Dynamics of Medical Terminology Documentation Quality in the SNOMED CT Era: A Literature Review

Abstract

Introduction: Accurate medical terminology recording is a cornerstone of medical record quality and health data validity, as mandated by Indonesian Ministry of Health Regulation No. 24 of 2022, which requires diagnosis coding to use the latest ICD-10 classification. Various studies in Indonesia still report low levels of terminology accuracy and diagnosis code accuracy, while the global shift toward SNOMED CT presents both opportunities and new challenges. This study aims to analyze the dynamics, impacts, and challenges of SNOMED CT-based medical terminology implementation on the quality of medical record documentation. Methods: This study used a literature review design guided by the PRISMA framework. Searches were conducted through Google Scholar using Publish or Perish with Boolean keyword combinations, yielding 1,000 initial articles that were screened using PICO-based inclusion-exclusion criteria, resulting in 19 articles for thematic analysis. Results: Medical terminology accuracy in Indonesia ranged from 36-59%, and diagnosis code accuracy ranged from 43-84.7%, with 89.3% of medical records found incomplete and 35.4% of BPJS Kesehatan claims delayed due to coding inaccuracies. Dominant factors included coder competence, completeness of clinical documentation, and weak standard operating procedures, while international experience showed comparable challenges in SNOMED CT adoption related to terminology mapping complexity and user readiness. Conclusion: The quality of medical terminology recording in Indonesia remains suboptimal and requires strengthened human resource competence, standardized operating procedures, and a phased transition strategy toward SNOMED CT supported by policy and adequate digital infrastructure.