Nurul Fitri Khumaira, Yastori, Shaola Syafrullah Kader

Concordance between physician’s clinical diagnostic terminology and ICD‑10 on surgical patient medical records

Introduction

Concordance between physician’s clinical diagnostic terminology and icd‑10 on surgical patient medical records. Evaluate physician diagnosis conformity with ICD-10 on surgical records. Inadequate terminology & abbreviation compliance affects health data accuracy. Strengthen training & communication.

Abstract

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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