The relationship between consistency in completing inpatient electronic medical records for internal medicine cases and ICD-10 coding accuracy at RSUD H. Moh. Ruslan Mataram City
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Abstract
High-quality documentation must meet criteria for completeness, accuracy, timeliness, and consistency. Incomplete or inconsistent medical records can lead to coding errors. A preliminary study conducted at RSUD H. Moh. Ruslan Mataram City examining a sample of ten inpatient internal medicine medical records from January to February 2026, found that medical record completion consistency was 50% and coding accuracy was 40%. This study aimed to determine the relationship between the consistency of inpatient internal medicine Electronic Medical Record completion and ICD-10 coding accuracy. This was a quantitative study using a correlational method. The sample consisted of 253 inpatient internal medicine medical records. The results showed that 117 records (46.2%) were completed consistently, while 136 records (53.8%) were inconsistent. Regarding coding, 154 records (60.9%) had accurate ICD-10 codes, and 99 records (39.1%) had inaccurate codes. Statistical analysis using the chi-square test revealed a significant relationship between the consistency of inpatient internal medicine EMR completion and ICD-10 coding accuracy (p-value = 0.000). Inconsistencies in medical record documentation can hinder staff in the disease coding process. Inaccurate diagnostic codes result in low data validity and inaccuracies in reports regarding the top ten diseases and morbidity. Improving the consistency of medical record documentation through periodic qualitative analysis and displaying the results on the Hospital Information Management System dashboard, nabling clinical staff to view the findings, complemented by notifications to the attending physician regarding incomplete records, alongside enhancing staff competence through coding training, revising standards for the use of approved and unapproved abbreviations, and conducting periodic evaluations of ICD-10 coding accuracy.
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