Relationship Between Completeness Medical Information and Accuracy of Gastroenteritis Diagnosis Codes in Inpatients at RSUD dr. Soediran Mangun Sumarso Wonogiri 2025

Abstract

Completeness of medical information is a critical prerequisite for accurate ICD-10 diagnosis coding. Incomplete documentation may lead to coding errors that distort morbidity data and impair healthcare reimbursement accuracy. This study aimed to determine the relationship between completeness of medical information and accuracy of gastroenteritis diagnosis codes among inpatients at RSUD dr. Soediran Mangun Sumarso Wonogiri in 2025. A quantitative analytic study with a cross-sectional design was used. Simple random sampling yielded 252 medical record documents from a population of 680 gastroenteritis inpatient cases. Data were collected through structured checklist observation of five medical information items and ICD-10 coding accuracy review, supplemented by guided interviews. Chi-square analysis was performed using SPSS. Results showed that 94.84% of documents (239/252) had complete medical information and 90.48% (228/252) had accurate diagnosis codes. Chi-square testing revealed a statistically significant relationship between completeness of medical information and coding accuracy (p = 0.001; OR = 13.091; 95% CI: 4.163–41.170). These findings confirm that complete medical documentation increases the likelihood of accurate ICD-10 coding by 13-fold, highlighting the necessity of comprehensive clinical documentation in hospital information management.