Penelitian ini membahas ketidaktepatan dalam pengisian catatan rekam medis,Dan ketidaktepatan dalam melakukan koding yang menyebabkan pelayananmenanggung risiko finansial pada kasus Tetralogy of Fallot di unit PediatrikKardiologi dan Penyakit Jantung Bawaan RS Harapan Kita periode Januari-September 2013. Dengan metode kualitatif. Dengan hasil 21,4% kasus dengandiagnosis sekunder yang tidak lengkap dan selisih klaim Rp 251.273.615,00 (4%).Saran untuk dilakukan peningkatan sarana dan prasarana fisik serta pengelolaankebijakan seperti adanya SPO pengisian rekam medis, sosialisasi, pembinaan stafdan pemantauan secara berkala.

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This study discusses the inaccuracies in medical record entry charging, and

inaccuracy in doing coding that caused service run the risk of financially in the

case of Tetralogy of Fallot in the Pediatric Cardiology and congenital heart

disease unit RS Harapan Kita from January-September 2013. With the qualitative

method. With the results at 21.4% of cases with a diagnosis of incomplete

secondary and the difference between the claim of Rp 251.273.615 b (4%).Advice

to do the physical facilities and infrastructure increased as well as themanagement

policies as there are SPO medical record filing, socialization, training staff and

monitoring at regular intervals.