Kelengkapan Laporan Operasi dan Keakuratan Kode Kasus Patah Tulang di Rumah Sakit Panti Waluya Sawahan Malang

Abstract

The operation report sheet is a very useful part of the medical record file, so research is needed that aims to analyze the relationship between the completeness of the patient's operation report and the accuracy of the fracture case code. The research design is a correlation study. This study used secondary data obtained from 82 medical record documents of surgical patients who visited from January to December 2020. Data were analyzed using the Spearman correlation test. It is known that the operation report files was in the complete category = 14, quite complete = 50 and incomplete = 18. The accuracy of fracture case codes was in the accurate category = 17, quite accurate = 55 codes and inaccurate = 10. The results of the hypothesis test showed that the value of p = 0.003. It was concluded that there was a relationship between the completeness of the operation report and the accuracy of the fracture case code.

Keywords: hospital; medical records; patient operation report; fracture case code

ABSTRAK

Lembar laporan operasi adalah salah satu bagian dari berkas rekam medis yang sangat berguna, sehingga diperlukan penelitian yang bertujuan untuk menganalisis hubungan antara kelengkapan laporan operasi pasien dengan keakuratan kode kasus patah tulang. Desain penelitian ini adalah studi korelasi. Penelitian ini menggunakan data sekunder yang diperoleh dari 82 dokumen rekam medis pasien bedah yang berkunjung pada bulan Januari sampai Desember 2020. Data dianalisis menngunakan uji korelasi Spearman. Diketahui bahwa berkas laporan operasi dalam kategori lengkap = 14, cukup lengkap = 50 dan tidak lengkap = 18. Akurasi kode kasus patah tulang dalam kategori akurat = 17, cukup akurat = 55 kode dan tidak akurat = 10. Hasil uji hipotesis menunjukkan nilai p = 0,003. Disimpulkan bahwa ada hubungan antara kelengkapan laporan operasi dengan keakuratan kode kasus patah tulang.

Kata kunci: rumah sakit; rekam medis; laporan operasi pasien; kode kasus patah tulang