Dian Fajar Hapsari, Dian and Djazuly Chalidyanto, Djazuly and Joni Wahyuhadi, Joni THE INFLUENCE OF SEAMLESS AND COMPLETENESS DISCHARGE SUMMARY FILLING TO SUITABILITY OF SEVERITY LEVEL IN TERTIARY REFERRAL HOSPITAL. Journal of the University of Malaya Medical Centre, 23. ISSN 2289-392X

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Abstract

Abstract Background: The implementation of the national health insurance program to fulfill the payment system related to a claim needs the documentation of services in the discharge summary. The discharge summary’s content becomes the basis for determining the code of disease especially the suitability between diagnoses and examination to determine the severity level of disease. Objective: To determine the influence of the seamless and completeness of discharge summary filling to the suitability of severity levels in tertiary referral hospitals. Method: Using a retrospective design analytic study with cross sectional method. The data was collected from observation completeness filling and seamless of information in inpatient’s discharge summary in October to December 2018. 99 samples were taken by random sampling system. Results: The results of the study showed that the seamless between diagnosis and supporting medical examinations was 75.78%, the completeness of discharge summary filling was 80.3%, and the non-conformity of severity level was 9.1%. The results of the statistical significance test showed that the congeniality between the diagnoses and the supporting medical examination (p=0.00) and the completeness of discharge summaries (p=0.00) had an influence on the suitability of severity levels. Conclusion: The seamless and the completeness of discharge summary filling is one of the factor that can influence the suitability of severity level. The completeness of discharge summary filling and intervention coding influences the amount of insurance expense and the severity level. A tertiary referral hospital is aimed for the patient’s condition categorized in advanced severity level. Therefore, completing the discharge summary is needed and should comply with the clinical pathway

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