Completeness of Gastroenteritis Medical Information Supports Accuracy of Diagnostic Codes at Bengkulu Hospital

Abstract

The completeness of medical information is crucial in supporting the accuracy of diagnostic coding for gastroenteritis. The initial survey of 10 medical records found that 6 records (60%) were complete and 4 records (40%) were incomplete. The incompleteness was caused by missing medical information, which affected the accuracy of diagnostic codes assigned by coders. Specifically, 5 records had incomplete anamnesis, 3 records had incomplete physical examination results, and 4 records had inaccurate laboratory results, which impacted the physician’s diagnosis and the diagnostic codes assigned by the coder. To determine the completeness of medical information for gastroenteritis cases in supporting the accuracy of diagnostic codes on medical resume sheets at RSUD Harapan dan Doa, Bengkulu City, in 2024. This study is an observational research with a descriptive quantitative design. The population and sample consisted of 140 inpatient medical records of gastroenteritis patients in 2024. Secondary data were collected through observation using a checklist sheet. The data were processed and analyzed using univariate analysis with frequency distribution. The study found that the completeness of anamnesis was 121(86,4%), physical examination 111(79,3%), laboratory examination 91(65%), and diagnostic confirmation 91(65%). The accuracy of gastroenteritis diagnostic coding was only 91(65%). It is recommended that coding officers pay greater attention to supporting documents when assigning diagnosis codes, participate in coding training, and develop standard operating procedures (SOP) for coding based on case types.