Analysis Difference of Diagnosis of Patients in Admission and Discharge Summary Form with Ina-Cbgs Verification Form in Hospital by Literature Study

Abstract

Medical personnel as the primary care provider
for patients are responsible for the correctness and
completeness of the data, especially clinical data (diagnoses)
in medical record. Diagnosis is based on a
classification of one’s patients the disease. The diagnosis
was chosen as the primary state of a patient’s disease into
something very important in setting and writing should
be clear and consistent from the pages of medical records
of patients in hospital. The research uses a method of
literature study study with descriptive analysis done
by describing the facts that exist later in the analysis,
described, looking for similarities, views, and summaries
of some studies. Based on 4 journals obtained the
accuracy of disease diagnosis on the in-and-out summary
form as much as 35.2%, diagnosis accuracy on the INACBGs
verification form of 26.0%, the suitability of the
disease diagnosis on the in/out summary form and the
INA-CBGs verification form of 61.2%, and the effect of
the suitability of the average disease diagnosis is still
<70% which means it is not suitable between the in-andout
summary form and the INA-CBGs verification form.
Based on the results of the study can be concluded the
writing of the main diagnosis of the patient’s disease is
still not good, because the writing of the diagnosis has
not referred to ICD-10 and ICD-9-CM, the doctor should
write the diagnosis in full, precisely, and readable. So the
researchers suggest that coding officers should be active
and thorough in adjusting the diagnosis of the patient’s
disease in order to produce good reporting so that the
quality of the hospital becomes better in the future.