The Affect of clinical documentation on the accuracy of diagnosis codes in the inpatients medical records Arief Tarmansyah Iman (a*), Diah Nurlita (a)
(a) Poltekkes Kemenkes Tasikmalaya
Jl. Cilolohan no.35 Kec. Kahuripan, Kec.Tawang Kota Tasikmalaya, Jawa Barat 46115
arief.tarmansyah[at]dosen.poltekkestasikmalaya.ac.id
Abstract
Medical records are official and legal documents that have legal value. Medical records have important aspects both for patients and for providers of health services where these patients get services. Medical records must be complete and readable including for codification of diagnoses and procedures. Inaccurate codes, especially for claim, will result in miss reporting for reimburst purposes.
The purpose of this research was to analyze the affect of clinical documentation on the accuracy of diagnosis codes in the inpatients medical records of Dr. Sooekardjo Hospital. The factors researched are completeness of data, specificity of diagnosis, clarity of writing, and use of medical terms. The analysis to be carried out is univariate, Chi square and multivariate analysis.
The results of the study there are significant affect of the completeness of data and information, the specificity of the diagnosis and the clarity of writing the diagnosis on the accuracy of the diagnosis code, and the most dominant factor affect on the accuracy of the diagnosis code is the factor of writing clarity with p value 0,000, and an OR value of 12.543
Keywords: Clinical documentation, medical record, diagnosis code
