KARAKTERISTIK RUMAH SAKIT DAN KEAKURATAN KODE DIAGNOSIS MEMPENGARUHI HASIL KLAIM INA-CBGs

Abstract

The quality of hospital services is determined by improving clinical quality and customer satisfaction-oriented services. This can be seen from the completeness of filling out the medical record. One indicator of the completeness of medical records in the quantitative analysis of medical records is the completeness of the medical resume. According to the Professional Standards for Medical Recorders and Health Information, one of the competencies that must be possessed by a medical recorder is clinical classification skills, codification of diseases and other health problems and clinical procedures. The quality of disease statistical data is largely determined by the accuracy of the diagnostic code generated by a medical recorder. It is known that the inaccuracy of the diagnosis code for childbirth cases is 57% because the coder does not provide a secondary code as a form of additional information regarding the type of birth that occurred. This study used secondary data obtained from medical records of accident patients at Panti Waluya Sawahan Hospital Malang in 2021. The research design was cross sectional with a correlation study. The sample was 44 medical record files. Data analysis using Spearman Rank analysis. The results showed that there was a significant relationship between the completeness of the medical resume and the accuracy of the diagnostic code for labor cases. If a medical resume is complete, the diagnostic code for delivery cases will also be more accurate.