21 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 PENGKODEAN DIAGNOSA HYPERTENSIVE HEART DISEASE PASIEN RAWAT JALAN DI RUMAH SAKIT SETIA MITRA PADA TAHUN 2022 1 Gama B. Kuntoadi , 2 Indah Kristina, 3 Andriyani R. Fahriati, 4 Deannisa Rachmatika 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 In the era of national health insurance in Indonesia, one of the benchmarks in the national health insurance system is the codification of diagnoses. The codification diagnosis must be precise and accurate in accordance with ICD 10, if it is not correct/inappropriate it will affect the data. Researchers are interested in conducting research related to the codification of the diagnosis Hypertensive Heart Disease on the outpatient medical record file at Setia Mitra Hospital. This research uses descriptive research. Collecting data using interview guidelines and checklist sheets. The subjects of this study were all medical record officers and the object of this study were all patient outpatient medical record files Hypertensive Heart Disease in October-December 2021. The results of this study indicate that the implementation of standard operating procedures in the Setia Mitra Hospital medical record has been carried out well, but there are still constraints or input systems. In hospital data, cases of Hypertensive Heart Disease in outpatients are as many as 307 cases. In these data, a review was carried out to get an overview of the level of accuracy of hypertensive heart disease, for the accuracy of the hypertensive heart disease code from a sample of 307 outpatient hypertensive heart disease diagnoses for the period October-December 2021, which was 161 (53.44%) and the inaccuracy was 146 (47.55%). And the accuracy of the code for Hypertensive heart disease without (congestive) heart failure is 113 (43.62%) and Hypertensive heart disease with (congestive) heart failure is 48 (100%). Name : Gama Bagus Kuntoadi E-mail: okudagama@gmail.com Keywords: Code accuracy _1 Code accuracy factor _2 Hypertensive heart disease_3 ICD-10_4 Kata Kunci: Ketepatan kode _1 Faktor ketepatan kode _2 Hypertensive heart disease_3 ICD-10_4 Dalam era jaminan kesehatan nasional di Indonesia, salah satu tolak ukur dalam sistem jaminan kesehatan nasional adalah kodifikasi diagnosis. Kodifikasi diagnosis harus tepat dan akurat sesuai dengan ICD 10, jika tidak benar/tidak tepat akan mempengaruhi data. Peneliti tertarik untuk melakukan penelitian terkait kodifikasi diagnosis Penyakit Jantung Hipertensi pada berkas rekam medis rawat jalan di Rumah Sakit Setia Mitra. Penelitian ini menggunakan penelitian deskriptif. Pengumpulan data menggunakan pedoman wawancara dan lembar checklist. Subyek penelitian ini adalah seluruh petugas rekam medis dan objek penelitian ini adalah seluruh berkas rekam medis pasien rawat jalan Penyakit Jantung Hipertensi pada bulan Oktober- Desember 2021. Hasil penelitian ini menunjukkan bahwa penerapan standar prosedur operasional di Rumah Sakit Setia Mitra rekam medis sudah dilaksanakan dengan baik, namun masih terdapat kendala atau sistem input. Dalam data rumah sakit, kasus Penyakit Jantung Hipertensi pada pasien rawat jalan sebanyak 307 kasus. Pada data tersebut dilakukan review untuk mendapatkan gambaran tingkat akurasi penyakit jantung hipertensi, untuk akurasi kode penyakit jantung hipertensi dari sampel 307 diagnosis penyakit jantung hipertensi rawat jalan periode Oktober-