Review of Diagnosis Coding Based on Medical Terminology Terms in the Outpatient Department at the RSUD Kota Mataram

Abstract

Medical terminology is the science of medical terminology used as a means of communication both directly and indirectly by medical and non-medical personnel. Writing a diagnosis must use medical terminology terms to help coders select lead terms in coding a diagnosis. The purpose of this study was to review the coding of diagnoses based on medical terminology terms at the Mataram City Regional General Hospital. The research method was a combination (Mixed Methods), the research design was Sequential Explanatory. The population was 300 and the sample size was 75 medical records. The sampling technique was random sampling, with 4 informants through interviews. The results showed that from a sample of 75 outpatient diagnoses, there were 25 (33%) correct terminologies and 50 (67%) incorrect terminologies using abbreviations, Indonesian, and letter errors. Writing a diagnosis without medical terminology will make it difficult for coders to find lead terms and it will take more time to change the diagnosis term into a medical terminology term to make it easier to code the diagnosis.