Tahun2014 Tentang Pusat Kesehatan Masyarakat, Puskesmas adalah fasilitas pelayanan kesehatan yang menyelenggarakan upaya kesehatan masyarakat dan upaya kesehatan perseorangan tingkat pertama, dengan lebihmengutamakan upaya promotif dan preventif, untuk mencapai derajat kesehatan yang setinggi tingginya di wilayah kerjanya.
PEMBUATAN BUKU PRAKTIS KODEFIKASI DIAGNOSIS PENYAKIT BERDASARKAN BUKU ICD-10 DI PUSKESMAS DINOYO KOTA MALANG ABSTRAK Sistem klasifikasi penyakit merupakan pengelompokan penyakit-penyakit yang sejenis dengan International Statistical Classification of Diseases and Related Health Problem Tenth Revisions ICD-10 untuk istilah penyakit dan masalah yang berkaitan dengan kesehatan. Penerapan pengodean harus sesuai ICD-10 guna mendapatkan kode yang akurat karena hasilnya digunakan untuk mengindeks pencatatan penyakit, pelaporan nasional dan internasional morbiditas dan mortalitas, analisis pembiayaan pelayanan kesehatan, serta untuk penelitian epidemiologi dan klinis. Tujuan penelitian ini untuk mengetahui keakuratan kode diagnosis penyakit berdasarkan ICD-10 di Puskesmas Dinoyo Kota Malang pada tahun 2021. Penelitian ini menggunakan jenis penelitian kualitatif dengan rancangan penelitian secara cross sectional. Populasi obyek dalam penelitian ini adalah seluruh berkas rekam medis pasien rawat jalan pada periode bulan Januari sampai dengan bulan Juni tahun 2021 sedangkan populasi subyeknya adalah seluruh dokter dan perawat. Sampel pada penelitian ini berjumlah 385 berkas rekam medis dengan menggunakan teknik simple random sampling sedangkan sampel subyeknya adalah 2 orang dokter dan 2 orang perawat. Hasil analisis menunjukkan bahwa jumlah kode yang akurat sebanyak 174 kode 45,2%, dan tidak akurat sebanyak 211 kode 54,8%. Ada beberapa faktor penyebab ketidakakuratan kode diagnosis di Puskesmas Dinoyo Kota Malang diantaranya tidak sesuainya kualifikasi SDM yang bertugas untuk mengode diagnosis, tidak adanya Standard Operating Procedure SOP untuk pengodean diagnosis, data diagnosis dan kodenya yang ada di sistem informasi manajemen puskesmas SIMPUS tidak lengkap, serta tidak optimalnya penggunaan buku ICD-10 sebagai panduan untuk mengode diagnosis penyakit. Kata Kunci ICD-10, keakuratan kode diagnosis, puskesmas. ABSTRACT The disease classification system is a grouping of similar diseases with the International Statistical Classification of Diseases and Related Health Problem Tenth Revisions ICD-10 for terms of diseases and problems related to health. The application of coding must comply with ICD-10 in order to obtain an accurate code because the results are used for indexing disease records, national and international reporting of morbidity and mortality, analysis of health care costs, as well as for epidemiological and clinical research. The purpose of this study was to determine the accuracy of the disease diagnosis code based on ICD-10 at the Dinoyo Public Health Center, Malang City in 2021. This study used a qualitative type of research with a cross sectional design. The object population in this outpatient study were all outpatient medical record files in the period from January to June 2021, while the subject population was all doctors and nurses. The sample in this study found 385 medical record files using simple random sampling technique while the sample subjects were 2 doctors and 2 nurses. The results of the analysis show that the number of accurate codes is 174 codes and 211 codes are not accurate There are several factors that cause the inaccuracy of the diagnosis code at the Dinoyo Public Health Center, Malang City, including the incompatibility of HR qualifications to code the diagnosis, the absence of a Standard Operating Procedure SOP for diagnosis coding, the diagnosis data and the code in the puskesmas management information system SIMPUS is incomplete. , and the use of the ICD-10 book is not optimal as a guide for coding disease diagnoses. Keywords ICD-10, accuracy of diagnosis code, puskesmas. UPAYA PENINGKATAN PELAYANAN KESEHATAN MELALUI PENGENDALIAN DOKUMEN REKAM MEDIS RAWAT INAP DI PUSKESMAS ARDIMULYO SINGOSARI
Kodeini digunakan untuk melakukan penginputan data pasien di Aplikasi Pcare BPJS Kesehatan. Pembahasan Kode ICD 10 Konstipasi Sembelit adalah suatu kondisi di
