CODIFICATION OF INPATIENTS ELECTRONIC MEDICAL RECORDS TO SUPPORT THE ACCURACY OF THE MAIN CONDITIONS IN HOSPITAL X

Abstract

The purpose of this study was to analyze the coding of inpatients related to the determination of the main conditions of inpatients at hospital X. The results of the study showed that the main conditions were not correct as many as 17 (17%) and the correct main conditions were 83 (83%). The cause of the inaccuracy of coding was the new implementation of the electronic medical record application at hospital X and also the lack of thoroughness of doctors in inputting diagnoses into the electronic medical record application and the incomplete number of characters in the electronic medical record, based on the results of the study conducted by the researcher concluded that the accuracy of the coding of the main conditions of inpatients at Hospital X has been running well. However, there are still some shortcomings that occur in the electronic medical record application at Hospital X. The researcher's suggestion is to hold a complete system update and also be more careful of doctors and coders in inputting diagnoses into the electronic medical record application so that it will minimize the occurrence of inaccurate coding.