Article Per Year (5 Year)
p-Index From 2020 - 2025
0.23
P-Index
This Author published in this journals
All Journal Media Ilmu Kesehatan
Yastori
Unknown Affiliation
Health Professions Medicine & Pharmacology Nursing Public Health

Published : 1 Documents Claim Missing Document
Claim Missing Document
Check
Articles

Found 1 Documents
Search

 1 
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.
Co-Authors Kader, Shaola Syafrullah Khumaira, Nurul Fitri