DAFTAR ISI

Halaman
BAB .I. PENDAHULUAN

A. Latar Belakang .................................................................................. 1

B. Rumusan Masalah ............................................................................. 4

C. Batasan Masalah ............................................................................... 4

D. Tujuan Penelitiaan ............................................................................ 4

1. Tujuan Khusus ........................................................................... 4

2. Tujuan Umum ............................................................................ 4

E. Manfaat Penelitian ............................................................................ 4

1. Bagi Peneliti............................................................................... 4

2. Bagi Institut Ilmu Kesehatan ..................................................... 5

3. Bagi Rumah Sakit ...................................................................... 5

BAB .II. TINJAUAN PUSTAKA ...................................................................... 6

A. Rumah Sakit ...................................................................................... 6

1. Pengertian Rumah Sakit ............................................................ 6

2. Tugas dan Fungsi Rumah Sakit ................................................. 6

3. Pelayanan dan Klasifikasi .......................................................... 7

B. Rekam Medis .................................................................................... 7

1. Pengertian Rekam Medis ........................................................... 7

2. Tujuan Rekam Medis ................................................................. 8

3. Fungsi Rekam Medis ................................................................. 9

4. Ruang Lingkup Rekam Medis .................................................. 10

C. Instalasi Rawat Inap ......................................................................... 10

1. Pengertian Instalasi ................................................................... 10

2. Penerimaan Pasien Rawat Inap ................................................. 11

3. Pasien ........................................................................................ 11

D. Diagnosis ......................................................................................... 11

1. Pengertian Diagnosis ................................................................ 11

2. Diagnosis Utama ....................................................................... 11

3. Diagnosis Sekunder .................................................................. 12

4. Cara Menegakkan Diagnosa ..................................................... 12

E. Sistem Klasifikasi Penyakit ............................................................. 13

1. Pengertian Koding .................................................................... 14

2. Tujuan Koding .......................................................................... 14

3. Faktor Yang Mempenagruhi Koding ........................................ 15

4. Manfaat Koding ........................................................................ 15

5. Peran Dokter dan Koder ........................................................... 16

F. ICD-10 ............................................................................................. 16

1. Pengertian ICD-10 .................................................................... 16

2. Dasar Hukum ICD-10 ............................................................... 16

a. Volume I .............................................................................. 16

b. Volume II ............................................................................. 17

c. Volume III ............................................................................ 18

3. Fungsi dan kegunaan ICD-10 ................................................... 18

4. Tata Cara Pemberian Kode ....................................................... 18

 5. Golden Coding Rules ................................................................ 20

6. Tahap Proses Pengkodean ........................................................ 21

G. Manifestasi Klinis ................................................................................................. 21

H. Pengertian Gagal Ginjal ........................................................................................ 22

1. Pengertian Gagal Ginjal ........................................................................................ 22

a. Gagal Ginjal Akut ................................................................................................. 24

b. Gagal Ginjal Kronik .............................................................................................. 25

2. Etiologi .................................................................................................................. 26

a. Gagal Ginjal .......................................................................................................... 26

b. Renal ..................................................................................................................... 27

c. Post-renal .............................................................................................................. 28

3. Penyebab Gagal Ginjal .......................................................................................... 28

4. Anatomi dan Fisiologi Ginjal ................................................................................ 30

a. Anatomi Ginjal ...................................................................................................... 30

b. Fisiologi Ginjal ..................................................................................................... 31

I. Kode ICD-10 ......................................................................................................... 34

1. Renal Failure (N17-N19) ...................................................................................... 34

2. N17 ( Acute Renal Failure) ................................................................................... 35

3. N18 (chronic kidney disease) ................................................................................ 35

4. N19 (Unspecified chronic kidney) ........................................................................ 35

J. Keakuratan ............................................................................................................ 35

BAB III KERANGKA KONSEP ..................................................................... 37

 A. Kerangka Konsep .................................................................................................. 37

BAB IV METODOLOGI PENELITIAN........................................................ 39

A. Desain Penelitian ................................................................................................... 39

B. Populasi,sampel, dan teknik sampling .................................................................. 39

1. Populasi 39

2. Sampel 39

3. Teknik Sampling ................................................................................................... 40

C. Lokasi dan Waktu Penelitian ................................................................................ 40

1. Lokasi Penelitian ................................................................................................... 40

2. Waktu Penelitian ................................................................................................... 40

D. Variabel Penelitian dan Definisi Operasional ....................................................... 40

1. Variable Penelitian ................................................................................................ 40

2. Definisi Operasional.............................................................................................. 41

E. Instrumen dan Prosedur Pengumpulan Data ......................................................... 42

1. Instrumen data ....................................................................................................... 42

2. Prosedur Pengumpulan Data ................................................................................. 42

a. Observasi 42

b. Wawancara 42

F. Analisis Data ......................................................................................................... 43

a. Editing 43

b. Coding 43
 c. Masukkan Data...................................................................................................... 43

d. Tabulasi 43

G. Etika Penelitian ..................................................................................................... 44

a. Anonomity 44

b. Confienditality ...................................................................................................... 44

H. Kerangka Kerja ..................................................................................................... 45

BAB V HASIL PENGAMATAN ................................................................... 46

A. Gambaran umum RSUD Ngudi Waluyo Wlingi .................................................. 46

1. Sejarah RSUD Ngudi Waluyo Wlingi .................................................................. 46

2. Visi Dan Misi ........................................................................................................ 47

a. Visi 47

b. Misi 47

3. Tugas Dan Fungsi ................................................................................................. 47

4. Jenis Pelayanan RSUD Ngudi Waluyo Wlingi ..................................................... 48

5. Jumlah Tempat Tidur di RSUD Ngudi Waluyo Wlingi........................................ 48

B. Gambaran Rekam Medis di RSUD Ngudi Waluyo Wlingi .................................. 49

C. Kebijakan Penggunaan ICD-10............................................................................. 50

D. SOP tentang Pengkodean ...................................................................................... 51

E. Proses Pemberian Kode diagnosa ......................................................................... 52

1. Proses Pemberian Kode ICD-10 Berdasarkan SOP di Rumah Sakit Ngudi Waluyo

Wlingi.................................................................................................................... 52

2. Proses Pemberian Kode Diagnosa Yang Dilakukan Oleh Petugas ...................... 53

 F. Keakuratan Kode Diagnosa Penyakit Gagal Ginjal Kronik Berdasarkan ICD-10 54

1. ICD-10 Edisi 2005 ................................................................................................ 55

a. Persentase Kode Diagnosa Yang Akurat .............................................................. 55

b. Persentasi Kode Diagnosa Yang Tidak Akurat ..................................................... 55

2. ICD-10 Tahun 2010 .............................................................................................. 55

a. Persentase Kode Diagnosa Yang Akurat .............................................................. 55

b. Persentase Kode Diagnosa Yang Tidak Akurat .................................................... 55

c. Grafik Keakuratan Kode Diagnosa Penyakit Gagal Ginjal Kronik ...................... 55

3. Elemen Keakuratan ............................................................................................... 56

BAB VI PEMBAHASAN................................................................................. 58

A. Kebijakan ICD 10 ................................................................................................. 58

B. SOP Pengkodingan ............................................................................................... 58

C. Cara Pengkodean Diagnosa Penyakit.................................................................... 59

D. Keakuratan Kode Diagnosa Penyakit.................................................................... 60

BAB VII PENUTUP.......................................................................................... 62

A. Simpulan ............................................................................................................... 62

B. Saran ...................................................................................................................... 63

DAFTAR PUSTAKA .......................................................................................... 64

Lampiran ............................................................................................................. 66