Hubungan Ketepatan Penulisan Diagnosis Dengan Keakuratan Kode Diagnosis Obstetri Di RSIJ Sukapura
DOI:
https://doi.org/10.25047/j-remi.v7i2.5435Keywords:
Code Accuracy, Diagnosis, Obstetrics, Writing AccuracyAbstract
Accurate documentation of diagnoses in medical records is essential, as inaccurate diagnostic statements may lead to incorrect diagnostic coding. Preliminary observations indicated that among 18 medical records, 61% of diagnoses were written accurately, while 78% of diagnostic codes were accurate. This study aimed to examine the relationship between the accuracy of diagnostic documentation and the accuracy of obstetric diagnostic coding at RSIJ Sukapura Hospital. This quantitative study employed a cross-sectional design and utilized the Chi-square test, with Fisher’s exact test applied as appropriate. Based on the analysis of 92 medical records, 77.2% of diagnoses were documented accurately and 88.0% of diagnostic codes were accurate. The results revealed a statistically significant association between the accuracy of diagnostic documentation and the accuracy of obstetric diagnostic coding (p = 0.002 < 0.05; OR = 8.375). This indicates that accurate diagnostic documentation increases the likelihood of producing accurate obstetric diagnostic codes by 8.375 times. Physicians in charge are therefore expected to pay closer attention to appropriate medical terminology when documenting diagnoses to ensure greater accuracy.
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