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LAMPIRAN 2

Tabel Analisis Kelengkapan Penulisan Diagnosa Utama Dan Ketepatan Pengkodean


N No. Diagnosa Utama Diagnosa Utama Lengkap Tidak Kode Kode Peneliti ICD 10
o Rekam Ringkasan Keluar Pada Resume Lengkap RS
Medis Medis
1 05.83.28 Fraktur Clavicula 2/4 Kiri Fraktur Clavicula S42.0 S42.00 Fracture of Clavicle closed
Tertutup 2/4 Kiri Tertutup
2 05.99.28 Fraktur Collum Femoris - S72.9 S72.90 Fracture of femur, part unspecified
Kanan closed
3 05.53.42 Fraktur Fibula Dextra Fraktur os Fibula S82.4 S82.40 Fracture of fibula alone closed
Dextra 1/3
tertutup
4 05.50.24 Fraktur Digiti 3 Maximus Fraktur Digiti 3 S62.6 S62.60 Fracture of other finger closed
Sinistra dan 4 Manus
Sinistra
5 05.53.87 Trauma Capitis Trauma Capitis S00.9 S09.9 Unspecified injury of head
6 04.24.20 Coller Fraktur Dextra Coller Fraktur S42.0 S42.00 Fracture of clavicle closed
Dextra
7 05.45.97 Fraktur Fibula Sinistra Fraktur Fibula S82.4 S82.41 Fracture of fibula alone open
Terbuka Grade III Sinistra Terbuka
Grade III
8 05.49.42 Fraktur Mandibula - S02.6 S02.60 Fracture of mandible closed
9 05.49.74 Fraktur Distal Phalax Digit - S62.5 S62.51 Fracture of thumb open
I Manus Sinistra Grade 3
10 05.49.97 Fraktur Clavicula 1/3 Fraktur Clavicula S42.0 S42.00 Fracture of clavicle closed
Lateral Tertutup 1/3 Lateral
Tertutup
11 05.49.41 Fraktur Clavicula 1/3 - S42.0 S42.00 Fracture of clavicle closed
Medial
12 05.49.36 Fraktur Distal IV Phalax - S92.5 S62.61 Fracture of other finger open
distal tangan Sinistra

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13 06.22.60 Haemorhoid internal Grade Haemorhoid I84.2 I84.2 Internal haemorrhoids without
III internal Grade III complication
14 01.24.46 Fraktur Compressi L1 Fraktur S32.0 S32.00 Fracture of lumbar vertebra
Compressi L1
15 01.24.46 Hypertensi Hypertensi I10 I10 Essential (primary) hypertension
16 05.57.65 Close Fraktur Right Neck Close Fraktur S42.0 S42.00 Fracture of clavicle closed
Scapula Right neck
Scapula
17 05.54.61 Trauma Capitis Ringan - S00.9 S09.9 Unspecified injury of head
18 05.54.50 Neurofibroma Multiple Neurofibroma Q85.0 Q85.0 Neurofibromatosis (nonmalignant)
Multiple
19 05.55.42 Appendisitis akut Appendisitis akut K35.9 K35.9 Acute Appendicitis, unspecified
20 05.58.56 Perdarahan pada gusi or Periodontitis akut K05.1 K05.0 Acute gingivitis
periodontitis akut x dan Gingivitis
gingivitis akut akut
21 05.56.20 Mammae Acessories dextra Mammae Q83.1 Q83.1 Accessory breast
acessories dextra
22 05.58.57 Fleura Efusion - J90 J90 Pleura effusion, not elsewhere
classified
23 04.13.75 Tumor Mammae Kiri - D24 D24 Benign neoplasma of breast
Gland Medialisis
24 00.29.01 Abces Besar Gluterus Kiri Abcess besar L02.3 L02.3 Cutaneous abscess, furuncle and
gluterus kiri carbuncle of buttock
25 05.60.22 Phimosis + Chancroid Phimosis+ A57 A57 Chancroid
Chancroid
26 05.62.65 Appendicitis Chronic Exa Appendicitis akut K36 K35.9 Acute Appendicitis, unspecified
Akut
27 05.64.35 cholelitiasis Cholelitiasis K80.2 K80.2 Calculus of gallbladder without
cholecystitis
28 05.63.96 SoftTissue Contusion Paha Softtissue S70.1 S70.1 Contusio of thigh
Kiri Distal contusion paha
kiri distal

