Evaluation of the Coding System for the Causes of Traffic Accidents at the Medical Records Unit of Hospital X in Merangin, Indonesia

Abstract

The coding system is one of the important things in several activity units in medical records. Writing a complete, clear, and specific diagnosis by the doctor and coding officer is a support in determining the correct code. This study aimed to describe writing equipment and accuracy of the results coding external causes (external cause) traffic accident cases in Hospital X in Merangin Regency. This research is a descriptive observational study. The research location is the medical records installation section coding of Hospital X in Merangin Regency. This research was conducted in November 2021-June 2022. The inclusion criteria for research subjects were medical records of patients in traffic accident cases recorded from September to 2021. A total of 64 medical record documents were sampled in this study. In the external cause of injury code, the completeness of the victim's role item was 39.06%, the victim's type of transportation was 96.88%, the opposing party involved in the collision was 92.19%, and the victim's activities during the accident were 3.12%. In this study, only 2 medical records explained the victim's activities during the traffic accident because the hospital reporting did not use the 5th character, which describes the victim's activities. In conclusion, most of the external cause items recorded in traffic accident cases are written completely. Factors related to inaccuracy external cause code in the form of man, method, material, and machine.