Assistance in the Implementation of the 2016 ICD-10-Based Musculoskeletal System Disease Diagnosis Codification to Improve the Quality of Medical Records

Abstract

One of the activities in medical record management is coding. Coding is the activity of assigning diagnosis codes using letters, numbers, or a combination of letters and numbers that represent data components. Based on the results of observations made on the assessment form, all medical record documents have not been given disease coding, so only the name of the diagnosis is listed. The purpose of this community service is to assist in providing coding for diagnoses or diseases of the musculoskeletal system at the UMSIDA Physiotherapy Clinic. The methods employed included lectures, interactive discussions, hands-on guidance for coding assessment forms, and SOP development. The activity involved presenting material on musculoskeletal system coding procedures to all participants, followed by the practical application of coding to 20 medical record assessment forms. The coding results showed that 13 records (65%) involved musculoskeletal system diagnoses or conditions, while 7 records (35%) involved injury-related diagnoses or conditions; the final step was the creation of the musculoskeletal disease coding SOP. In conclusion, the community service activity proceeded smoothly, and the outcomes aligned with the initial plan.