60 Available online at: EDU RMIK Journal ISSN (Print) XXXX-XXXX ISSN (Online) XXXX-XXXX Edu RMIK Journal page Vol 2 No 1, Juni 2023 TINJAUAN KETEPATAN KODE DIAGNOSIS GASTROENTERITIS ACUTE PASIEN RAWAT INAP RSUP DR. SITANALA KOTA TANGERANG TAHUN 2021 1 Gama B. Kuntoadi , 2 Indah Kristina, 3 Andriyani R. Fahriati, 4 Nurhana D. Ashari 1, 2, 3 Lecturer STIKes Widya Dharma Husada Tangerang , Kota Tangerang Selatan dan Kode Pos 15417, Indonesia 4 Student STIKes Widya Dharma Husada Tangerang , Kota Tangerang Selatan dan Kode Pos 15417, Indonesia ARTICLE INFORMATION A B S T R A C T *Corresponding Author Assigning a diagnosis code to the patient's medical record refers to the rules of ICD-10 (International Statistical Classification of Disease and Related Health Problems). A coder has responsibility for the accuracy of the coding, therefore the ability and skills on how to code the main diagnosis in accordance with the Standard Operating Procedures (SPO) at the Sitanala Doctors General Hospital, Tangerang City. Doctor Sitanala General Hospital has 9 medical record officers (coders). The purpose of this study was to identify SOP Codefication, calculate the level of accuracy of the diagnosis code for acute gastroenteritis, and identify the professionalism of the coder in the hospital. The research method is descriptive qualitative, which is a method that is carried out with the aim of describing how and why problems in the field occur using interview and observation methods. The population of this study were 122 medical record files for the diagnosis of acute gastroenteritis and a sample of 94 samples based on calculations based on the Slovin formula. The sampling technique in this study used Simple Random Sampling. The results showed that the number of correct codes was 0 (0.00%), the wrong codes were 94 (100%). Not all SOPs related to the determination of the diagnosis code have been implemented. Writing a doctor's diagnosis is the main obstacle in carrying out the codification process. The reason for the inaccuracy of the diagnostic code is the lack of a fourth character in the code. Name: Gama Bagus Kuntoadi E-mail: okudagama@gmail.com Keywords: Diagnostic Code Accuracy _1 Acute Gastroenteritis _2 ICD-10 _3 Kata Kunci: Ketepatan Kode Diagnosis _1 Gastroenteritis Akut _2 ICD-10 _3 Pemberian kode diagnosis pada rekam medis pasien mengacu pada aturan ICD-10 (International Statistical Classification of Disease and Related Health Problem). Seorang coder memiliki tanggung jawab terhadap keakuratan pengkodean, oleh karena itu kemampuan dan keterampilan tentang cara pengkodean diagnosis utama sesuai dengan Standar Prosedur Operasional (SPO) di Rumah Sakit Umum Pusat Dokter Sitanala Kota Tangerang. Rumah Sakit Umum Pusat Dokter Sitanala memiliki 9 orang petugas rekam medis (koder). Tujuan penelitian ini adalah untuk mengidentifikasi SPO Kodefikasi, menghitung tingkat ketepatan kode diagnosis gastroenteritis acute, dan mengidentifikasi keprofesionalan petugas koder RS. Metode penelitiannya adalah kualitatif deskriptif adalah metode yang dilakukan dengan tujuan untuk mendeskripsikan bagaimana dan mengapa permasalahan yang ada di lapangan terjadi dengan metode wawancara dan observasi. Populasi penelitian ini adalah berkas rekam medis diagnosis gastroenteritis akut sebanyak 122 dan sampel sebanyak 94 sampel berdasarkan perhitungan berdasarkan rumus Slovin. Teknik pengambilan sampel dalam penelitian ini menggunakan Simple Random Sampling. Hasil penelitian menunjukkan jumlah