Pengaruh Kualitas Catatan terhadap Keakuratan Kode Penyebab Kematian di Rumah Sakit Pertamina Jaya
DOI:
https://doi.org/10.54259/sehatrakyat.v5i2.7440Keywords:
Code Accuracy, Quality of Cause of Death Records, SMPKAbstract
The accuracy of cause-of-death coding is essential for health statistics and policy-making. Incomplete, inaccurate, and unclear documentation by physicians can lead to coding errors and reduce the validity of mortality data. This study aimed to analyze the effect of documentation quality on the accuracy of cause-of-death coding at Pertamina Jaya Hospital. This quantitative study used a cross-sectional design and was conducted in January 2026. The sample consisted of 56 Medical Certificates of Cause of Death (MCCD) from September–November 2024, selected using quota sampling. Data were collected through observation and analyzed using univariate and bivariate analyses with logistic regression. The results showed that 14 MCCDs (25%) had accurate cause-of-death coding, while 42 MCCDs (75%) were inaccurate. Poor-quality documentation was found in 30 MCCDs (54%), while good-quality documentation was found in 26 MCCDs (46%). Bivariate analysis demonstrated a significant effect of documentation quality on coding accuracy (p = 0.037). An odds ratio of 4.062 indicated that good-quality documentation had four times greater odds of producing accurate cause-of-death codes, explaining 12.1% of the variance in coding accuracy (R² = 0.121). The study concludes that standard operating procedures and training for physicians and coders are needed to improve accuracy and validity of mortality data.
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AbouZahr, C., Savigny, D. de, Mikkelsen, L., Setel, P. W., Lozano, R., Nichols, E., Notzon, F., & Lopez, A. D. (2020). Civil Registration and Vital Statistics: Progress in the Data Revolution for Counting and Accountability. 386(10001), 1373–1385. https://doi.org/10.1016/S0140-6736(15)60173-8.
Busaidi, S. Al, Alawi, A. M. Al, Masruri, R. Al, Balushi, S. Al, & Badi, A. A.-. (2023). Quality of death certification based on the documented underlying cause of death: A retrospective study. Journal of Forensic and Legal Medicine, 97. https://doi.org/10.1016/j.jflm.2023.102547
Departemen Kesehatan Republik Indonesia. (2006). Pengelolaan Rekam Medis Rumah Sakit di Indonesia (Revisi II). Direktorat Jenderal Bina Pelayanan Medik.
Hatta, G. R. (2013). Pedoman Informasi kesehatan disarana Pelayanan Kesehatan. 2.
Hess, P. C. (2015). Clinical Documentation Improvement: Principles and Practice. American Health Information Management Association.
Lu, T. H., Lee, M. C., & Chou, M. C. (2000). Accuracy of cause-of-death coding in Taiwan: types of miscoding and effects on mortality statistics. International Journal of Epidemiology, 29, 336–343. https://doi.org/10.1093/ije/29.2.336
National Health Service Digital. (2021). Clinical Coding Audit Methodology 2021-22. 1–66.
Patricia, R., Deasy Rosmala Dewi, Puteri Fannya, & Putra, D. H. (2023). Ketepatan Kodifikasi Penyebab Dasa Kematian pada Resume Medis di RSKD Duren Sawit Tahun 2022. SEHATMAS: Jurnal Ilmiah Kesehatan Masyarakat, 2(4), 966–975. https://doi.org/10.55123/sehatmas.v2i4.2545
Peraturan Pemerintah Indonesia. (2022). Peraturan Menteri Kesehatan Republik Indonesia No 24 Tahun 2022 tentang Rekam Medis (Issue 8.5.2017, pp. 2003–2005). https://yankes.kemkes.go.id/unduhan/fileunduhan_1662611251_882318.pdf
Rahmawati, E. N., & Lestari, S. (2018). Tinjauan Keakuratan Kode Sebab Dasar Kematian pada Sertifikat Kematian di RSUP dr. Soeradji Tirtonegoro Klaten. 8(2), 86–97.
Rusdi, A. J., Prisusanti, R. D., & Ularan, R. A. R. (2022). Systematic Review Keakuratan Underlying Cause of Death (UCOD) pada Sertifikat Kematian di Fasilitas Pelayanan Kesehatan. Indonesian of Health Information Management Journal (INOHIM), 10(1), 57–65. https://doi.org/10.47007/inohim.v10i1.414
Rusman, A. A., Triningtyas, A. Y., & Mahendra, M. D. (2022). Format Dan Kelengkapan Pengisian Sertifikat Medis Penyebab Kematian Di Rumah Sakit Tk. Ii 03.05.01 Dustira Kota Cimahi Tahun 2020. Medika Kartika Jurnal Kedokteran Dan Kesehatan, 5(Volume 5 No 4), 378–387. https://doi.org/10.35990/mk.v5n4.p378-387
Sari, O. R., Indawati, L., Yulia, N., Widjaja, L., & Esa Unggul, U. (2023). Gambaran Ketepatan Pengodean Penyebab Kematian pada Sertifikat Medis Penyebab Kematian Kasus Perinatal di RSIA Tiara Cikupa. Nusantara Hasana Journal, 3(3), 12–18.
Sarimawar, & Suhardi. (2008). Buku Panduan Penentuan Kode Penyebab Kematian Menurut ICD-10. Badan Penelitian dan Pengembangan Kesehatan Departemen Kesehatan RI.
Schaffar, R., Rapiti, E., Rachet, B., & Woods, L. (2013). Accuracy of cause of death data routinely recorded in a population-based cancer registry : impact on cause-specific survival and validation using the Geneva cancer registry.
Welhelmina, F., Viatiningsih, W., Widjaja, L., & Yulia, N. (2022). Ketepatan Kode Diagnosis Penyebab Dasar Kematian Di Rumah Sakit Di Indonesia : Literatur Review. Jurnal Kesehatan Tambusai, 3(3), 514–520. https://doi.org/10.31004/jkt.v3i3.7693
Wittri, Z., Temesvari, N. A., & Zuama, W. (2024). Hubungan Kelengkapan Penulisan Penyebab Kematian pada Sertifikat Medis Penyebab Kematian (SMPK) dengan Ketepatan Kode Penyebab Kematian di RSIJ Sukapura Kelapa Gading Tahun 2023. Jurnal Kesehatan Tambusai, 5.
World Health Organization. (2014). Civil Registration and Vital Statistics 2013 : challenges, best practice and design principles for modern systems.
World Health Organization. (2016). International Statistical Classification of Disease and Related Health Problem 10 Version. 2.
World Health Organization. (2024). Civil Registration and Vital Statistics. https://www.who.int/news-room/fact-sheets/detail/civil-registration-and-vital-statistics
Zahra, P. A., Kurniasih, D. L. S., Kamelia, E., & Junaedi, F. A. (2022). Analisis Data Kematian UCoD dengan Tabel MMDS di Rumah Sakit X tahun 2022. 3(1), 1–7.
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