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Muhammad Yunus
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Program Studi Rekam Medik Politeknik Negeri Jember Jl. Mastrip PO Box 164, Jember, Jawa Timur
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J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan
Published by Politeknik Negeri Jember
ISSN : -     EISSN : 2721866X     DOI : https://doi.org/10.25047/jremi
Core Subject : Health,
Health Professions Public Health
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan is a scientific journal that is managed and published by the Program Studi Rekam Medik, Jurusan Kesehatan, Politeknik Negeri Jember. J-REMI contains the publication of research results from students, lecturers and or other practitioners in the field of medical records and health information with coverage and focus on the fields of Health Information Management, Health Information Systems, Health Information Technology, Health Quality Information Management and Classification, Coding of Diseases and Problems. Health and Action.
Arjuna Subject : Profesi Kesehatan - Menejmen Informasi Kesehatan
Articles 271 Documents
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Analisis Faktor Penyebab Ketidakakuratan Kode Diagnosis Cedera di Rumah Sakit 'Aisyiyah Siti Fatimah Tulangan Yuliani, Resta Dwi; Ariani, Suci; Widanti, Herista Novia
J-REMI : Jurnal Rekam Medik dan Informasi Kesehatan Vol 7 No 1 (2025): December
Publisher : Politeknik Negeri Jember

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.25047/j-remi.v7i1.6567

Abstract

The accuracy of diagnostic and medical procedure coding depends on the completeness and clarity of information in medical records. A preliminary survey of 59 inpatient records showed that 23 were coded accurately, while 36 were inaccurate. This study aims to analyse factors contributing to inaccurate injury diagnosis coding at RS ‘Aisyiyah Siti Fatimah Tulangan. A descriptive design was used, with data collected through observation and interviews. Observations were conducted on 100 inpatient medical records of injury cases, and interviews involved two coders. The results showed that the fourth-character coding was accurate in 96 records (96%) and inaccurate in 4 records (4%), mainly due to non-specific diagnoses documented by physicians. For the fifth character, 53 records (53%) were coded accurately and 47 records (47%) inaccurately, primarily because the documentation did not specify whether the injury was open or closed. No records (0%) included accurate external cause codes, while all records (100%) were inaccurate, largely due to limited coder knowledge and the fact that coders were not trained medical record professionals. Hospitals are advised to improve clinical documentation, provide regular disease coding training, and strengthen collaboration between coders and physicians to enhance coding accuracy.

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