UPAYA MENDUKUNG KELENGKAPAN KLASIFIKASI DAN KODEFIKASI PENYAKIT SERTA MASALAH TERKAIT BERDASARKAN ICD 10 PADA DOKUMEN REKAM MEDIS DI PUSKESMAS SINGOSARI

Abstract

Puskesmas is a health service facility that carries out public health efforts and first-level individual health efforts, by prioritizing promotive and preventive efforts, to achieve the highest level of public health. Singosari Community Health Center is a community health center located on Jl. Tohjoyo III/1. Singosari District, Malang Regency. Medical records are documents that contain patient identity data, examinations, treatment, procedures, and other services that have been provided to the patient. Therefore, every doctor or dentist in carrying out medical practice is obliged to keep a medical record. The coding process at the Singosari Community Health Center can use the community health center's E-Pus application which has a feature to obtain diagnosis codes based on ICD-10. However, the coding of disease diagnoses at the Singosari Community Health Center is still incomplete for manual medical record documents (in paper form). So medical recorders have the authority to complete medical records according to their educational qualifications, namely implementing a system of classification and coding of diseases related to health and medical procedures according to correct medical terminology.