Comparison of Medical Record Before-alter Medical Audit in Dontoom Hospital

Abstract

To compare medical record before-after medical audit of Dontoom hospital. This research aims to study an accuracy of diagnosis, hand checking, coding and complete of medical audit compare with relative weight before and after audit of Dontoom hospital’s medical audit. Retrospective analytical study check medical audit data of IPD in Dontoom hospital 643 records of 3 fiscal years (2005-2007) using statistic, percentile, average and x² test and Pair-t-test and have a relationship with the statistic level at 0.05

The result founded that accuracy of the doctor in discharge summary has an accuracy of 80.25% compare with statistic to find the different between an accuracy and mistake of medical audit. Categorize each hospital found that mistake relation in statistic (P<0.05). Checking of code assessment found that coding have an accuracy of 75.90%. Checking of coder found that mistake relation in statistic (P <0.05) compare with relative weight before and after medical audit. Patient file have relative weight 70 file about 11.00% average of relative weight before and after accurate medical audit found that it isn’t different in (P<0.05). Quality of medical audit is medium-level or 57.58%.