<![CDATA[The quality of clinical information documentation in Electronic Medical Records (EMR) is a factor supporting the accuracy of ICD-10 diagnosis coding. This study aimed to determine the relationship between the quality of clinical information entry in EMRs and the accuracy of ICD-10 diagnosis coding for inpatients at General Hospital X. An observational analytic design with a cross-sectional approach was employed. A total of 95 inpatient EMR documents were selected as the sample using purposive sampling. Data collection involved observation via a checklist, supplemented by interviews to provide additional information. Data were analyzed using univariate and bivariate methods—specifically Fisher’s exact test—with the aid of IBM SPSS Statistics version 27. The results showed that 85 documents (89.5%) exhibited good quality in clinical information entry, while 84 documents (88.4%) demonstrated accuracy in ICD-10 diagnosis coding. Errors in ICD-10 code assignment were the most frequently identified cause of inaccuracy, accounting for 72.7% of cases. Fisher’s exact test yielded a p-value of < 0.001, indicating a significant relationship between the quality of clinical information entry in EMRs and the accuracy of ICD-10 diagnosis coding. Thus, high-quality clinical information documentation plays a role in ensuring the accuracy of the diagnosis coding process for inpatients.]]>
Copyrights © 2026
