Nurses’ Role in Completing Anamnesis Supporting Coding of External Cause Injury Diagnoses
DOI:
https://doi.org/10.47701/hy0has42Keywords:
The Role of Nurses, Completeness of Anamnesis, Coding Diagnosis, External Cause of Injuries, ICD-10Abstract
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.
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1. Kementerian Kesehatan Republik Indonesia. Peraturan Menteri Kesehatan Republik Indonesia Nomor 3 Tahun 2020 Tentang Klasifikasi dan Perizinan Rumah Sakit. 2020.
2. Peraturan Menteri Kesehatan Republik Indonesia Nomor 24 Tahun 2022 Tentang Rekam Medis [Internet]. 2022. Available from: www.peraturan.go.id
3. Hatta G. Pedoman Manajemen Informasi Kesehatan di sarana Pelayanan Kesehatan. Jakarta; 2016.
4. Mirhashemi SH, Ramezanghorbani N, Asadi F, Rangraz MH. Auditing the Accuracy of Medical Diagnostic Coding based on International Classification of Diseases, Tenth Revision. Iran Red Crescent Med J. 2020 Sep 12;
5. Kementerian Kesehatan Republik Indonesia. Keputusan Menteri Kesehatan Republik Indonesia Nomor : HK.01.07/MENKES/312/2020 Tentang Standar Profesi Perekam Medis dan Informasi Kesehatan. 2020.
6. Budiaty WOS, Ramadhan S. Faktor Penyebab Belum Dilaksanakannya Kode External Causes Pada Berkas Rekam Medis Kasus Kecelakaan Pasien BPJS di Rumah Sakit Umum Daerah Kota Baubau. Journal of Health Quality Development. 2021 Dec 30;1(2):116–22.
7. Friscilla D, Manalu C, Putra DH, Fannya P, Indawati L. Analisis Ketepatan Kode Cedera dan Kode External Cause Pasien Kecelakaan Lalu Lintas di Rumah Sakit Pusat Angkatan Darat Gatot Soebroto Tahun 2020. Jurnal Manajemen Informasi dan Administrasi Kesehatan (JMIAK). 2021;05(01):22–32.
8. Redhono D, Putranto W, Budiastuti VI. History Taking-Anamnesis.
9. Direktorat Jenderal Pelayanan Kesehatan. Petunjuk Teknis Pelaporan Sistem Informasi Rumah Sakit (SIRS) Revisi 6.3. 2024;
10. Ellison ML, Schutt RK, Yuan LH, Mitchell-Miland C, Glickman ME, McCarthy S, et al. Impact of Peer Specialist Services on Residential Stability and Behavioral Health Status Among Formerly Homeless Veterans With Cooccurring Mental Health and Substance Use Conditions. Med Care. 2020 Apr;58(4):307–13.
11. Stewart CC, Simon G, Ahmedani BK, Beck A, Daida YG, Lynch FL, et al. Variation in completeness of coding external cause of injuries under ICD-10-CM. Injury Prevention. 2025 Oct;31(5):412–5.
12. Shalatiya U, Widjaja L, Indawati L, Yulia N. Tinjauan Kelengkapan Penulisan dan Ketepatan Kode External Cause Kasus Kecelakaan Lalu Lintas di Siloam Hospital Kebon Jeruk. 2022;2(3):287–99.
13. Febriana D, Osadawedya Hakim A, Nur Indira Z, Anggraeni O. Faktor-Faktor Yang Mempengaruhi Proses Pengkodean Diagnosis Di Rumah Sakit Umum Daerah Cilacap [Internet]. Vol. 9. Online; 2024. Available from: http://jurnal.uimedan.ac.id/index.php/JIPIKI150Journalhomepage:http://jurnal.uimedan.ac.id/index.php/JIPIKI
14. Muthee V, Bochner AF, Osterman A, Liku N, Akhwale W, Kwach J, et al. The impact of routine data quality assessments on electronic medical record data quality in Kenya. PLoS One. 2018;13(4):1–14.
15. Taggart J, Liaw ST, Yu H. Structured data quality reports to improve EHR data quality. Int J Med Inform. 2015;84(12):1094–8.
16. World Health Organization. International Statistical Classification of Diseases and Related Health problems : 10th revision ICD-10 Volume 3. World Health Organization; 2016.
17. Nurdiyansyah AK, Darussalam M, Asgiani P, Praptana P. Peningkatan Akurasi Pengodean Diagnosis Cedera Penyebab Luar Melalui Sosialisasi Manajemen Informasi Asuhan Keperawatan Pasien Gawat Darurat Pada Mahasiswa Profesi NERS. Journal of Community Empowerment [Internet]. 2025 Sep 28 [cited 2026 Jan 5];4(2):594. Available from: https://journal.ummat.ac.id/index.php/jce/article/view/34427
18. Raziansyah, Ifansyah MN, Pertiwi MR, Reviagana KP. Penguatan Pengisian Dokumen Rekam Medik Secara Elektronik Pada Petugas Kesehatan di RSD Idaman Banjarbaru. 2023;7(2).
