Regy Permata Sari, Husni Abdul Muchlis, Hosizah Hosizah, Yati Maryati

Pengaruh Kualitas Catatan terhadap Keakuratan Kode Penyebab Kematian di Rumah Sakit Pertamina Jaya

Introduction

Pengaruh kualitas catatan terhadap keakuratan kode penyebab kematian di rumah sakit pertamina jaya. Studi ini menganalisis pengaruh kualitas catatan dokter terhadap akurasi kode penyebab kematian di RS Pertamina Jaya. Dokumentasi berkualitas tinggi meningkatkan validitas data mortalitas untuk kebijakan kesehatan.

Abstract

The accuracy of cause-of-death coding is essential for health statistics and policy-making. Incomplete, inaccurate, and unclear documentation by physicians can lead to coding errors and reduce the validity of mortality data. This study aimed to analyze the effect of documentation quality on the accuracy of cause-of-death coding at Pertamina Jaya Hospital. This quantitative study used a cross-sectional design and was conducted in January 2026. The sample consisted of 56 Medical Certificates of Cause of Death (MCCD) from September–November 2024, selected using quota sampling. Data were collected through observation and analyzed using univariate and bivariate analyses with logistic regression. The results showed that 14 MCCDs (25%) had accurate cause-of-death coding, while 42 MCCDs (75%) were inaccurate. Poor-quality documentation was found in 30 MCCDs (54%), while good-quality documentation was found in 26 MCCDs (46%). Bivariate analysis demonstrated a significant effect of documentation quality on coding accuracy (p = 0.037). An odds ratio of 4.062 indicated that good-quality documentation had four times greater odds of producing accurate cause-of-death codes, explaining 12.1% of the variance in coding accuracy (R² = 0.121). The study concludes that standard operating procedures and training for physicians and coders are needed to improve accuracy and validity of mortality data.

Review

The study, "Pengaruh Kualitas Catatan terhadap Keakuratan Kode Penyebab Kematian di Rumah Sakit Pertamina Jaya," addresses a critical issue concerning the reliability of mortality data. Accurate cause-of-death coding is foundational for robust health statistics, epidemiological surveillance, and effective policy development. The abstract clearly articulates the problem of incomplete or inaccurate physician documentation leading to coding errors, thereby undermining data validity. This research appropriately aims to quantify the relationship between the quality of medical documentation and the accuracy of cause-of-death coding, making a significant contribution to understanding a key challenge in health information management within a hospital setting. Employing a quantitative, cross-sectional design, the study examined 56 Medical Certificates of Cause of Death (MCCD) from Pertamina Jaya Hospital, utilizing quota sampling for data collection in early 2026, retrospectively analyzing documents from September–November 2024. The findings reveal a concerning landscape: only 25% of the MCCDs had accurate cause-of-death coding, with a substantial 75% being inaccurate. Concurrently, 54% of the documentation was deemed of poor quality. The bivariate analysis, using logistic regression, established a statistically significant effect of documentation quality on coding accuracy (p = 0.037). Specifically, good-quality documentation was found to increase the odds of accurate coding by more than four times (OR = 4.062), explaining 12.1% of the variance in coding accuracy. These results underscore the profound impact of physician documentation quality on the integrity of mortality data, highlighting a significant area for improvement in hospital information systems. While the R² value of 0.121 suggests that documentation quality, though a strong predictor, accounts for only a modest proportion of the overall variance in coding accuracy, its statistically significant effect and substantial odds ratio cannot be overlooked. The study's conclusion, advocating for enhanced standard operating procedures and targeted training for both physicians and coders, is a logical and essential step towards rectifying these inaccuracies. This pragmatic recommendation offers a clear pathway for Pertamina Jaya Hospital, and potentially other healthcare institutions, to enhance the reliability and validity of their vital health statistics.

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