(KTI) THE ACCURACY OF USING MEDICAL TERMINOLOGY IN THE MAIN DIAGNOSES OF MEDICAL RECORD FILES AT SUMBER WARAS HOSPITAL CIREBON CITY

Medical terminology is a system designed to compile a list of medical terms related to
disease, symptoms and procedures. One of the purposes of using medical terminology is to
create standards, universality and ensure that terms written by doctors in one country are still
understood by doctors around the world. The purpose of this study was to determine the
accuracy of the use of medical terminology in the main diagnosis of medical record files at
the Sumber Waras Cirebon Hospital.
The type of research uses quantitative methods. The population of this study were all
medical record files at Sumber Waras Cirebon Hospital for the period October-December
2023 totaling 410 medical record files. sampling was done by simple random sampling as
many as 80 medical record files.The data collection techniques using observation methods
with the research instrument used was a checklist sheet.
The results showed that the accuracy of the use of medical terminology in the main
diagnosis of medical record files at Sumber Waras Cirebon Hospital was in the appropriate
category (22.5%) and inappropriate (77.5%).research instrument used is a checklist sheet. the
use of medical terminology in the main diagnosis still has many inaccuracies, so it is hoped
that the hospital will conduct periodic evaluations and reviews on the use of medical
terminology.
Keywords :Accuracy of terminology, Principal diagnosis, Codification
References : 36 (2014-2023)