ACCURACY OF DIAGNOSTIC CODES IN REFERRAL PATIENTS BASED ON ICD – 10 AT UPTD PUSKESMAS CIGEUREUNG

Abstract

The implementation of patient referrals is related to the recording and reporting of diseases served by the Puskesmas including disease diagnosis methods to obtain more accurate morbidity data. The accuracy of diagnostic data is important in the fields of clinical data management, medical information management and medical facilities. The research was conducted to determine the accuracy of the diagnosis code in referral patients based on ICD-10 at UPTD Cigeureung Health Center. This study uses mix methods. The population in this study is 934 referral patient data in 2021 with a sample of 90, also used supporting data with subjects to complete quantitative data consisting of 7 officers, namely 2 doctors and 5 nurses at UPTD Puskesmas Cigeureung by accidental sampling. Based on the results of the study, the highest level of accuracy of the diagnosis code with the inaccurate category was 55.6%, while the lowest was in the accurate category at 44.4% and the factors that become obstacles in coding the diagnosis include the absence of a medical recorder for coding, the coding steps are not in accordance with the ICD-10 guidelines, there is incomplete clinical data content, and the ICD-10 book and support for coding the diagnosis of referral patients are not yet available.

Keywords: Accuracy, Diagnostic Code, ICD-10, Patient Referral, Puskesmas