(KTI) ACCURACY OF DISEASE DIAGNOSIS CODES IN MEDICAL RECORD DOCUMENTS FOR INPATIENTS AT RSUD M.A SENTOT PATROL

Medical records is a documents that contais data on patient identity, examination, treatment, actions, and other services that have been given to the patients. One of the main medical record competencies is the classification and coding of disease. One of the complex codes in ICD is the diagnosis code for inpatient disease. The purpose of this study was to determine the accuracy of the disease diagnosis code to inpatient documents hospitalized at M.A Sentot Patrol Regional General Hospital. The type of research used was a descriptive methodwith a quantitative population approach that was used in this study for 700 medical record documents of inpatients on march 2023 at Regional General Hospital M.A Sentot Patrol. The sample was used a random sampling of 100 medical record documents from inpatients. The instrument used in this study was an observation sheet (checklist).
The results of this study indicated that of the 100 medical record documents from inpatients studied, there were 81 inpatient medical records documents that were correct and there were 19 medical records documents from inpatient disease that were not correct.
Suggestion through this research, for hospitals to be able to reaffirm the coder’s duties, they must provide a clear andconsistent code if a diagnosis is not clear, then they immediately give confirmation backto the doctor in charge of the service to generate the correct code.