ANALYSIS OF FACTORS CAUSING INACCURACY OF DIAGNOSIS CODING OF INPATIENTS AT RSI AISYIYAH MALANG

Abstract

A preliminary survey conducted on 50 inpatient medical records at Aisyiyah Islamic Hospital Malang showed that the accuracy rate of diagnostic coding was 68%, while the inaccuracy rate was 32%. This study aims to identify the factors contributing to the inaccuracy of inpatient diagnostic coding at Aisyiyah Islamic Hospital Malang based on the elements of Man and Materials. This research employed a qualitative method with a cross-sectional approach, using interviews and observations as instruments. The participants consisted of the head of the medical records unit and two medical record officers responsible for coding at Aisyiyah Islamic Hospital Malang. The findings revealed that there were no dedicated officers assigned specifically for coding inpatient medical records. Coding was conducted alternately, and training was not provided regularly. The completeness of important reports in medical record documents reached only 66%. Furthermore, 40% of diagnoses were unreadable, based on the researcher’s observation of 70 inpatient medical records. Additionally, 40% of the medical records lacked the attending physician’s signature, and 47% did not include the attending physician’s name. The factors contributing to inaccuracies in inpatient diagnostic coding based on the Man element include experience, educational background, years of service, training, and knowledge. Meanwhile, the contributing factors based on the Materials element are reflected in the completeness of important reports in inpatient medical record documents, the readability of diagnoses, and the use of abbreviations or medical terminology by physicians.