Accuracy in determining the diagnosis code was something that must be considered, an accurate code was obtained with information that was able to support the coder in determining the diagnosis code. The accuracy of diagnosis codes was very important in the fields of education, research, national health statistics, quality of hospital services, and the basis for decision-making. This study aims to analyze the relationship between completeness of medical record information and accuracy of the diagnosis code in the hospital. The method used  descriptive analytic with a retrospective approach. The study population consisted of 6,069 inpatient medical record documents with a sample of 375 documents taken using simple random sampling technique. Based on the results of statistical tests using Chi-square, a p value of was obtained that there was a relationship between the completeness of medical record information and the accuracy of the diagnosis code at the hospital. Evaluation of the completeness of each medical record documents for a certain period of time was highly recommended to improve the accuracy of the diagnosis code.

Keakuratan dalam penegakkan kode diagnosis harus menjadi perhatian khusus, kode yang akurat didapatkan dengan informasi yang mampu mendukung koder dalam menegakkan kode diagnosis. Akurasi kode diagnosis sangat penting dalam bidang pendidikan, peneitian, statistik kesehatan skala nasional, mutu pelayanan kesehatan di rumah sakit, dan sebagai dasar dalam proses pengambilan keputusan. Penelitian ini bertujuan untuk menganalisis hubungan antara kelengkapan informasi rekam medis dengan keakuratan kode diagnosis di rumah sakit. Metode yang digunakan adalah deskriptif analitik dengan pendekatan retrospektif. Populasi penelitian adalah dokumen rekam medis pasien rawat inap sejumlah 6.069 dengan sampel sejumlah 375 dokumen yang diambil dengan teknik simple random sampling. Berdasarkan hasil uji statistik menggunakan Chi-square diperoleh ada hubungan antara kelengkapan informasi rekam medis dengan keakuratan kode diagnosis di rumah sakit. Evaluasi tingkat kelengkapan pengisian dokumen rekam medis masing-masing dokter per periode waktu tertentu sangat disarankan untuk meningkatkan keakuratan kode diagnosis.

Diagnostic codification must fulfill 10 characteristics of quality data, namely one of which is accurate, namely the truth and validity of data values. External Causes are external causes of fracture cases which classify based on the place and activity of the incident. It is very important that external causes codes are documented in medical record files for financing analysis, health services and reporting. The purpose of this study was to determine the accuracy of the fracture diagnosis code and external causes at Mardi Waluyo Hospital, Blitar City in 2021. The research method used a retrospective descriptive. The sampling technique is simple random sampling, with 52 samples. The implementation of coding at Mardi Waluyo Hospital, Blitar City, was carried out by coder officers and was in accordance with the policies and standard operating procedures at the hospital. The level of accuracy of the fracture diagnosis code with a percentage of 85% is included in the category that needs improvement and external causes with a percentage of 6% is included in the unsatisfactory category. The inaccuracy of the external causes code is caused by the use of the 5th character or the activity code that has not yet been coded. The inaccuracy of the officers in coding caused the resulting code to be inaccurate, so it was suggested that filling out medical record documents must be filled in completely and clearly to support proper and accurate coding of fractures and external causes so as to produce a better percentage of accuracy.