Sosialisasi Optimalisasi Kemampuan Kodifikasi Koder Dalam Implementasi Rekam Medis Elektronik di RSIA CICIK Padang

Abstract

Accurate and consistent coding is a crucial element in health information management. Properly coded data not only supports insurance claim processes and health statistics but also plays a role in clinical and managerial decision-making. Pending cases that occur include confirmation regarding the accuracy of coding, whether the requirements and procedures provided have been met, and whether the attached documents are complete. The purpose of this PKM is to provide training for medical record officers to optimize their ability to provide accurate codes so that pending cases can be minimized. The PKM methods are lectures, socialization, discussions, and case studies. The activity was held on Tuesday, May 28, 2024, at RSIA Cicik Padang. The activity went smoothly, and it was known that the coders had begun to understand how coding regulations are based on ICD-10, the implementation of BPJS regulations, and what pending cases often occur. This can be seen from the results of discussions between coders, medical record officers, and the PKM chairman. It is recommended that RSIA Cicik provide coders for each inpatient and outpatient department, implement coding SOPs properly, conduct performance evaluations and organize BPJS claims, and further improve the analysis of quality management and prepare to meet the challenges of Electronic Medical Records.