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October 5, 2025Jurnal Rekam Medis dan Informasi Kesehatan Indonesia.Open Access

Analysis of the Accuracy of Diagnosis and Coding in Patient Medical Records at the Mutiara Delima Clinic Sawoo, Ponorogo Regency

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Authors

RRRismawati RismawatiRNRia Fajar Nurhastuti

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Overview

Descriptive analysis reveals diagnostic coding inaccuracies in patient records, highlighting training needs.

Key Points

  • Only 31.54% of medical records were accurately coded, indicating a significant gap in documentation quality.
  • Analysis of 260 medical records within one month shows 59.62% had diagnosis but lacked coding, stressing the need for improved practices.
  • The approach involved qualitative methods, including interviews and observations with healthcare personnel, to gather comprehensive data.
  • Enhancing training for medical staff and better monitoring systems are crucial to improve coding accuracy and support service quality.

Cite This Study

Rismawati et al. (2025) studied this question.

synapsesocial.com/papers/68e22da774308421369aefc3https://doi.org/10.62951/jurmiki.v4i2.104
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