(KTI) ANALYSIS OF MEDICAL RECORD IMPLEMENTATION IN THE CODING SECTION AT SUMBER WARAS HOSPITAL IN CIREBON DISTRICT

Medical records are crucial documents in healthcare services, containing patient
identity data, examination results, treatments, procedures, and other services. A
crucial part of medical record management is the process of properly coding
diagnoses and medical procedures. This study aims to analyze the quality of
medical record management in the coding department at Sumber Waras Hospital,
Cirebon Regency, by examining three main aspects: reliability (consistency),
accuracy (appropriateness), and timeliness (timeliness).
This is a quantitative descriptive study using an observational approach using a
checklist instrument. The sample used was 95 electronic medical records of
inpatients from June 2025, selected using simple random sampling. Data were
collected at Sumber Waras Hospital, Cirebon Regency, over a 30-day period (June
1–30, 2025), then manually processed through editing, coding, and tabulation.
The results showed that the reliability aspect had a suitability level of 58%,
accuracy of 48%, and timeliness of 46%. The discrepancies were found due to a

lack of training for coding staff, an uneven understanding of the ICD-10 and ICD-
9-CM coding standards, and a discrepancy between coding results and BPJS claim

reports.
The conclusions of this study indicate that the quality of medical records
management in the coding department is suboptimal. Hospitals are advised to
improve routine training and supervision of coders, and to develop internal policies
that support the timeliness and accuracy of coding to support a quality hospital
management information system.