THE PROBLEMS OF DOCUMENTING MEDICAL RECORDS IN THE IMPLEMENTATION OF A PAYMENT SYSTEM BASED ON DIAGNOSIS-RELATED GROUPS (DRG): A QUALITATIVE RESEARCH

The payment system based on diagnosis-related groups was created to control the costs of health care services, increase efficiency in inpatient care, and improve transparency in hospital activities. The success of this system depends on complete and accurate documentation of medical records and correct coding of diagnoses and procedures. This research aimed to determine the problems of documenting medical records to implement a payment system based on DRGs.

This research was a qualitative study that was conducted using the semi-structured interview method in 2022. The research population included experts in health information management and health economics at Urmia University of Medical Sciences, who were selected purposefully. Data analysis was done through content analysis using ATLAS.ti software.

From the point of view of the interviewees, the most important problems of documenting medical records in the implementation of DRGs, included the lack of clinical documentation guidelines, the lack of necessary information elements, the lack of accurate evaluation of the quality of documentation, and coding, the lack of continuous training courses, the incompleteness of documentation, and the lack of sufficient interaction between doctors and coders were in the hospital.

The results of this research showed that some essential variables for implementing the DRGs system are not defined separately and clearly in the medical records and the hospital information system, and the quality of the documentation and coding is not accurate and complete. Therefore, it seems necessary to consider separate information elements for the main diagnosis, the main action, and the comorbidity and complications in the standard medical record forms.