Concordance between physician’s clinical diagnostic terminology and ICD‑10 on surgical patient medical records
DOI:
https://doi.org/10.30989/mik.v14i3.1771Keywords:
Diagnostic, ICD-10, Medical Recor, Medical Terminology, SurgeryAbstract
Background: The accurate use of medical terminology in clinical diagnosis is crucial for proper disease classification, coding accuracy, and reliable health data reporting. However, inconsistencies remain due to non-standard terminology and abbreviations that do not comply with the International Classification of Diseases (ICD-10).
Objective: This study aims to evaluate the conformity of physicians’ diagnostic terminology with ICD-10 and with the hospital’s official abbreviation guidelines.
Methods: This descriptive quantitative cross-sectional study was conducted from March to July 2025 at RSKB Ropanasuri Padang. A 96 surgical patient medical records from 2024 were selected through simple random sampling. Diagnostic data were evaluated using a conformity checklist based on ICD-10 Volume 1 and 3 and the hospital’s standardized abbreviation guidelines.
Results: : The results showed that not all diagnoses complied with ICD-10 terminology or abbreviation guidelines. Common discrepancies included non-standard abbreviations, inconsistent anatomical terminology, and non-specific terms such as “tumor” without further details.
Conclusion: Concordance Physician’s diagnostic terminology with ICD-10 and Abbreviation guidelines remains inadequate. Strengthening standard operating procedures, enhancing clinician training in ICD-10 nomenclature, and establishing more structured coder–clinician communication are essential to ensure valid and reliable health data.
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