Evaluation of Documentation and Coding Requirements of Medical Records in the Implementation of a Payment System Based on Diagnosis-Related Groups (DRG) in Medical Education Centers of Urmia University of Medical Sciences

In the health system, reimbursement methods are an important criterion for the allocation of resources and the performance of service providers. The use of diagnosis-related groups (DRG) system reduces the length of stay and additional costs of the patient, prevents unnecessary treatment, increases resource efficiency and transparency of health care services. The development of the DRG system focuses on the accurate documentation of medical records and the correct coding of diagnoses and procedures. The purpose of this research is to evaluate the documentation and coding requirements of medical records in the implementation of a payment system based on diagnosis-related groups in Iran.

This research was descriptive-cross-sectional and was conducted in 2022. The data collection tool was a researcher-made checklist, the validity of which was confirmed based on the opinion of experts (health information management health economics) and its reliability was obtained by calculating Cronbach’s alpha (0.83). The research population consisted of 418 medical records in five medical training centers affiliated to Urmia University of Medical Sciences, which were selected through stratified-proportional sampling. Data were analyzed using SPSS software.

The results of the evaluation of the documentation and coding requirements of medical records for the implementation of the DRG system showed that the demographic/administrative variables including age, sex, type of admission, length of stay, health insurance, and doctor’s expertise were completely recorded. Evaluation of clinical variables also showed that the main diagnosis, main procedure, secondary diagnosis and other procedures were documented in medical records in 98%, 97%, 88% and 75% respectively. Regarding the coding of the main diagnosis and the main procedure, 100%, secondary diagnosis 68% and other procedures 80% have been done.

Considering that some essential clinical variables for the implementation of DRG, especially co-morbidities, complications and other procedures are not recorded separately and completely, therefore it is necessary to define separate information elements in medical records and HIS for accurate recording of these variables and proper interaction between coders and doctors is established to increase the possibility of correct coding. It is also suggested that the DRG system be implemented in our country in a phased and gradual approach so that necessary changes are made in the documentation process and hospital information systems.