External Cause Clinical Coding In UMM Hospital

Abstract

The completeness of the information provided by the doctor from the beginning of the patient's admission to the patient's discharge is very influential on the coding of external causes. In UMM Hospital, the author found that the coding of morbidity or external causes of a disease was not carried out by coding officers. This is the reason why the author raises the case regarding external cause coding. The purpose of this study was to analyze the influence factors of external cause codification that were not carried out in the medical record file. The methodology used is case reports on 3 medical record files with different morbidity cases. The results showed the results of the study based on the accuracy of the diagnosis from the 3 files that had been studied, it was found that there were inconsistencies of doctors in providing diagnoses to patients from the beginning of the patient's admission to the patient's discharge. This is one of the obstacles for officers in providing specific codes.