Analysis of the Relationship between Completeness of Completion of Medical Record Documents for Surgical Patients and Compliance with INA-CBG's Tariff Standards

Abstract

The aim of this study was to analyze the relationship of the completeness of the surgical inpatient medical records filling to the suitability of the INA-CBG’s Tariff Standards. The analyzed forms are the Exit Patient Summary Form (Medical Resume) Surgery Report, Anesthesia Report, Hospitalization Warrant and Diagnostic Support Examination. This study is a quantitative study with a cross sectional design. The sample size in the study was 96 medical records. The measuring instrument used was a check sheet list. Data were analyzed bivariate with Chi-square Test and multivariate with Multiple Logistic Regression Test. The results of the Bivariate Analysis obtained a completeness relationship for filling out the Surgery Report form (P-Value 0.001) Anesthesia Report (P-Value 0,000) and the Hospitalization Warrant (P-Value 0.004) with the suitability of the INA-CBG Tariff Standards, and there is no completeness relationship for filling out the Exit Patient Summary form (Medical resume) and Examination of Diagnostic Support with the suitability of INA-CBG Tariff Standards. The Multivariate Analysis revealed that the completeness of the Anesthesia Report Form is the dominant factor affecting the suitability of INA-CBG’s Tariff Standards with P (Sig) 0.006 < 0.05, Odds Ratio (OR) = 21.000, Coefficient Value B = 3.045). With this research, it is hoped that regular socialization and training will emphasize the completeness of the documents needed for claiming.