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LAMPIRAN 2

29 05.63.65 Trauma capitis Ringan Trauma capitis S06.9 S09.9 Unspecified injury of head
ringan
30 05.64.37 Hernia Inguinal - K40.3 K40.9 Unilateral or unspecified inguinal
hernia, without obstruction or
gangrene
31 05.66.01 Tumor Abdomen Bagian - D48.7 D36.7 Other specified sites
Kanan Atas
32 05.66.10 Cysta TyroGlossar Cysta Tyroglossar Q89.2 Q89.2 Congenital malformations of other
endocrine glands
33 05.66.24 Clavus kaki kiri Clavus Kaki Kiri L84 L84 Corns and callosities
34 05.49.70 Appendicitis Akut Appendicitis akut K35.0 K35.9 Acute appendicities, unspecified
35 04.97.13 Hernia Inguinal Lateralis HIL sinistra K.40.3 K40.9 Unilateral or unspecified inguinal
Sinistra Lepouibilis Lepouibilis hernia, without obstruction or
gangrene
36 06.32.52 Fistel Perianal Fistel Perianal K60.2 K60.3 Anal fistula
37 01.88.76 Tumor Mammae Sinistra Tumor Mammae D24 D24 Benign neoplasm of breast
sinistra
38 06.31.87 Dysmoroid Cysta Dysmoroid Cysta D36.7 D13.5 Extrahepatic bile ducts
39 05.58.20 Apendicitis Acute Appendicitis akut K35.9 K35.0 Acute appendicitis with
Perforation Perforation generalized peritonitis
40 05.64.32 Abscess Hepar - K75.0 K75.0 Abscess of liver
41 05.63.76 Peritonitis gen. Acausi Peritonitis K35.0 K35.0 Acute appendicitis with
perforasi appendicitis generalized acausi generalized peritonitis
perforasi
appendicitis
42 05.63.78 Peritonitis generalized Peritonitis K35.0 K35.0 Acute appendicitis with
Appendicitis acute generalized generalized peritonitis
Appendicitis
acute
43 05.67.55 Hemorohoid Fissura ani - I84.2 I84.2 Internal haemorrhoids without
complication
44 05.67.52 Fibroma Paha Kanan Fibroma Paha D16.2 D21.2 Connective and other soft tissue of

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LAMPIRAN 2

lower limb, including hip


45 05.67.17 Vulnus Laceration Ibu jari V. Laceration Ibu S91.1 S91.1 Open wound of toe without
kaki kiri jari kaki kiri damage to nail
46 05.68.02 Tumor Mammae Dextra Tumor Mammae D24 D24 Benign neoplasm of breast
Gland Atas Dextra gland atas
47 06.26.29 Lipoma Kuduk Lipoma Kuduk D36.7 D17.0 Benign lipomatous neoplasm of
skin and subcutaneous tissue of
head, face and neck
48 05.65.61 Hyperemesis Gravidarum Hyperemesis O21.0 O21.0 Mild hyperemesis gravidarum
Gravidarum
49 05.56.61 Infeksi Saluran Kemih Infeksi Saluran N39.0 N39.0 Urinary tract infection, site not
Kemih specified
50 04.28.18 Hypertensi Hypertensi I10 I10 Essential (primary) hypertension
51 03.82.46 Appendicitis akut - K35.9 K35.9 Acute appendicitis, unspecified
52 04.52.92 Hypertensi Hypertensi I10 I10 Essential (primary) hypertension
53 04.34.99 Dispepsia Dispepsia K30 K30 Dyspepsia
54 04.53.46 Hipertensi Hipertensi I10 I10 Essential (primary) hypertension
55 00.10.09 KOCH Pulmonary KOCH A16.2 A16.2 Tuberculosis of lung, without
Pulmonary mention of bacteriological or
histologi confirmation
56 06.26.19 Gastritis Gastritis K29.7 K29.7 Gastritis, unspecified
57 06.22.40 Hypertropi Prostat Grade Hypertropi N40 N40 Hyperplasia of prostate
IV Prostat Grade IV
58 06.26.14 Appendicitis Akut Appendicitis akut K35.9 K35.9 Acute appendicities, unspecified
59 06.22.30 Dispepsia Dispepsia K30 K30 Dyspepsia
60 06.22.26 Demam Thypoid Demam Thypoid A01.0 A01.0 Typhoid fever
61 06.22.23 Bronchitis Bronchitis J40 J40 Bronchitis, not specified as acute
or chronic
62 06.22.10 ISK ISK N39.0 N39.0 Urinary tract infection, site not
specified
63 06.21.89 Tumor Paru Kiri Tumor Paru Kiri D14.3 D14.3 Bronchus and lung
64 06.22.02 Hipertensi Hipertensi I10 I10 Essential (primary) hypertension

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LAMPIRAN 2

65 05.36.01 Low Back Pain Lumbar Low Back Pain M54.8 M54.56 Low back pain (lumbar legion)
Lumbar 8
66 06.21.86 Dysentri Baciler Dysentri Baciler A03.9 A03.9 Shingellosis, unspecified
67 06.21.91 OMA OMA H66.9 H66.9 Otitis media, unspecified
68 06.21.90 Gastritis Erosiva Gastritis Erosiva K29.1 K29.1 Other acute gastritis
69 05.21.84 Low Back Pain Low Back Pain M54.5 M54.59 Low back pain (site unspecified)
8
70 06.21.86 Anemia Aplastik Anemia Aplastik D61.9 D61.9 Aplastic anaemia, unspecified

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