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All Journal Media Ilmu Kesehatan Journal of Hospital Administration and Management (JHAM)
Yastori
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Decision Sciences, Operations Research & Management Health Professions Medicine & Pharmacology Nursing Public Health

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Concordance Between Physician’s Clinical Diagnostic Terminology and ICD‑10 on Surgical Patient Medical Records Khumaira, Nurul Fitri; Yastori; Kader, Shaola Syafrullah
MEDIA ILMU KESEHATAN Vol 14 No 3 (2025): Media Ilmu Kesehatan
Publisher : Universitas Jenderal Achmad Yani Yogyakarta

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.30989/mik.v14i3.1771

Abstract

Background: The accurate use of medical terminology in clinical diagnosis is crucial for proper disease classification, coding accuracy, and reliable health data reporting. However, inconsistencies remain due to non-standard terminology and abbreviations that do not comply with the International Classification of Diseases (ICD-10).Objective: This study aims to evaluate the conformity of physicians’ diagnostic terminology with ICD-10 and with the hospital’s official abbreviation guidelines.Methods: This descriptive quantitative cross-sectional study was conducted from March to July 2025 at RSKB Ropanasuri Padang. A 96 surgical patient medical records from 2024 were selected through simple random sampling. Diagnostic data were evaluated using a conformity checklist based on ICD-10 Volume 1 and 3 and the hospital’s standardized abbreviation guidelines.Results: : The results showed that not all diagnoses complied with ICD-10 terminology or abbreviation guidelines. Common discrepancies included non-standard abbreviations, inconsistent anatomical terminology, and non-specific terms such as “tumor” without further details.Conclusion: Concordance Physician’s diagnostic terminology with ICD-10 and Abbreviation guidelines remains inadequate. Strengthening standard operating procedures, enhancing clinician training in ICD-10 nomenclature, and establishing more structured coder–clinician communication are essential to ensure valid and reliable health data.
ANALISIS KASUS PENDING KLAIM SEBAGAI DASAR PERANCANGAN APLIKASI AUDIT KODING INTERNAL DI RUMAH SAKIT Yastori; Khumaira , Nurul Fitri
Journal of Hospital Administration and Management (JHAM) Vol 6 No 1 (2025): Journal of Hospital Administration and Management (JHAM)
Publisher : LPPM Universitas Awal Bros

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.54973/jham.v6i1.795

Abstract

Pending claims in hospitals impact cash flow constraints, increase verifier workloads, and disrupt operational stability and service quality. This study aims to analyze pending claims cases as a basis for designing a claims audit application in hospitals. The type of research used in this study is descriptive quantitative research, namely research that uses numbers to describe, explain, and draw conclusions from a phenomenon. Research with quantitative methods uses research data in the form of numbers for statistical processing of frequency distributions, calculating data percentages and analyzing pending claims cases based on BPJS regulations and ICD-10 and ICD-9-CM coding rules. The population of the study was 616 cases. The sample in this study was 15 pending claims cases determined by the Purposive Sampling technique. The results of this study obtained the main problems of pending claims at Hospital X include coding errors, incomplete mandatory supporting documents (examination results, PA, microbiology), and differences in perception with BPJS, can be minimized through strategic solutions in the form of increasing accuracy in reviewing medical record documents and claims to ensure completeness, compliance with regulations (BA, PMK, ICD), and building a strong perception of equality between DPJP and all verifiers. Further research is recommended for the design of prototypes and web-based applications that are fully functional, so that they can be used in real life in the internal claim audit process to minimize pending claims in hospitals.
Co-Authors Kader, Shaola Syafrullah Khumaira , Nurul Fitri Khumaira, Nurul Fitri