Analisis Pengetahuan Petugas Rekam Medis Tentang Penggunaan Kode R Dalam Penentuan Kode Diagnosis Utama Di Rumah Sakit

Abstract

Accurate coding of diagnoses and procedures is crucial in medical record data processing, particularly for supporting health insurance claims under the BPJS system. Errors or inaccuracies in diagnosis coding can lead to claim file rejections and potentially reduce hospital revenue. One category requiring specific understanding is the "R Code," which is subject to specific criteria for assignment as the primary diagnosis. This study aimed to analyze the knowledge of medical record staff regarding the use of R Codes in determining primary diagnoses in the hospital. This was an observational analytic study with a cross-sectional design. The study population consisted of 25 healthcare workers selected via total sampling. Data were collected using questionnaires and interview guidelines. The data were analyzed descriptively and presented in frequency distribution tables and percentages. Respondent characteristics showed that the largest age group was 30–40 years (40%), the dominant education level was a bachelor's degree (48%), the majority were female (64%), the largest work unit was Medical Record and Health Information (PMIK) at 40%, and most had a tenure of 1–5 years (40%). The majority of respondents fell into the high category regarding knowledge of R Code usage for primary diagnosis determination (15 respondents or 60%), followed by the medium category (32%) and the low category (8%). The knowledge level of medical record/health information staff regarding R Code usage for primary diagnosis determination was generally high. Staff are advised to regularly attend training sessions, seminars, and workshops on coding and medical terminology to maintain and improve the accuracy of diagnosis coding.