DOI: https://doi.org/10.14710/jmki.13.2.2025.201-210

THE RELATIONSHIP BETWEEN ACCURACY OF MEDICAL TERMINOLOGY DOCUMENTATION AND DIAGNOSTIC CODE ACCURACY IN OBSTETRIC CASES AT RSIA PURI MALANG

*Chyntia Vicky Alvionita scopus  -  Poltekkes Kemenkes Malang, Indonesia
Eiska Rohmania Zein  -  Poltekkes Kemenkes Malang, Indonesia

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Abstract

The Accurate medical documentation and diagnostic coding are essential components of healthcare services, directly influencing the quality of patient care, health data reporting, and hospital reimbursement systems. Therefore, this study aims to identify the relationship between the accuracy of medical terminology documentation and diagnosis code accuracy, providing insights for improvement in coding systems at hospitals. This study uses a quantitative, cross-sectional approach to examine the relationship between the accuracy of medical terminology documentation and diagnosis coding in Obstetric cases. The research was conducted in 2024 at RSIA Puri Malang. Data were collected from 300 medical records through simple random sampling. Descriptive statistics were used to analyze the accuracy of documentation and coding, followed by a chi-square test to assess the correlation between medical terminology accuracy and diagnosis coding precision. The study shows a statistically significant relationship between the accuracy of medical terminology documentation and diagnosis coding accuracy in Obstetric cases, with a p-value of 0.048. Since the p-value is less than the significance level of 0.05, this indicates that the observed relationship is unlikely to be due to chance, supporting the hypothesis that accurate medical terminology documentation positively impacts the precision of diagnosis coding. The findings suggest that improving the quality of documentation can lead to more accurate coding, which is crucial for effective healthcare delivery, billing processes, and insurance claims.

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Keywords: Medical Terminology Accuracy, Diagnosis Coding Precision, Healthcare Documentation, Obstetric Cases

