(KTI) ACCURACY OF MEDICAL TERMINOLOGY IN WRITING INPATIENT DIAGNOSES ON MEDICAL RESUME SHEET A T HOSPITALS LEVEL III 03.06.01 CIREMAICIREBON

Medical terminology is the language and terms used as a means of
communication between officers. Writing medical terminology that is correct and
clear can help coding officers in coding. The aim o f this study was to determine the
accuracy o f medical terminology in writing inpatient diagnoses on medical resume
sheets at Level IIIHospital 03.06.01 Ciremai Cirebon.
The type o f research used is descriptive with a quantitative approach. The
population in this study were all inpatient medical record documents for 2020 at
Level III Hospital 03.06.01 Ciremai Cirebon, totaling 10,160 medical record
documents. Sampling was carried out by Simple Random Sampling as many as 99
medical record documents. The data collection technique uses the observation
method with the research instrument used, namely the Checklist sheet. This
research was carried out in 25 May-4 June 2021.
The results showed that the accuracy in using medical terminology in
writing the diagnosis o f inpatients on the medical resume sheet at Level III
Hospital 03.06.01 Ciremai Cirebon obtained the right medical terminology
(62.7%) and the wrong one (37.3%) .
Suggestions for this study are that Medical Record officers should broaden
their knowledge o f medical terminology by participating in training in order to
increase the accuracy in diagnosing patient diseases according to ICD-10.