The Relationship Between Medical Record Complexity and Completeness and Coding Accuracy in Injury and External Cause Cases

Hanifah; Reza Widiantoro; Tunjung Bayu Sinta; Rakhman Dwi Sampurna

Authors

Hanifah Universitas Mitra Husada
Reza Widiantoro
Tunjung Bayu Sinta
Rakhman Dwi Sampurna

Keywords:

completeness, code accuracy, iDRG, injury, external cause

Abstract

The complexity and completeness of supporting information are essential for determining injury and external cause codes. The iDRG coding guidelines for injury cases require the addition of an external cause code, so complete information about the incident is needed. This study aimed to determine the association of complexity and completeness with iDRG coding accuracy and to compare iDRG and INA-CBG coding. The study used a mixed-methods approach with an explanatory sequential design. The quantitative component was analytical with a cross-sectional design, while the qualitative component was conducted through FGD. A purposive sample of 150 inpatient medical records of injury cases from January to June 2026 was selected. Data were collected through observation of inpatient medical records of injury and external cause cases, and through FGD with coder informants to identify the causes of incomplete documentation and inaccurate coding. The instrument used was a checklist. Data were analyzed using SPSS with the chi-square test and a difference test. The results indicated that the majority of medical records exhibited low complexity (71.3%), while completeness (90.0%) and iDRG coding accuracy (92.0%) were high. Neither complexity nor completeness significantly influenced iDRG code assignment, with p-values of 0.255 and 0.841, respectively (p>0.05).

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