ICD-10-TM ontology development in infectious disease for support coding system

Abstract

Medical records are records of the patient's illness history and information about the patient's care. However, ICD-10 coding is another important for evaluating the quality of medical records. ICD-10 coding guidelines are numerous and extremely complex. This can cause errors or incomplete ICD-10 codes. This study aimed to analyze ICD-10 coding criteria in infectious diseases by developing a prototype ontology and a semantic retrieval system to support decision-making in choosing the correct and appropriate disease code. By creating an ontology and developing a semantic retrieval system based on a physician's diagnosis and coding criteria in infectious diseases for users to choose an ICD-10 code correctly according to the guidelines and allow users to evaluate the suitability of the information search system that has been created. The results found that the overall user satisfaction of the system was at the strongly agree level (x̅ = 4.70, SD. = 0.74) due to the overall use of the system is complete content information covering the needs of users, has an uncomplicated and easy to use. Further research can be developed more than the prototype ontology and semantic retrieval system for ICD-10 coding guidelines of other diseases to support decision-making in collecting ICD-10 codes correctly. Implication of Thematic Paper: An ontology and the semantic retrieval system of ICD-10 coding, it can be a tool to help these medical coders find ICD-10 coding guidelines to help them decide on the right and appropriate ICD-10 coding, this results in the quality of medical records that are accurate according to the National Health Security Office (NHSO) guidelines.