The Relationship of Completeness of Medical Information with the Accuracy of Diabetes Mellitus Diagnosis Codes at X Kediri Hospital

Abstract

Completeness of medical information is very supportive in determining the accuracy of the diagnosis code for each disease. The correct diagnosis code determines the value of the claim following the tariff pattern that has been determined by the insurance company. Diabetes mellitus is a disease that is in the top 10 diseases in Indonesia, so research in this field is important. The analysis of the relationship between the completeness of medical information and the accuracy of the diabetes mellitus diagnosis code is the purpose of this study. The research design used correlation analytics with the cross-sectional approach. The population consisted of 68 medical record documents with diabetes mellitus cases in January-August 2021. The research sample used the entire population, namely 68 inpatient medical record documents. The results showed that complete medical information was 39 medical record documents (57%) and incomplete was 29 medical record documents (43%). The accuracy of the correct diagnosis code for diabetes mellitus is 17 medical record documents (24%) and the incorrect code is 51 medical record documents (76%). Based on the results of the Chi-Square statistical test, the results obtained p-value = 0.023, which means p-value <0.05 so H0 is rejected, which means that there is a significant relationship between the completeness of medical information and the accuracy of the diabetes mellitus diagnosis code. As conclusion, the completeness of information in medical record influence the accuracy of diagnose, specifically in diabetes mellitus cases (p-value = 0.023) Therefore, medical record officer plays important roles for the completeness of the documents