THE ANALYSIS OF DIAGNOSIS CODE ACCURACY BASED ON ICD 10 IN

MEDICAL RECORD DOCUMENT OF INPATIENT IN MUHAMMADIYAH

PONOROGO HOSPITAL

DESY RIYANTIKA NURHIDAYATI

Coding activity is one way of providing the code determination using letters and numbers or
a combination of letters and numbers that represent data components that are able to uniform
individual data collection of patients’ sickness with the purpose of certainty of accuracy,
precision, timeliness and action.
International Statistical Classification of Diseases and Related Health Problems Tenth
Revision (ICD-10) is a reference used in Indonesia to code a diagnosis. This study is aimed to
analyze the accuracy of code diagnosis based on ICD 10 and analyze the factors that cause
the inaccuracy of code diagnosis of Medical Record Document in inpatient at
Muhammadiyah General Hospital Ponorogo. This research design used a descriptive method
with a quantitative approach. The sampling technique in this study was purposive sampling of
354 medical record documents of inpatient and 2 informants. The results showed that 25.48%
of medical record documents were not accurate
Factors which makes inaccuracies code are the lack of effective communication between the
coding officer and the doctor, the unclear writing of the doctor's diagnosis, the absence of
common perception between related subject, the coding audit is not being carried out and the
unavailability of ICD 10 at Muhammadiyah Ponorogo Hospital for general inpatient coding
staff.

Keywords : Accuracy, Code Diagnosis, ICD 10