Hubungan Ketepatan Terminologi Medis Dengan Keakuratan Kode Diagnosis Rawat Jalan di Rumah Sakit “X” Pekanbaru Tahun 2020

Abstract

Determining the diagnosis of a patient is an obligation, the rights and responsibilities of the doctor (medical personnel) concerned should not be changed, therefore the diagnosis in the medical record is filled in completely and clearly in accordance with the directions in the ICD-10 book. In medical terminology, which is a special language between the medical / health professions, both in written and oral form, the means between those who are continuous in the field of health care / services require high accuracy and precision for morbidity and mortality statistics. This type of research used in this research is quantitative analytic research using cross sectional design. The results of this study obtained the accuracy of medical terminology in medical records as many as 59 (59.9%) medical records, and 40 (40.4%) incorrect. And the code accuracy is 53 (53.5%), and the inaccurate is 46 (46.4%). So the inaccuracy of medical terminology will have an impact on the accuracy in carrying out the coding.

Keywords: Relation of accuracy of medical terminology with accuracy of                                outpatient diagnosis.