The accuracy of the fracture diagnosis code is the accuracy of the determination of the code according to the ICD-10 guidelines based on medical record data. The accuracy of coding is related to the completeness of electronic medical records which include identity, anamnesis, physical examination, supporting examinations, and diagnosis. Incompleteness of data can cause coding errors and have an impact on the quality of services, hospital data processing, and financing claims. This study aims to identify the relationship between the accuracy of the fracture diagnosis code and the completeness of electronic medical records at H. Adam Malik Hospital Medan in 2026. The study uses an analytical design with a cross sectional approach. The population is 981 medical records of fracture patients in 2025, with a sample of 87 medical records using simple random sampling. Data was collected through observation sheets and checklists, then analyzed using the chi-square test. Results showed that 75 medical records (86.2%) had accurate codes and 83 (95.4%) complete medical records. The chi-square test yielded a p-value of 0.008 (p<0.05), indicating a significant relationship between the accuracy of the fracture diagnosis code and the completeness of electronic medical records.
Copyrights © 2026