ICD-10-CM Codes › Z00-Z99 › Persons encountering health services for examinations Z00-Z13 NoteNonspecific abnormal findings disclosed at the time of these examinations are classified to categories ICD-10-CM Diagnosis Code R70Elevated erythrocyte sedimentation rate and abnormality of plasma viscosity2016 2017 2018 2019 2020 2021 2022 2023 Non-Billable/Non-Specific Code R70-ICD-10-CM Diagnosis Code R94Abnormal results of function studies2016 2017 2018 2019 2020 2021 2022 2023 Non-Billable/Non-Specific Code Includesabnormal results of radionuclide [radioisotope] uptake studiesabnormal results of scintigraphyR94. Type 1 ExcludesType 1 Excludes HelpA type 1 excludes note is a pure excludes. It means "not coded here". A type 1 excludes note indicates that the code excluded should never be used at the same time as Z00-Z13. A type 1 excludes note is for used for when two conditions cannot occur together, such as a congenital form versus an acquired form of the same related to pregnancy and reproduction ICD-10-CM Diagnosis Code Z30Encounter for contraceptive management2016 2017 2018 2019 2020 2021 2022 2023 Non-Billable/Non-Specific Code Z30-ICD-10-CM Diagnosis Code Z36Encounter for antenatal screening of mother2016 2017 2018 - Converted to Parent Code 2019 2020 2021 2022 2023 Non-Billable/Non-Specific Code IncludesEncounter for placental sample taken vaginallyScreening is the testing for disease or disease precursors in asymptomatic individuals so that early detection and treatment can be provided for those who test positive for the 1 Excludesdiagnostic examination- code to sign or symptomencounter for suspected maternal and fetal conditions ruled out fetal condition affecting management of pregnancy - code to condition in Chapter 15Type 2 Excludesabnormal findings on antenatal screening of mother counseling and testing prenatal care Z34Z36, ICD-10-CM Diagnosis Code Z39 Z39 Encounter for maternal postpartum care and ex... Encounter for care and examination of mother ... Encounter for care and examination of lactati... Encounter for routine postpartum Codes Z00 Encounter for general examination without complaint, suspected or reported diagnosis Z01 Encounter for other special examination without complaint, suspected or reported diagnosis Z02 Encounter for administrative examination Z03 Encounter for medical observation for suspected diseases and conditions ruled out Z04 Encounter for examination and observation for other reasons Z05 Encounter for observation and evaluation of newborn for suspected diseases and conditions ruled out Z08 Encounter for follow-up examination after completed treatment for malignant neoplasm Z09 Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm Z11 Encounter for screening for infectious and parasitic diseases Z12 Encounter for screening for malignant neoplasms Z13 Encounter for screening for other diseases and disorders ICD-10-CM Diagnosis Codes Z00-* Z00 Encounter for general examination without com... Encounter for general adult medical examinati... Encounter for general adult medical examinati... Encounter for general adult medical examinati... Encounter for newborn, infant and child healt... Newborn health examination Health examination for newborn under 8 days o... Health examination for newborn 8 to 28 days o... Encounter for routine child health examinatio... Encounter for routine child health examinatio... Encounter for routine child health examinatio... Encounter for examination for period of rapid... Encounter for examination for adolescent deve... Encounter for examination of potential donor ... Encounter for examination for normal comparis... Encounter for examination for period of delay... Encounter for examination for period of delay... Encounter for examination for period of delay... Encounter for other general examination ICD-10-CM Diagnosis Codes Z01-* Z01 Encounter for other special examination witho... Encounter for examination of eyes and vision Encounter for examination of eyes and vision ... Encounter for examination of eyes and vision ... Encounter for examination of eyes and vision ... Encounter for examination of eyes and vision ... Encounter for examination of eyes and vision ... Encounter for examination of ears and hearing... Encounter for examination of ears and hearing... Encounter for examination of ears and hearing... Encounter for hearing examination following f... Encounter for examination of ears and hearing... Encounter for hearing conservation and treatm... Encounter for dental examination