Abstrak
Penelitian ini membahas ketidaktepatan dalam pengisian catatan rekam medis,
Dan ketidaktepatan dalam melakukan koding yang menyebabkan pelayanan
menanggung risiko finansial pada kasus Tetralogy of Fallot di unit Pediatrik
Kardiologi dan Penyakit Jantung Bawaan RS Harapan Kita periode Januari-
September 2013. Dengan metode kualitatif. Dengan hasil 21,4% kasus dengan
diagnosis sekunder yang tidak lengkap dan selisih klaim Rp 251.273.615,00 (4%).
Saran untuk dilakukan peningkatan sarana dan prasarana fisik serta pengelolaan
kebijakan seperti adanya SPO pengisian rekam medis, sosialisasi, pembinaan staf
dan pemantauan secara berkala.
......This study discusses the inaccuracies in medical record entry charging, and
inaccuracy in doing coding that caused service run the risk of financially in the
case of Tetralogy of Fallot in the Pediatric Cardiology and congenital heart
disease unit RS Harapan Kita from January-September 2013. With the qualitative
method. With the results at 21.4% of cases with a diagnosis of incomplete
secondary and the difference between the claim of Rp 251.273.615 b (4%).Advice
to do the physical facilities and infrastructure increased as well as themanagement
policies as there are SPO medical record filing, socialization, training staff and
monitoring at regular intervals.
