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( Nanda Lucky Prasetya ),( Muchtaruddin Mansyur ),( Andy Omega ),( Adam Prabata ),( Aghnia Permatasari ),( Ayudhia Kartika ) 대한내과학회 2014 대한내과학회 추계학술대회 Vol.2014 No.1
Background: Diagnosing is a main verb in medicine. Diagnosis is set based on clinical reasoning. Factors contributing in clinical reasoning are clinical competency and other factors related with physician; sociodemographical factor and others related with patients; diagnostic facility and others related to health policy. Methods: This descriptive-analytic cross sectional research was done in 904 medical record of adult polyclinic patient, using proportional random sampling and chi square analysis to show how many disease could not be identifi ed, and what factors signifi cantly contribute. Results: Although Cipto Mangunkusumo Hospital is a referral centre and national hospital, our research found that there is 5, 60% (n =51) of polyclinic cases are diagnosed as Unidentifi ed Disease (ICD10: R69), ranked at 4th after Senile Cataract, Hypertension, and DM Type 2. Their 84, 30% (n=43) are from Internal Medicine Department, mainly from Unspecifi ed Division (patient of more than one division or unmentioned) for 63% (n=27), and Pulmonology Division for 33% (n=14). At this research also, we were going to fi nd the connection between Unidentified Disease and one of the factors contributing in clinical reasoning: Sociodemographical Factors. The variables are age, gender, educational level, employment, and health insurance. We found no variable is signifi cantly related to Unidentifi ed Disease (all p>0, 05). Conclusions: Hence, the other factors beside Sociodemographical Factors have contribution to clinical reasoning that is set up to Unidentifi ed Disease: physician`s factors (clinical competency and others), diagnostic facility, and others. However, which one defi nitely contributing is still questionable as CM Hospital is educational hospital; have thousands of doctors consist of consultants, residents, and others; one of the most complete diagnostic facility in nation. Further research shall be done to defi ne this relatively big number of disease which still being unidentifi ed in national referral hospital.
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