THE IMPLEMENTATION OF ELECTRONIC MEDICAL RECORDS ON DIAGNOSIS CODING ACCURACY AT X HOSPITAL
Keywords:
Electronic Medical Records, Diagnostic Code Accuracy, ICD-10, Hospitals, Health InformationAbstract
The development of information technology has driven the transformation of medical record recording systems from manual formats to Electronic Medical Records (EMR) to improve the efficiency and accuracy of patient data. The accuracy of diagnosis codes is an important indicator in hospital management because it impacts the quality of service, claims processes, and clinical decision-making. This study aims to analyze the effect of EMR implementation on the accuracy of outpatient diagnosis codes at X Hospital. The study used a quantitative descriptive method with a cross-sectional design. The study population was all outpatient medical record files for the period January–March 2025, with a sample of 99 files selected using a purposive sampling technique. Data were collected through an ICD-10-based checklist and interviews with three medical record officers. The results showed that 92% of diagnosis codes were recorded accurately, while the remaining 8% were inaccurate. Factors supporting coding include easier data access, completeness of information in the EMR system, and staff competence in operating the application. Obstacles found were inconsistencies in data entry and limited training. These findings confirm that the implementation of RME has made a positive contribution to increasing the accuracy of diagnostic codes, but efforts to improve the quality of the system and human resource training are still needed to maximize its utilization.
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References
Agustine, D. M., & Pratiwi, R. D. (2017). Hubungan Ketepatan Terminologi Medis dengan Keakuratan Kode Diagnosis Rawat Jalan oleh Petugas Kesehatan di Puskesmas Bambanglipuro Bantul. Jurnal Kesehatan Vokasional, 2(1), 113-121.
Annisa, H. N. (2023). Faktor yang Berhubungan dengan Tingkat Kesiapan Petugas Kesehatan Terhadap Implementasi Rekam Medis Elektronik di RSUD Sayang Rakyat Kota Makassar. (Skripsi). Universitas Hasanuddin, Makassar, Indonesia.
Asgiani, P., Purwanti, E., Azizah, F. N., Nurdiyansyah, A. K., & Suryaningsih, Y. (2024). Prosentase Akurasi Kode Diagnosa Kasus Gangguan Jiwa pada Implementasi Rekam Medis Elektronik di Rsud Nyi Ageng Serang. Jurnal Ilmiah Rekam Medis Dan Informatika Kesehatan, 14(2).
Asgiani, P., Pamungkas, D. R., Suhada, R. I., & Aninda, I. (2025). Implementasi Rekam Medis Elektronik Belum Menjamin Ketepatan Kode Diagnosis Kasus Gagal Ginjal. Jurnal Adijaya Multidisplin, 3(01), 56-62.
Ernawati, D., & Rossandra, L. (2020). Kelengkapan Informasi Medis Dalam Penetapan Kode Morbiditas, Pada Kasus Chronic Kidney Disease Di Rumah Sakit Panti Wiloso Dr Cipto Semarang. VISIKES: Jurnal Kesehatan Masyarakat, 19(2).
Faizah, S. C., Pribadi, F. A., & Wijaya, A. (2024). Ketepatan Pengkodean Diagnosis Penyakit Diabetes Mellitus Di Rumah Sakit X Kota Malang. Indonesian Journal of Health Insurance and Medical Records (IJHIMR), 1(1), 30-38.
Hartati, & Aini, R. (2023). Literature Review: The Benefits of Electronic Medical Record Implementation for Hospital Management in Indonesia. Journal of Operation Sysytem, 1(2), 91–98.
Haryanto, B. (2024). Sistem Informasi Rekam Medis Berbasis Web (Studi Kasus: Klinik Gaga Medika). INNOVATIVE: Journal Of Social Science Research, 4(2), 1976-1992.
Harmanto, D., Budiarti, A., & Rahayu, D. S. (2022). Gambaran Pelaksanaan Kodefikasi Diagnosa Sistem Sirkulasi Berdasarkan ICD-10 Di Rumah Sakit Rafflesia Bengkulu. Jurnal Ilmu Kesehatan Mandira Cendikia, 3(1), 90-98.
Heltiani, N., Widyawati, D., & Pratama, A. E. (2024). Accuracy Of Writing The Diagnosis And Accuracy Of The Cerebral Infarction Code Inpatient Patients At Hospital X. Journal of Sustainable Development Goals, 1(1), 1–10.
Nahor, A. B., Izza, N. C., & Putra, M. D. C. (2024). Analisis Ketepatan Kode Diagnosa Penyakit Terkait Kelengkapan Informasi Penyakit Pada Pengisian ICD-10 Di Aplikasi E-Puskesmas Di Puskesmas Kecamatan Makasar. Jurnal Ilmiah Rekam Medis dan Informasi Kesehatan Indonesia, 1(1), 40-46.
Naryanti, I., Anurogo, D., Milah, S., Putri, N. G. K., Ashari, A. (2023). Dasar-Dasar Manajemen Kesehatan. Klaten: Lakeisha.
Izza, A. Al, & Lailiyah, S. (2024). Kajian Literatur: Gambaran Implementasi Rekam Medis Elektronik di Rumah Sakit Indonesia berdasarkan Permenkes Nomor 24 Tahun 2022 tentang Rekam Medis. Media Gizi Kesmas, 13(1), 549–562.
Nugroho, Y. W., & Pramudita, F. A. (2024). Peran Rekam Medis Elektronik dalam Meningkatkan Efisiensi, Kualitas Layanan Kesehatan, dan Keselamatan Perawatan Pasien: Analisis Systematic Literature Review. Media Publikasi Promosi Kesehatan Indonesia (MPPKI), 7(2), 343-350.
Nurwito, B. S. (2024). Manfaat Dan Efektivitas Penerapan Sistem Informasi Pada Rumah Sakit Swasta Dan Rumah Sakit Pemerintah. Jurnal Manajemen Informasi Kesehatan Indonesia, 12(2), 165–170.
Undang-Undang Nomor 44 Tahun 2009 tentang Rumah Sakit.
Peraturan Pemerintah Nomor 28 Tahun 2024 tentang Peraturan Pelaksana UU Nomor 17 Tahun 2023 tentang Kesehatan.
Peraturan Menteri Kesehatan Nomor 3 Tahun 2020 tentang Klasifikasi dan Perizinan Rumah Sakit
Peraturan Menteri Kesehatan (Permenkes) Nomor 24 Tahun 2022 tentang Rekam Medis
Putri, W. (2023). Pendampingan Digitalisasi Berkas Rekam Medis Guna Mendukung Keberhasilan Implementasi Rekam Medis Elektronik Di Klinik Panacea. Initium Community Journal, 3(1), 12-15.
Soesana, A., Subakti, H., Karwanto, K., Fitri, A., Kuswandi, S., Sastri, L., ... & Lestari, H. (2023). Metodologi Penelitian Kuantitatif. Medan: Yayasan Kita Menulis.
Sondakh, V., Lengkong, F., & Palar, N. (2023). Kualitas Pelayanan Kesehatan Rawat Jalan Di Rumah Sakit Umum Daerah Noongan. Jurnal Administrasi Publik, 8(4), 244-253.