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Language : EN
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  1. Agustina, R. (2022). Terminologi medis. Qiara Media
  2. Agustine, D. M., & Pratiwi, R. D. (2017). Hubungan ketepatan terminologi medis dengan keakuratan kode diagnosis rawat jalan oleh petugas kesehatan di Puskesmas Bambanglipuro Bantul. Jurnal Kesehatan Vokasional, 2(1), 113–121
  3. Andriyani, O. V. (2021). Hubungan antara pengetahuan terminologi medis petugas rekam medis dengan ketepatan kode diagnosa di Rumah Sakit Tingkat IV Kota Madiun [Tesis tidak dipublikasikan]. STIKES Bhakti Husada Mulia
  4. Baker McKenzie. (2022, Desember 20). Indonesia: New medical records regulation — what's new? https://www.globalcompliancenews.com/2022/12/20/https-insightplus-bakermckenzie-com-bm-healthcare-life-sciences-indonesia-new-medical-records-regulation-whats-new_12162022/
  5. Cheng, P., Gilchrist, A., Robinson, K. M., & Paul, L. (2019). The risk and consequences of clinical miscoding due to inadequate medical documentation: A case study of the impact on health services funding. Health Information Management Journal, 38(1), 35–46
  6. Feorentina, L., & Ulfa, H. M. (2020). Hubungan ketepatan terminologi medis dengan keakuratan kode diagnosis rawat jalan di Rumah Sakit “X” Pekanbaru tahun 2020. JHMHS: Jurnal Hospital Management and Health Sciences, 1(2), 35–39
  7. Hatta, G. R. (2013). Pedoman manajemen informasi kesehatan di sarana pelayanan kesehatan. UI-Press
  8. Heltiani, N., Manalu, A. K., & Anggita, F. (2022, November). Analisis ketepatan penulisan terminologi medis terhadap keakuratan kodefikasi kasus rawat inap RSKJ Soeprapto Provinsi Bengkulu. Dalam Prosiding Seminar Nasional Penelitian Poltekkes Kemenkes Tasikmalaya (Vol. 1, No. 1, hlm. 51–73)
  9. Kementerian Kesehatan Republik Indonesia. (2016). Peraturan Menteri Kesehatan Nomor 76 Tahun 2016 tentang Pedoman Indonesian Case Base Groups (INA-CBG) dalam Pelaksanaan Jaminan Kesehatan Nasional
  10. Kementerian Kesehatan Republik Indonesia. (2022). Peraturan Menteri Kesehatan Nomor 24 Tahun 2022 tentang Rekam Medis
  11. Maryati, W. (2016). Hubungan antara ketepatan penulisan diagnosis dengan keakuratan kode diagnosis kasus obstetri di RS PKU Muhammadiyah Sukoharjo. Infokes: Jurnal Ilmiah Rekam Medis dan Informatika Kesehatan, 6(2), 1–10
  12. Permenkes RI. (2013). Peraturan Menteri Kesehatan Republik Indonesia Nomor 55 Tahun 2013 tentang Penyelenggaraan Perekam Medis
  13. Pratama, B. A. (2020). Analysis of the accuracy of medical terminology with the accuracy of diagnosis codes in Puskesmas Baki, Sukoharjo in 2019. Indonesian Journal of Medical Science, 7(2), 45–50
  14. Puspaningtyas, C. A., Sangkot, H. S., Akbar, P. S., Dewi, E. S., & Wijaya, A. (2022). Analisis hubungan ketepatan penulisan diagnosis dengan keakuratan kode diagnosis pada kasus obstetri dan ginekologi di Rumah Sakit Tk. IV DKT Kediri. Jurnal Rekam Medik dan Manajemen Informasi Kesehatan, 1(2), 104–110
  15. Putra, D. M., Yulia, Y., Rahmadhani, R., & Holindra, A. (2022). Hubungan ketepatan terminologi medis dengan keakuratan pengodean berdasarkan ICD-10 di Rumah Sakit secara studi literature review. Oceana Biomedicina Journal, 5(1), 1–6
  16. Rahmah, L. (2020). Hubungan ketepatan penulisan terminologi medis dengan keakuratan kode diagnosis typhoid fever pasien rawat inap di Rumah Sakit Panti Waluyo Surakarta tahun 2018 [Tesis tidak dipublikasikan]. Universitas Duta Bangsa Surakarta
  17. Rahmawati, E. N., & Utami, T. D. (2020). Hubungan ketepatan penulisan terminologi medis terhadap keakuratan kode pada sistem cardiovascular di Rumah Sakit Panti Waluyo Surakarta. Jurnal Manajemen Informasi Kesehatan Indonesia, 8(2), 101–106
  18. Rosita, R., & Wiqoyah, N. M. (2018). Hubungan ketepatan penulisan terminologi medis diagnosis utama dengan keakuratan kode diagnosis kasus penyakit dalam pasien rawat inap. Indonesian Journal of Medical Science, 5(1), 14–18
  19. Sari, S. N. (2018). Ketepatan kode diagnosis kasus persalinan triwulan 1 pada pasien rawat inap di Rumah Sakit Khusus Ibu dan Anak Sadewa Yogyakarta [Tesis tidak dipublikasikan]
  20. SM, R. O. (2019). Analisis ketepatan pengodean diagnosis obstetri di RS Naili DBS Padang. Jurnal Manajemen Informasi Kesehatan Indonesia, 7(2), 86–90
  21. Sugiyono. (2009). Metode penelitian kuantitatif, kualitatif dan R&D. Alfabeta
  22. Suryani, N. W. A. (2022). Hubungan ketepatan terminologi medis diagnosis utama dengan keakuratan kode diagnosis pasien BPJS Kesehatan di Rumah Sakit Umum X Denpasar. Jurnal Manajemen Informasi Kesehatan Indonesia, 10(2), 122–130
  23. Utami, Y. T., Wariyanti, A. S., & Susilowati, S. (2023, September 23). Correlation between the accuracy of medical terminology and diagnosis codes for respiratory cases in hospital inpatients. Dalam Proceeding of International Conference on Science, Health, and Technology (hlm. 482–493)
  24. Widyaningrum, L. (2020, Juli). Hubungan ketepatan penulisan informasi diagnosis dengan keakuratan kode diagnosis kasus obstetri di Rumah Sakit Umi Barokah Boyolali. Dalam Prosiding Seminar Rekam Medis dan Manajemen Informasi Kesehatan (Vol. 1, hlm. 55–65)
  25. Widyaningrum, L. (2021). Hubungan ketepatan terminologi medis dengan keakuratan kode diagnosis penyakit sistem genitourinary. Jurnal Manajemen Informasi dan Administrasi Kesehatan, 4(1), 34–41
  26. World Bank. (2023). Training medical coders in Indonesia. https://www.worldbank.org/en/programs/multi-donor-trust-fund-for-integrating-externally-financed-health-programs/brief/training-medical-coders-in-indonesia
  27. Yulia, R., & Faturrahman, A. (2022). Hubungan ketepatan terminologi medis dengan kode diagnosis rawat inap di Rumah Sakit Universitas Kristen Satya Wacana Salatiga. Jurnal Manajemen Informasi Kesehatan, 11(1), 64–72

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