The Correlation Between The Completeness of Patient Anamnesis form and External Causes Diagnosis Code Accuracy in Bahagia Hospital Makassar

Abstract

Completeness of filling in the data on the patient’s
history form is important to support the accuracy of the
diagnosis code including in the case of injury and external
causes. The accuracy of the diagnosis code can affect the
quality of statistical data on diseases and health problems,
as well as the determination of payment for hospital
claims. This study aimed to analyze the correlation
between the completeness in filling in patient anamnesis
form and the accuracy of the external causes code. This
study was an observational study using a cross-sectional
design. Systemic random sampling was taken from 51
patients’ medical records. The results show that the
complete anamnesis taking is 35.3%, and the incomplete
is 64.7%. Whereas accurate coding is 78.4% and 21.6%
is inaccurate. analysis using the chi-square test showed
that there is a relationship between the completeness of
filling in the patient’s history form and the accuracy of the
diagnosis code of external causes, especially in the 4th
and 5th characters.