Correlation Between Medical Information Completeness and Accuracy of The Diagnosis Code for Upper Respiratory Tract Infection and Hypertension Based on ICD-10 in Medical Record at Cibening Health Center

Background: Completeness of patient medical information in records is one indicator assessing the quality health services. Complete and accurate contribute to accuracy staff making a diagnosis so that they can determine correct code according ICD-10 guidelines. A good record shows doctor or other has carried out their duties by demands profession as stated Medical Practice Law No.29 2004. Purposes: To find there not correlation between completeness for upper respiratory tract infection hypertension based on documents outpatients at Cibening Health Center 2019. Method: The method used this study observational analytic with cross-sectional design. population was outpatient sampling technique simple random sample size 100. Results: Out obtained 71 complete (71%) filling records, 64 (64%) were giving codes, 63 (88.7%) had codes comparison 8 (11.3%) which but inaccurate code. Conclusion: With p-value 0.000, significant Upper Respiratory Tract Infection Hypertension ICD-10.