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Hotmarina Lumban Gaol
Sekolah Tinggi Ilmu Kesehatan Santa Elisabeth Medan
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Hubungan Ketepatan Terminologi Medis dengan Keakuratan Kode Diagnosa Penyakit Respirasi Irma Novitasari Br. Sihotang; Hotmarina Lumban Gaol; Arjuna Ginting
Journal of Language and Health Vol. 6 No. 3 (2025): Journal of Language and Health: September 2025
Publisher : CV. Global Health Science Group

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37287/jlh.v6i3.349

Abstract

Keakuratan dalam pemberian kode diagnosa merupakan hal yang harus diperhatikan oleh tenaga rekam medis, ketepatan kode diagnosa sangat penting dibidang manjemen data klinis, penagihan biaya, beserta hal-hal yang berkaitan dengan pelayanan kesehatan. Faktor penyebab ketidakakuratan kode diagnosis adalah penggunaan singkatan diagnosis, dan penulisan diagnosis tidak menggunakan istilah terminologi medis. Tujuan penelitian untuk menganalisis hubungan ketepatan terminologi medis dengan keakuratan kode diagnosis penyakit sistem respirasi di Rumah Sakit Advent Medan Tahun 2025. Jenis rancangan penelitian yang digunakan dalam penelitian ini adalah rancangan penelitian analitik dengan pendekatan cross sectional. Sampel dalam penelitian ini data resume medis pasien, sebanyak 72 sampel. Instrument yang digunakan dalam penelitian ialah lembar checklist. Analisa data menggunakan uji statistik chi-square. Hasil penelitian diperoleh bahwa ketepatan terminologi medis sebanyak 33 dan dan keakuratan kode diagnosa penyakit sistem respirasi sebanyak 44. Hasil uji statistik chi-square diperoleh p-value 0,000 (p<0,05) sehingga disimpulkan bahwa ada hubungan yang signifikan antara ketepatan terminologi medis dengan keakuratan kode diagnosa penyakit sistem respirasi di Rumah Sakit Advent Medan Tahun 2025. Diharapkan hasil penelitian ini dapat digunakan rumah sakit untuk mendorong dan memberikan pelatihan berkelanjutan kepada dokter dan tenaga kesehatan lain mengenai pentingnya dokumentasi rekam medis yang lengkap, jelas, dan menggunakan terminologi medis yang standar dan konsisten.
Hubungan Ketepatan Terminologi Medis dengan Keakuratan Kode Diagnosa Penyakit Sistem Respirasi di Rumah Sakit Hotmarina Lumban Gaol; Nasipta Ginting; Jev Boris; Flower Desma Sihaloho; Kajol Santa Monika
INSOLOGI: Jurnal Sains dan Teknologi Vol. 5 No. 4 (2026): Agustus 2026
Publisher : Yayasan Literasi Sains Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.55123/insologi.v5i4.8992

Abstract

Accuracy in the provision of diagnosis codes is something that must be considered by medical record personnel, the accuracy of diagnosis codes is very important in the field of clinical data management, cost billing, along with matters related to health services. Factors causing inaccuracies in diagnosis codes are the use of diagnosis abbreviations, and writing diagnoses that do not use medical terminology terms. The purpose of the study is to analyze the relationship between the accuracy of medical terminology and the accuracy of diagnosis codes for respiratory system diseases. The type of research design used in this study is an analytic research design with a cross sectional approach. The sample in this study is patient medical resume data, totaling 72 samples. The instrument used in the study is a checklist sheet. Data analysis using the chi-square statistical test. The results of the chi-square statistical test obtain a p-value of 0.000 (p <0.05) so it is concluded that there is a significant relationship between the accuracy of medical terminology and the accuracy of the diagnosis code of respiratory system diseases. It is hoped that the results of this study can be used by hospitals to encourage and provide ongoing training to doctors and other health workers regarding the importance of complete, clear medical record documentation, and using standardized and consistent medical terminology.
Co-Authors Arjuna Ginting Flower Desma Sihaloho Irma Novitasari Br. Sihotang Jev Boris Kajol Santa Monika Nasipta Ginting