Accuracy and Completeness of ICD-10 Diagnostic Coding for Non-Communicable Diseases at Wismarini Hospital, Pringsewu

Gambaran Keakuratan Dan kelengkapan kode diagnosis ptm dengan menggunakan icd 10 di rumah sakit wismarini pringsewu

Abstract

Medical records play an important role in health services, particularly through coding diagnoses according to ICD-10. The accuracy and completeness of diagnosis codes affect data quality, insurance claims, and health service delivery.Objective: To describe the accuracy and completeness of non-communicable disease (NCD) diagnosis codes using ICD-10 at Wisma Rini Hospital Pringsewu.Method: A descriptive quantitative study with a sample of 71 NCD medical records (30% of 237 population) in the first quarter of 2025, selected by random sampling. A checklist was used as the research instrument, analyzed with univariate methods. Of 71 records, 60 (84.51%) were accurate and 11 (15.49%) were inaccurate. Completeness analysis showed 56 (78.87%) were complete and 15 (21.13%) incomplete. Most NCD diagnosis codes at Wisma Rini Hospital Pringsewu were accurate (84.51%) and complete (78.87%). However, some inaccuracies (15.49%) and incompleteness (21.13%) remain, requiring improvements through stricter compliance with medical resume filling and coder training.