19. Nurdiyansyah AK, Agushybana F, Arso SP. Evaluasi penerapan sistem informasi manajemen rumah sakit di bagian rekam medis. MEDIA ILMU KESEHATAN [Internet]. 2022 Jan 31;10(2):175–85. Available from: https://ejournal.unjaya.ac.id/index.php/mik/article/view/705
20. Wuryanto S, Nurdiyansyah AK, Raharjo DU. Kelengkapan Pengisian Rekam Medis Elektronik dalam Mendukung Ketepatan Pengodean Diagnosis Penyakit. Bhakti Sabha Nusantara. 2023 Dec 31;2(2):98–107.
21. Huffman EK. Health Information Management. Berwyn, lllinois: Physician Record Company; 1994.
22. Organization WH, Partnership ST, Global Fund to Fight AIDS T and M. Technical briefing note: technical step process to switch to new paediatric tuberculosis formulations [Internet]. World Health Organization; 2016 [cited 2026 Feb 14]. Available from: https://iris.who.int/handle/10665/204839
23. Torab-Miandoab A, Samad-Soltani T, Jodati A, Akbarzadeh F, Rezaei-Hachesu P. The impact of electronic medical records on clinical documentation: A case study. J Educ Health Promot [Internet]. 2025 Jun 1 [cited 2026 Feb 14];14(1):246. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC12327706/
24. Jurnal J(, Medis R, Manajemen D, Kesehatan I, Akurasi D, Ketepatan P, et al. Akurasi dan Ketepatan Pengkodean Diagnosis pada Kasus Obstetric di RST Dr. Asmir DKT Salatiga. Jurnal Rekam Medis & Manajemen Infomasi Kesehatan [Internet]. 2024 Jun 30 [cited 2026 Feb 14];4(1):37–45. Available from: https://unkartur.ac.id/journal/index.php/jurmik/article/view/262
25. Susanto A, Candraningtyas GM, Trijono A. Akurasi Pengkodean Diagnosis dan Prosedur Medis serta Implikasinya terhadap Klaim JKN di RSUD Pandan Arang. Jurnal Ilmiah Kedokteran dan Kesehatan [Internet]. 2025 Jun 26 [cited 2026 Feb 14];4(3):306–17. Available from: https://journalcenter.org/index.php/klinik/article/view/4610
26. Xu Y, Zhu H, Xu Z, Jin F, Chen J, Pan X, et al. Physician–clinical coder collaboration effectively improves coding accuracy: A single-centre prospective study in China. Health Information Management Journal [Internet]. 2025 Sep 1 [cited 2026 Feb 14];54(3):268–78. Available from: /doi/pdf/10.1177/18333583241302402?download=true
27. Hwang TS, Thomas M, Hribar M, Chen A, White E. The Impact of Documentation Workflow on the Accuracy of the Coded Diagnoses in the Electronic Health Record. Ophthalmology Science [Internet]. 2023 Jan 1 [cited 2026 Feb 14];4(1):100409. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10694743/
28. Nurdiyansyah AK, Asgiani P, Septiyani N, Sita Devi P, Hanita Yasmin S. Problem Solving Permasalahan Unit Rekam Medis di Rumah Sakit Jiwa Daerah DR. RM. Soedjarwadi Jawa Tengah. 2024.
29. Asgiani P, Sari RY, Purwanti E, Suryaningsih Y. Manajemen Rekam Medis dalam Mendukung Alih Media Medis Rekam Elektronik di RSUD Nyi Ageng Serang [Internet]. 2024 [cited 2026 Feb 14]. Available from: https://jurnalpengabdianmasyarakatbangsa.com/index.php/jpmba/article/view/614/526
30. Asgiani P, Purwanti E, Azizah FN, Nurdiyansyah AK, Suryaningsih Y. Prosentase Akurasi Kode Diagnosis Kasus Gangguan Jiwa Pada Implementasi Rekam Medis Elektronik di RSUD Nyi Ageng Serang. Vol. 14. 2024.
31. World Health Organization. International Statistical Classification of Diseases and Related Health problems : 10th revision ICD-10 Volume 2. World Health Organization; 2016.
32. Li Q, Yu S, Chen T, Bishai DM, Bachani A, Hyder AA. Road safety risk factors for non-motorised vehicle users in a Chinese city: an observational study. Injury Prevention [Internet]. 2020 Apr 1 [cited 2026 Feb 14];26(2):116–22. Available from: https://injuryprevention.bmj.com/content/26/2/116
33. Harrison JE, Weber S, Jakob R, Chute CG. ICD-11: an international classification of diseases for the twenty-first century. BMC Med Inform Decis Mak. 2021 Nov 1;21.
34. Ou W, Chang P, Zhou J, Zhou Z, Jiang M, Wu C. The application of quality control circle in improving the accuracy of ICD coding on medical records. BMC Health Serv Res. 2025 May 28;25(1):769.
35. Ahmad Fuad AS, Ooi ECW, Ahmad A, Abdullah ID, Mohd Marzuki N, Ng AK. The effectiveness of the ICD-11 training program among clinical coders in Malaysia. Health Information Management Journal. 2025 Jul 4;
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