Analysis of The Accuracy Of Referral Diagnosis Codes for Elderly Patients Based on ICD-10 at Jetis Public Health Center, Yogyakarta City
DOI:
https://doi.org/10.56727/bsm.v11i2.167Keywords:
ICD-10, Coding Inaccuracy, Diagnosis Code, Elderly, Primary Health CenterAbstract
Disease classification is a system that categorizes diseases and procedures into specific codes. The accuracy of diagnostic coding in medical records is crucial, as inaccurate coding can diminish the quality of healthcare services and result in data with low validity. A preliminary study at the Jetis Community Health Center (Puskesmas) in Yogyakarta revealed that, out of 10 electronic medical records (EMR), 60% contained inaccurate codes, while only 40% were accurate. This study aimed to examine the implementation of diagnostic coding for elderly patients’ referrals and to analyze the accuracy of these diagnostic codes based on the ICD-10 standard within the P-Care system used at the health center. A descriptive qualitative research method with a cross-sectional design was employed. The subjects included one medical record professional and one general practitioner, while the objects of the study consisted of 81 electronic medical records of elderly patients. The research process involved data collection, data processing (analysis), and data presentation, utilizing observation, interviews, and document review. The findings indicate that diagnostic coding is performed by the physician following patient examinations; the codes are entered directly into the P-Care system without consulting the ICD-10 manual or an online ICD-10 resource. An analysis of 81 electronic medical records in the P-Care system showed that 47% (38 records) contained accurate diagnostic codes, while 53% (43 records) contained inaccurate codes. In conclusion, the diagnostic coding for elderly patient referrals is still carried out by general practitioners, and the rate of inaccurate diagnostic coding is higher than that of accurate coding.
Downloads
References
Permenkes (2024). Sistem Rujukan Pelayanan Kesehatan Perorangan. 3–11.
Arimbawa, I. W. G., Putu, N., Yunawati, L., Ayu, I., & Feby, P. (2020). Hubungan Kelengkapan Penulisan Diagnosis terhadap Keakuratan Kode ICD-10 Kasus Obstetri Triwulan III Pasien Rawat Inap di RSU Premagana. 31–35.
Dama, S. P., Ismail, G. A., & Ahmad, R. (2026). Analisis Ketepatan Kode Diagnosis Berdasaran ICD-10 Pada Pasien Rawat Jalan di Poli Penyakit Dalam RSUD Dr . Hasri Ainun Habibbie. 4, 777–783.
Indra, Zulfahmi ; Harahap, M. R. P. (2022). Development of an Expert System To Diagnose Tb in Pandemi Time Using the Forward Chaining Method in Puskesmas Medan, Johor. Karismatika, 2(1), 40–46.
Kemenkes RI. (2020). Standar Profesi Perekam Medis dan Infomasi Kesehatan. 1–42.
Nurhasanah. (2022). Analysis of The Accuracy of The Diagnosis Code OF. 15–20.
Pujilestari, I., Medis, R., Kesehatan, I., Diagnosa, K., & Klaim, P. (2020). Analisis Ketepatan Pemberian Kode Diagnosa dan Tindakan Terhadap Pembayaran Klaim JKN Rawat Inap di RSUP DR . HASAN. 14 (2).
Puspaningtyas. (2022). Analisis Hubungan Ketepatan Penulisan Diagnosis dengan Keakuratan Kode Diagnosis pada Kasus Obstetri dan Ginekologi. 1(2), 104–110.
Rahayu, A., Sri, E., Hastuti, D., Sangkot, H. S., & Wijaya, A. (2024). Hubungan Antara Karakter Petugas Koding Dengan Akurasi. 13(2), 118–126.
Restinia, M., Khairani, S., & Manninda, R. (2021). Faktor Resiko Penyebab Multidrug Resistant Tuberkulosis: Sistematik Review. Pharmaceutical and Biomedical Sciences Journal (PBSJ), 3(1), 9–16. https://doi.org/10.15408/pbsj.v3i1.20049
Rista, N., & Jepisah, D. (2021). Jurnal Rekam Medis ( Medical Record Journal ) Tinjauan Pelaksanaan Pengkodean Penyakit Gastroenteritis Pasien Rawat Inap di Rumah Sakit PMC Pekanbaru Tahun 2020. 01, 97–105.
WHO. (2010). ICD-10. International Statistical Classification of Diseases and Related Health Problems, Vol. 2, Hal 16-17.
Downloads
Published
Issue
Section
License
Copyright (c) 2026 JURNAL ILMU KESEHATAN BHAKTI SETYA MEDIKA
This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.
Hak cipta artikel dimiliki oleh Jurnal Ilmu Kesehatan Bhakti Setya Medika.