and cleaning... Encounter for dental examination and cleaning... Encounter for dental examination and cleaning... Encounter for examination of blood pressure Encounter for examination of blood pressure w... Encounter for examination of blood pressure w... Encounter for gynecological examination Encounter for routine gynecological examinati... Encounter for gynecological examination gene... Encounter for gynecological examination gene... Encounter for cervical smear to confirm findi... Encounter for other specified special examina... Encounter for preprocedural examinations Encounter for preprocedural cardiovascular ex... Encounter for preprocedural respiratory exami... Encounter for preprocedural laboratory examin... Encounter for other preprocedural examination... Encounter for allergy testing Encounter for blood typing Encounter for antibody response examination Encounter for other specified special examina... ICD-10-CM Diagnosis Codes Z02-* Z02 Encounter for administrative examination Encounter for examination for admission to ed... Encounter for pre-employment examination Encounter for examination for admission to re... Encounter for examination for recruitment to ... Encounter for examination for driving license... Encounter for examination for participation i... Encounter for examination for insurance purpo... Encounter for issue of medical certificate Encounter for disability determination Encounter for issue of other medical certific... Encounter for other administrative examinatio... Encounter for paternity testing Encounter for adoption services Encounter for blood-alcohol and blood-drug te... Encounter for other administrative examinatio... Encounter for administrative examinations, un... ICD-10-CM Diagnosis Codes Z03-* Z03 Encounter for medical observation for suspect... Encounter for observation for suspected toxic... Encounter for suspected maternal and fetal co... Encounter for suspected problem with amniotic... Encounter for suspected placental problem rul... Encounter for suspected fetal anomaly ruled o... Encounter for suspected problem with fetal gr... Encounter for suspected cervical shortening r... Encounter for other suspected maternal and fe... Encounter for observation for other suspected... Encounter for observation for suspected expos... Encounter for observation for suspected expos... Encounter for observation for suspected expos... Encounter for observation for suspected forei... Encounter for observation for suspected inges... Encounter for observation for suspected aspir... Encounter for observation for suspected inser... Encounter for observation for suspected condi... Encounter for observation for other suspected... ICD-10-CM Diagnosis Codes Z04-* Z04 Encounter for examination and observation for... Encounter for examination and observation fol... Encounter for examination and observation fol... Encounter for examination and observation fol... Encounter for examination and observation fol... Encounter for examination and observation fol... Encounter for examination and observation fol... Encounter for general psychiatric examination... Encounter for examination and observation fol... Encounter for examination and observation fol... Encounter for examination and observation fol... Encounter for examination and observation for... Encounter for examination and observation of ... Encounter for examination and observation of ... Encounter for examination and observation for... Encounter for examination and observation for... ICD-10-CM Diagnosis Codes Z05-* Z05 Encounter for observation and evaluation of n... Observation and evaluation of newborn for sus... Observation and evaluation of newborn for sus... Observation and evaluation of newborn for sus... Observation and evaluation of newborn for sus... Observation and evaluation of newborn for sus... Observation and evaluation of newborn for sus... Observation and evaluation of newborn for sus... Observation and evaluation of newborn for sus... Observation and evaluation of newborn for sus... Observation and evaluation of newborn for sus... Observation and evaluation of newborn for sus... Observation and evaluation of newborn for sus... Observation and evaluation of newborn for sus... Observation and evaluation of newborn for sus... Observation and evaluation of newborn for oth... Observation and evaluation of newborn for uns... ICD-10-CM Diagnosis