HUBUNGAN KUALITAS DOKUMENTASI REKAM MEDIS DENGAN KEAKURATAN KODE DIAGNOSIS PADA KLAIM INA-CBGs PASIEN HEMODIALISIS DI RUMAH SAKIT GRANDMED LUBUK PAKAM TAHUN 2026

The data used were secondary data analyzed through univariate and bivariate analysis using the Chi-Square test with a confidence level of 95% (α = 0.05). The results showed that the quality of medical record documentation was mostly in the sufficient category (35.8%), while the accuracy of diagnosis coding was mostly in the accurate category (55.8%). The bivariate analysis showed a significant relationship between the quality of medical record documentation and the accuracy
of diagnosis coding, with a p-value of 0.033 (p < 0.05).The conclusion of this study is that there is a significant relationship between the quality of medical record documentation and the accuracy of diagnosis coding. Therefore, improving the quality of medical record documentation is necessary to support the accuracy of diagnosis coding and enhance the effectiveness of the INA-CBGs claim system in hospitals.