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All Journal Jurnal Rekam Medis dan Informasi Kesehatan
Ida Sugarti
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Health Professions

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Medical Terminology Conformity and ICD-10 Coding Accuracy for Circulatory Diagnoses at Dr. Soekardjo Hospital, Tasikmalaya Ari Sukawan; Ida Sugarti; Ayu Rahayu Lestari; Yanti Susanti; Arief Azhari Ilyas
Jurnal Rekam Medis dan Informasi Kesehatan Vol. 9 No. 2 (2026): OCTOBER 2026
Publisher : Poltekkes Kemenkes Semarang

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Abstract

Accurate diagnosis coding supports reliable health information. This study examined the association between medical terminology conformity and ICD-10 coding accuracy for circulatory system diagnoses at Dr. Soekardjo Regional General Hospital, Tasikmalaya. A quantitative study retrospectively reviewed 214 inpatient medical records from a population of 459 records for the first quarter of 2025. Data collection began on July 13, 2026. Terminology conformity and coding accuracy were assessed through document observation. Frequencies and percentages were calculated, and the association was examined using a two-sided Fisher’s exact test. Terminology was classified as conforming in 11 records (5.1%) and non-conforming in 203 (94.9%). Codes were accurate in 46 records (21.5%) and inaccurate in 168 (78.5%). Accurate codes occurred in 9 of 11 records with conforming terminology (81.8%), compared with 37 of 203 records with non-conforming terminology (18.2%). The association was statistically significant (p < 0.001). Medical terminology conformity was associated with coding accuracy in the assessed records. The findings support attention to standardized diagnostic documentation but do not establish a causal relationship.
Co-Authors Ari Sukawan Arief Azhari Ilyas Ayu Rahayu Lestari Yanti Susanti