Codes Z08-* Z08 Encounter for follow-up examination after com... ICD-10-CM Diagnosis Codes Z09-* Z09 Encounter for follow-up examination after com... ICD-10-CM Diagnosis Codes Z11-* Z11 Encounter for screening for infectious and pa... Encounter for screening for intestinal infect... Encounter for screening for respiratory tuber... Encounter for screening for other bacterial d... Encounter for screening for infections with a... Encounter for screening for human immunodefic... Encounter for screening for other viral disea... Encounter for screening for human papillomavi... Encounter for screening for COVID-19 Encounter for screening for other viral disea... Encounter for screening for other protozoal d... Encounter for testing for latent tuberculosis... Encounter for screening for other infectious ... Encounter for screening for infectious and pa... ICD-10-CM Diagnosis Codes Z12-* Z12 Encounter for screening for malignant neoplas... Encounter for screening for malignant neoplas... Encounter for screening for malignant neoplas... Encounter for screening for malignant neoplas... Encounter for screening for malignant neoplas... Encounter for screening for malignant neoplas... Encounter for screening for malignant neoplas... Encounter for screening for malignant neoplas... Encounter for screening for malignant neoplas... Encounter for screening mammogram for maligna... Encounter for other screening for malignant n... Encounter for screening for malignant neoplas... Encounter for screening for malignant neoplas... Encounter for screening for malignant neoplas... Encounter for screening for malignant neoplas... Encounter for screening for malignant neoplas... Encounter for screening for malignant neoplas... Encounter for screening for malignant neoplas... Encounter for screening for malignant neoplas... Encounter for screening for malignant neoplas... Encounter for screening for malignant neoplas... Encounter for screening for malignant neoplas... Encounter for screening for malignant neoplas... Encounter for screening for malignant neoplas... Encounter for screening for malignant neoplas... ICD-10-CM Diagnosis Codes Z13-* Z13 Encounter for screening for other diseases an... Encounter for screening for diseases of the b... Encounter for screening for diabetes mellitus... Encounter for screening for nutritional, meta... Encounter for screening for nutritional disor... Encounter for screening for metabolic disorde... Encounter for screening for lipoid disorders Encounter for screening for other metabolic d... Encounter for screening for other suspected e... Encounter for screening examination for menta... Encounter for screening examination for menta... Encounter for screening for depression Encounter for screening for maternal depressi... Encounter for screening examination for other... Encounter for screening for certain developme... Encounter for screening for unspecified devel... Encounter for autism screening Encounter for screening for global developmen... Encounter for screening for other development... Encounter for screening for eye and ear disor... Encounter for screening for cardiovascular di... Encounter for screening for genetic and chrom... Encounter for nonprocreative screening for ge... Encounter for other screening for genetic and... Encounter for screening for other specified d... Encounter for screening for digestive system ... Encounter for screening for upper gastrointes... Encounter for screening for lower gastrointes... Encounter for screening for other digestive s... Encounter for screening for musculoskeletal d... Encounter for screening for osteoporosis Encounter for screening for other musculoskel... Encounter for screening for respiratory disor... Encounter for screening for dental disorders Encounter for screening for nervous system di... Encounter for screening for traumatic brain i... Encounter for screening for other nervous sys... Encounter for screening for disorder due to e... Encounter for screening for other disorder Encounter for screening, unspecified
M001 Arthritis dan poliarthritis pneumokokus. M00.2 Arthritis dan poliarthritis streptokokus lain. M00.8 Arthritis dan poliarthritis akibat bakteri lain yang dijelaskan. Gunakan kode tambahan (B95-B96), kalau perlu, untuk identifikasi agen bakteri. M00.9 Arthritis piogenik, tak dijelaskan. Arthritis infektif NOS.
kode icd 10 konsultasi kesehatan
