Review of Outpatient Diagnosis Codes According to ICD-10 at Pringgarata Health Center 2023
DOI:
https://doi.org/10.37824/f99krq08Keywords:
accuracy , coding, diagnostic, outpatients, completenessAbstract
Coding refers to the assignment or establishment of diagnostic codes that utilize a combination of letters and numbers to represent data components. Accurate diagnostic codes are essential to achieve the objectives of the disease classification system, one of which is the recording of mortality and morbidity data. The aim of this research is to ascertain the accuracy of disease diagnostic codes based on ICD-10 in the outpatient medical records at the Pringgarata Health Center in Central Lombok. This study employs a quantitative descriptive research design with a cross-sectional approach. The sample size for this research consists of 74 outpatient medical records, selected using proportional stratified sampling. The results of the study indicate that the medical records with complete diagnosis entries amount to 65 (88%), while those with incomplete diagnosis entries total 9 medical records (12%). Among the 65 medical records with complete diagnosis entries, only 6 records (9%) contain accurate codes, whereas 59 records (91%) bear inaccurate codes. From the findings, it can be concluded that the accuracy of diagnosis coding for outpatient patients at the Pringgarata Health Center remains relatively low. The primary factors contributing to the inaccuracy of diagnosis codes include the fact that none of the Diagnosis Coding Officers possess a background in medical records, have never participated in specialized training on ICD-10 coding, and do not utilize the available electronic ICD-10 resources at the health center for coding diagnoses. A recommendation is to conduct regular evaluations and training regarding diagnosis codes at the Pringgarata Health Center.
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