use of medical action term is largely in accordance ICD-9-CM with the corresponding percentage at 78% and in non-accordance of 22%. However, in order to homogenize the perceptionof the medical action term usage, efforts should be made to address the impact caused, by further enhancing the cooperation that has existed between physicians, nurses and other healthcare practitioners with medical records clerk about writing medical term measures appropriately based on ICD- 9-CM.