EVALUASI PELAKSANAAN CODING PENYAKIT OLEH DOKTER DAN PERAWAT BERDASARKAN UNSUR MANAJEMEN (5M) DI PUSKESMAS GONDOKUSUMAN II YOGYAKARTA

Background: Primary health services are the responsibility of health centers, in which there are health professionals who have their main duty each including doctors and nurses on duty to serve and treat patients. Besides doctors and nurses also perform classification and codefication against a diagnosis of a disease even though it is not competence but competence of a medical recorder. As well as the SOP has not been made regarding the conduct of coding. Methods: This was a descriptive type of research with a qualitative approach. The study design used is fenomenalogi research. Subjects who used researchers that nurses and doctors at the public service, the nurse at the dental services, and staff in the Administration section. Sample data is the data used in SIMPUS 95 diagnosis codes. Data collection techniques used were interviews, observation, and study documentation. Results: In the element of man, the implementation of disease coding is done by trained doctors and nurses who have not received training related to the correct classification of diseases and shortage of officers in the general treatment. Elements provides no reward money to the officer as increased work motivation. In the material elements, there are significant constraints on the writing of the diagnosis in the patient's medical record file. On machine elements, there are constraints experienced officers in the use of data and code SIMPUS SIMPUS less specific as to the ICD-10 coding results influence the officers. In element method, work instructions or SOPs are clearly written on the implementation of disease coding has not been made so that the workers do not have a fixed reference in the work. The accuracy of the diagnosis code criteria are grouped into A by 29.48%, amounting to 49.47% B criteria, and criteria C of 21.05