Analysis of the implementation of BPJS regulations on the completeness of medical records and the accuracy of obstetric coding at RS X Sukabumi
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Abstract
The completeness of medical records and the accuracy of coding are important aspects in supporting the BPJS claim process. However, previous research has not extensively examined the relationship between the completeness of medical records and the accuracy of obstetric coding, nor the factors influencing the implementation of BPJS regulations. This study aims to analyze the implementation of BPJS regulations regarding medical record completeness and obstetric diagnosis coding accuracy and identify influencing factors. The research uses a qualitative approach involving 244 obstetric patient medical record files from January to May 2026. Data were collected through document review, observation, and in-depth interviews with six purposively selected informants. Medical record completeness was assessed across six dimensions, while coding accuracy was evaluated through recoding based on ICD-10, the POGI 2022 Coding Guidelines, and BPJS claim regulations. Results showed that 92 files (38%) were complete, while 152 (62%) were incomplete. Of the diagnosis codes, 139 (56.97%) were accurate and 105 (43.03%) were inaccurate. Contributing factors included staff competence and workload, outdated SOPs, hybrid medical record systems, clinical documentation quality, and resource limitations. The novelty of this research lies in the integrated analysis of medical record completeness, obstetric coding accuracy, and the 5M factors in the context of BPJS regulation implementation. Incomplete medical records and inaccurate diagnosis codes may hinder claim verification and increase the risk of pending or rejected BPJS claims. Strengthening staff competencies, updating SOPs, improving documentation, integrating systems, and conducting periodic coding audits are required to improve claim accuracy and completeness.
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