Analysis Of The Completeness And Accuracy Of Labor Diagnosis Coding At Bataraguru Public Health Center

Abstract

Medical records are essential documents in healthcare services as they serve as a basis for clinical decision-making, quality evaluation, and reimbursement claims. One important component of medical records is diagnosis coding, which must be complete and accurate according to ICD-10 standards. However, in practice, challenges related to the completeness and accuracy of delivery of diagnostic coding are still frequently encountered. This study aims to determine the level of completeness and accuracy of delivery diagnosis coding at Bataraguru Health Center. This was a descriptive quantitative study. The sample consisted of 28 delivery medical record files selected using purposive sampling. The research instrument was an observation checklist assessing completeness and accuracy of diagnosis coding based on ICD-10 guidelines. The study showed that the completeness of diagnosis coding reached 82.14%, while incompleteness accounted for 17.86%. The accuracy of diagnosis coding reached 60.71%, while inaccuracy accounted for 39.28%. Most inaccuracies were caused by the use of unofficial reference sources (Google) and insufficient training of coding staff in ICD-10 applications. Conclusion The completeness of diagnosis coding at Bataraguru Health Center is relatively good; however, the accuracy still needs improvement. Regular ICD-10 training, mandatory use of official references, and continuous monitoring and evaluation are required to improve the quality of diagnostic coding.