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All Journal Barongko : Jurnal Ilmu Kesehatan
Ghazi Septiandi
Politeknik Piksi Ganesha
Education Engineering Health Professions Medicine & Pharmacology Nursing Public Health

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Systematic Literature Review Tentang Keakuratan Pengkodean Diagnosis Berdasarkan ICD-10 Pada Rekam Medis Ghazi Septiandi; Sali Setiatin
Barongko: Jurnal Ilmu Kesehatan Vol 5 No 1 (2026): Barongko : Jurnal Ilmu Kesehatan (November)
Publisher : Asosiasi Guru dan Dosen Seluruh Indonesia

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.59585/bajik.v5i1.1534

Abstract

This study aims to analyze the accuracy of diagnosis coding based on the International Classification of Diseases Tenth Revision (ICD-10) in medical records using a Systematic Literature Review approach. Accurate diagnosis coding is essential for producing reliable health information and supporting healthcare services. Literature was collected from Google Scholar, GARUDA, and Open Journal System (OJS) databases for articles published between 2022 and 2025. The selection process followed the PRISMA 2020 guidelines, resulting in 20 eligible articles. Data were analyzed descriptively through identification, comparison, and synthesis of the selected studies. The findings showed that diagnosis coding accuracy remains suboptimal. The main factors affecting coding accuracy were the completeness of medical documentation, the accuracy of physicians' diagnosis documentation, and the competence of medical record coders. These findings suggest that improving medical documentation, providing regular ICD-10 coding training, implementing standard operating procedures, conducting coding audits, and applying the WHO ICD-10 guidelines consistently are essential for improving diagnosis coding accuracy. Overall, diagnosis coding accuracy is influenced by several interrelated factors that require continuous improvement to support the quality of health information.
Co-Authors Sali Setiatin