Andi karisma Nurdiyansyah, Deby Zulkarnain Rahadian Syah, Ida Aninda, Ragil Lintang Juliana, Gebi Yulanda, Piping Asgiani, Nik Azliza Nik Ariffin

Nurses’ Role in Completing Anamnesis Supporting Coding of External Cause Injury Diagnoses

Introduction

Nurses’ role in completing anamnesis supporting coding of external cause injury diagnoses. Nurses play a key role in complete anamnesis for accurate external cause injury coding. This study reveals how education and electronic medical records boost documentation quality and ICD-10 coding accuracy.

Abstract

The accuracy of ICD-10 external cause injury coding depends heavily on the completeness of anamnesis documentation, particularly information on event chronology, place of occurrence, and patient activity. Nurses, as primary healthcare professionals responsible for anamnesis documentation in the Emergency Department (ED), play a key role in supporting accurate diagnostic coding. However, incomplete documentation of external cause injury information remains a common challenge in hospital settings. This study aimed to analyze the role of nurses in ensuring the completeness of external cause injury anamnesis to support accurate diagnostic coding at Mitra Paramedika Hospital, Yogyakarta. A qualitative descriptive study with a case study approach was conducted involving 12 healthcare workers, consisting of 10 emergency nurses and 2 medical record coders. Data were collected through pre-tests, focused group discussions (FGDs), post-tests, medical record observations, and in-depth interviews. Descriptive analysis was used to assess changes in knowledge and documentation practices before and after the intervention. The results indicated that prior to the FGD, several nurses had limited understanding of the importance of documenting place of occurrence and patient activity for external cause coding. Following the FGD, all participants demonstrated adequate knowledge in the post-test. Additionally, the use of electronic medical records improved documentation readability and completeness, facilitating more accurate coding. This study concludes that nurses play a critical role in external cause injury documentation, and that educational interventions and electronic medical record implementation effectively enhance documentation quality and coding accuracy.

Review

This paper addresses a critical issue within healthcare documentation: the accuracy of external cause injury coding, heavily reliant on comprehensive anamnesis, particularly event chronology, place, and patient activity. Recognizing nurses' pivotal role as primary documenters in the Emergency Department (ED), the study investigates how their practices influence coding accuracy. Through a qualitative descriptive case study involving emergency nurses and medical record coders at Mitra Paramedika Hospital, Yogyakarta, the researchers employed a robust mixed-method approach including pre/post-tests, FGDs, observations, and interviews. The findings reveal an initial knowledge gap among nurses regarding the importance of specific documentation elements, which was effectively mitigated by educational interventions (FGDs), leading to improved understanding and post-test scores. Furthermore, the implementation of electronic medical records (EMR) significantly enhanced documentation readability and completeness, thereby supporting more accurate diagnostic coding. The study offers several commendable strengths. Its focus on a tangible problem – incomplete documentation impacting public health data and resource allocation – makes it highly relevant and practical. The mixed-method design, incorporating both qualitative insights and objective measures like pre/post-tests and medical record observations, provides a comprehensive understanding of the issue and the impact of the interventions. The clear demonstration that educational initiatives and technological solutions (EMR) can effectively enhance documentation quality and coding accuracy offers valuable insights for hospital administrators and educators. By highlighting the critical role of nurses, the research underscores the necessity of targeted training and supportive systems to optimize healthcare data integrity. Despite its valuable contributions, the study has certain limitations. As a qualitative descriptive case study conducted at a single hospital in Yogyakarta, its findings may not be broadly generalizable to other healthcare settings, different countries, or diverse hospital types with varying resources and workflows. The abstract does not specify the duration of the intervention or the follow-up period for the post-test, making it difficult to assess the long-term sustainability of the improved knowledge and documentation practices. While EMR implementation is identified as beneficial, further detail on specific EMR functionalities that contributed to improvement (e.g., mandatory fields, smart forms, prompts) would offer more transferable recommendations. Future research could replicate this study in diverse clinical environments, assess the long-term impact of educational and technological interventions, and explore the systemic barriers, such as time constraints and workload, that might still impede comprehensive documentation even with improved knowledge and tools.

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