Informasi ringkas dokumen repository.
| Advisor(s) | Sitorus, Friska Ernita | |
| Author(s) | LUBIS, WIDYA LESTARI | |
| Issued Date | 2026 | |
| Abstract | Background: The completeness of Electronic Medical Record (EMR) entries is a factor influencing the accuracy of ICD-10 diagnosis codes. Incomplete medical documentation can lead to errors in the diagnosis coding process, thereby impacting health information. Objective: To determine the relationship between the completeness of EMR entries and the accuracy of ICD-10 diagnosis codes for outpatients at UPTD Puskesmas Pabatu in 2026. Methods: This study employed a quantitative design with an analytical, cross-sectional approach. The sample consisted of 91 outpatient medical records selected via purposive sampling using the Slovin formula. Data were collected using an observation checklist and analyzed through univariate analysis, the Shapiro-Wilk normality test, and the Spearman Rank correlation test (due to non-normal data distribution). Results: The study showed a mean EMR entry completeness score of 4.67 (SD=1.291) and a mean ICD-10 diagnosis code accuracy score of 0.63 (SD=0.486). The Spearman Rank correlation test yielded a correlation coefficient of 0.450 with a significance value of p=0.000 (p<0.05), indicating a significant, positive relationship of moderate strength between EMR completeness and ICD-10 diagnosis code accuracy. These results are consistent with the study by Rahmawati et al. (2022) at Jati Husada General Hospital, Karanganyar, which found a significant relationship between medical record completeness and the accuracy of diagnostic information coding (p=0.000), and the study by Yulia et al. (2021) at Dr. Reksodiwiryo Level III Hospital, Padang, which also found a significant relationship (p=0.003). Both studies reinforce the conclusion that the quality of medical record documentation is a primary factor determining the success of the diagnostic coding process. Conclusion: There is a significant relationship between the completeness of Electronic Medical Record (EMR) entries and the accuracy of ICD-10 diagnostic codes. Therefore, periodic monitoring and evaluation of healthcare personnel regarding the completeness of medical record documentation are necessary to improve the quality of healthcare services. | 1 |
| Item Type | Skripsi | |
| Keywords | Rekam Medis Elektronik(Electronic Medical Records), Kelengkapan Pengisian(Completeness of Documentation), Keakuratan Kode Diagnosis(Accuracy of Diagnosis Coding), ICD-10, Rawat Jalan(Outpatient Care) | 1 |
| Collection | Fakultas Kesehatan Masyarakat, D4-Manajemen Informasi Kesehatan | |
| Publisher | INSTITUT KESEHATAN DELI HUSADA DELI TUA | |
| Submitted Date | 23-10-2026 | |
| Updated Date | 23-10-2026 | |
| URI | https://repo.delihusada.mediantarakreasindo.com/handle/123456789/11275 | |
| File |
25199100_WIDYALESTARILUBIS_SKRIPSI_D4.pdf
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