TINJAUAN KELENGKAPAN PENCATATAN ANAMNESA PASIEN IGD DENGAN KASUS CIDERA SEBAGAI PENDUKUNG KETEPATAN PENGKODEAN ICD 10 DI RUMAH SAKIT X PEKANBARU TAHUN 2022

Abstract

The completeness of filling out the IGD form, especially Anamnesa, is very necessary in maintaining the quality of health services where what anamnesis if filled in completely can only be known about the diagnosis that will be coded using ICD 10. Hospital X Pekanbaru still has incompleteness in recording the anamnesis of emergency room patients from 10 samples found 6 that are not completely filled, The purpose of this study is regarding the completeness of recording the anamnesis of erroneous patients with injury cases as a support for the accuracy of ICD 10 coding. The design of this study is descriptive quantify aimed at determining the picture and calculation of the completeness of recording the anamnesis of emergency room patients. With data collection methods, including interviews and observations on the completeness of recording the IGD form at the X Islamic Hospital Pekanbaru. The study sample was 95 random sampling. The results of this study show that there are still many IGD forms on the anamnesis sheet that are filled out completely with an average percentage of filling in the IGD form data of 48.15% and the incomplete one of 51.84%. Factors of incompleteness in filling out the emergency room form related to anamnesis are energy awareness, time to serve patients, and forgetfulness. Meanwhile, the impact caused is on making reports to determine the 10 most diseases, determining the disease code, making disease indexes and doctors have difficulty in determining the diagnosis and determining the actions given. Conclusion that the possibility of filling out medical resumes is still not in accordance with the SPM standard, which is 100%, It is recommended to the emergency room officers to further increase awareness in completing the anamnesis recording of emergency room patients with injury cases.