Tesis ini membahas tentang kelengkapan pengisian resume medis (diagnosis utama, diagnosis sekunder, prosedur utama) terhadap kesesuaian standar Tarif INA-CBGs di Instalasi rawat inap Teratai Rumah Sakit Umum Pusat Fatmawati. Penelitian menggunakan pendekatan kuantitatif dan kualitatif dengan desain studi cross sectional.Hasil penelitian masih ditemukannya ketidaklengkapan pengisian resume medis terkait variabel diagnosis utama, diagnosis sekunder, dan prosedur utama, sehingga menyebabkan potensi ketidaksesuaian standar tarif INA-CBGs. Ketidaklengkapan pengisian resume medis disebabkan banyak faktor dan hasil peneltian ini menyarankan agar dilakukan evaluasi dan sosialisasi Standar Prosedur Operasional (SPO), diberlakukannya system reward dan punishment, Monitoring dan Evaluasi tentang formulir rekam medik, ditambahkan buku atau daftar kode diagnosis dan pemutakhiran software INA-CBGs.

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This research discussed on the completeness of medical resume (primary diagnostic, secondary diagnostic and major procedure) in consistency with INACBGs costing at Teratai Inpatient Instalation Central General Hospital (RSUP). This research used mix methods approach with cross sectional design.

This research found that there is still incompleteness in filling medical records especially for primary diagnostic, secondary diagnostic and major procedure that potentially may cause inconsistency with INA-CBSs costing. The incompleteness were caused by many factors, and this research suggest to conduct evaluation and socialization of the Standard Procedure Operational (SPO), the implementation of reward and punishment system, monitoring and evaluation on medical record forms, addition of book or list of diagnostic code, upgrading of INA-CBGs software.