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.

Information technology is currently developing very rapidly. The development of this technology is evidenced by the use of computers in Electronic Medical Records. Computer use can have both positive and negative impacts on its users. One of the negative impacts is Computer Vision Syndrome. The design of this research is quantitative research with descriptive method. The study population consisted of 24 medical record officers who used computers using a purposive sampling technique, with a sample of 6 officers who met the inclusion criteria. Data collection was carried out by interview and observation sheets. The results of this study found that the number of medical record officers at the X Hospital in Kediri City who were more at risk of experiencing symptoms of Computer Vision Syndrome were 6 officers with age ?45 years, 4 officers with ?5 years of service and 2 officers >5 years, staring at the computer monitor for a long time of the 6 officers included in the >2 hour time category, the distance between the computer monitor and the eyes of 3 officers was 45-60 cm and the other 3 officers were<45->60 cm. It is recommended that officers can blink their eyes periodically, adjust the brightness of the computer monitor, check visual acuity, take regular eye breaks according to the 20-20-20 rule and use the zoom in or zoom out technique to adjust the writing on the computer screen.

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.

 
Puskesmas is health service facilities that are implementing publih health efforts and individual health effort which is also obliged to carry out a medical record. The purpose of this study was to determine the completeness of filling out outpatient forms in terms of health legal aspects at the Semen Health Center, Kediri Regency in 2020. This type of research was descriptive with a retrospective approach. Collecting data by observation and interviews. Sampling used simple random sampling, namely 10 outpatient medical record documents in 2020. The results obtained were from 10 incomplete samples (6%) which were filled in completely (4%) item incompleteness contained in the writing of the icd10 code and the signature of the officer. This is not in accordance with Permenkes number 269 year medical record and Permeneks Number 46 Year 2015 abaout Accreditation of Puskesmas Which requires that in every medical record should be named and signatures a doctor or other health workers directly providing health services. In addition fill forms a medical record complete must be filled because it will become the foundation in giving the diagnosis next and knows the way a patient. Should be done socialization fill forms outpatient done by the head of this, to avoid incompleteness fill forms outpatient.

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.