Author : GEBBY RAHELINA TAMPUBOLON (2213462014), Tahun : 2025
Abstrak : Codification in medical records is the process of providing diagnosis and action codes according to ICD-10 and ICD-9 CM. This study aims to determine the coding of a disease in the Cardiovascular System based on ICD 10. The method used is a case study with a retrospective approach, data obtained from purposive sampling techniques, meaning that patient medical record documents that meet the inclusion criteria. There are 7 main diagnoses: Congestive Heart Failure (CHF), Unstable Angina Pectoris (UAP), Supraventricular Tachycardia (SVT), Ventricular Tachycardia (VT), Right Heart Failure (RHF), Pseudoaneurysm, and Non-ST-Elevation Myocardial Infarction (NSTEMI). The results of the study show that the enforcement of diagnosis in cardiovascular cases requires data support from anamnesis, physical examinations, supporting examinations such as laboratories, radiology, and other supporting examinations. All established diagnoses have complied with ICD-10 guidelines for diagnosis and ICD-9-CM for procedure of action. The obstacle encountered is that the writing on medical records is difficult to understand, which has the potential to cause misinterpretation in coding. Tip: it is best to conduct training for coding officers who have never participated in training.
Link URL : #Bahasa : Indonesia
Kata Kunci : Case Study, Coding the Cardiovascular System
| File | Deskripsi | Format | |
|---|---|---|---|
| COVER.pdf | COVER | ||
| ABSTRAK.pdf | ABSTRAK | ||
| BAB I.pdf | BAB I | ||
| BAB II.pdf | BAB II | ||
| BAB III.pdf | BAB III | ||
| BAB IV.pdf | BAB IV | ||
| BAB V.pdf | BAB V | ||
| DAFTAR PUSTAKA.pdf | DAFTAR PUSTAKA | ||
| LAMPIRAN.pdf | LAMPIRAN |