PENGARUH KUALITAS DOKUMENTASI KLINIS TERHADAP KETEPATAN WAKTU KODEFIKASI KLINIS PASIEN JKN DI INSTALASI CASEMIX RSU KABUPATEN TANGERANG
DOI:
https://doi.org/10.54314/yf2jxx52Keywords:
Medical Record Data. Timeliness of Coding, Quality of Clinical DocumentationAbstract
Abstract: Timeliness of coding is crucial and requires attention, as failure to do so will delay the coding process and even impact financing claims. Initial observations indicate that 38.88% of coding is inaccurate. This study aims to analyze the effect of clinical documentation quality on the timeliness of clinical coding in the Casemix Installation of Tangerang Regency General Hospital. The study was conducted from August to October 2025 using a quantitative approach with a cross-sectional case study. A sample of 96 medical records was obtained using a random sampling technique. Data collection was carried out by reviewing medical records. The analysis technique used binary logistic regression. The results of the study showed that there was a 52.08% inaccuracy in the timeliness of coding and only 12.5% ??met the 7 criteria of clinical documentation quality. The Nagelkerke R Square value of 0.346 was obtained, which means that the quality of clinical documentation (Independent Variable) contributed 34.6% in explaining the timeliness of clinical coding (Dependent Variable), while 65.4% was explained by other factors outside the research model such as hospital information systems, doctor workloads and other internal policies. The Wald test showed a significant influence between the quality of clinical documentation on the timeliness of clinical coding with a p-value of 0.000 (p = <0.05). It is necessary to update the SIMRS coding system and optimal socialization in filling in the completeness and timeliness of clinical documentation.
Keywords: Medical Record Data. Timeliness of Coding, Quality of Clinical Documentation
Abstrak: Ketepatan waktu kodefikasi merupakan hal penting dan perlu mendapatkan perhatian, jika tidak akan menyebabkan keterlambatan proses pengkodean salah satunya diakibatkan oleh kualitas dokumentasi, bahkan berdampak pada klaim pembiayaan. Hasil observasi awal menunjukkan terdapat 38,88% ketidaktepatan waktu kodefikasi. Penelitian ini bertujuan untuk menganalisis pengaruh kualitas dokumentasi klinis terhadap ketepatan waktu kodefikasi klinis di Instalasi Casemix RSU Kabupaten Tangerang. Penelitian dilakukan pada bulan Agustus - Oktober 2025 menggunakan pendekatan kuantitatif dengan kasus potong lintang (Cross- Sectional). Didapatkan Sampel sebanyak 96 rekam medis dengan teknik random sampling. Pengumpulan data dilakukan dengan cara telaah rekam medis. Teknik analisis menggunakan regresi logistik biner. Hasil Penelitian menunjukkan terdapat ketidaktepatan waktu kodefikasi sebesar 52,08% dan hanya terdapat 12,5% yang memenuhi kriteria 7 kriteria kualitas dokumentasi klinis, Diperoleh nilai Nagelkerke R Square sebesar 0,346, dapat diartikan kualitas dokumentasi klinis (Variabel Independen) memiliki konstribusi sebesar 34,6% dalam menjelaskan ketepatan waktu kodefikasi klinis (Variabel Dependen), sedangkan 65,4% dijelaskan oleh faktor lain diluar model penelitian seperti sistem informasi rumah sakit, beban kerja dokter dan kebijakan internal lainnya. Uji wald menunjukkan adanya pengaruh signifikan antara kualitas dokumentasi klinis terhadap ketepatan waktu kodefikasi klinis dengan nilai p-value 0,000 (p = < 0,05). Perlu dilakukan update sistem SIMRS kodefikasi dan sosialisasi optimal dalam pengisian kelengkapan dan ketepatan
waktu dokumentasi klinis.
Kata Kunci: Data Rekam Medis, Ketepatan Waktu Kodefikasi, Kualitas Dokumentasi Klinis
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