QUALITY OF MEDICAL RECORD DOCUMENTATION AND ACCURACY OF DIAGNOSIS AND PROCEDURES FOR HEALTH SERVICE REIMBURSEMENT AT A TERTIARY HOSPITAL IN NORTHEASTERN THAILAND: A MIXED METHODS RESEARCH.

Abstract

This explanatory sequential mixed methods study aimed to evaluate medical record audit (MRA) quality and Summary Assessment (SA) accuracy of diagnosis and procedure coding, examine their relationship, and develop quality improvement guidelines at a tertiary care hospital in Northeast Thailand. The quantitative phase analyzed 400 inpatient records (1,625 items) from fiscal year 2025, selected through cluster random sampling and analyzed using Multiple Logistic Regression. The qualitative phase engaged 25 key informants, analyzed through thematic analysis and integrated with the quantitative findings via a Joint Display Matrix.

The results showed that 72.75% of records met the MRA criterion (95% CI: 68.19 - 76.88), while chart - level SA accuracy was 55.75% (95% CI: 50.85 - 60.54). Diagnosis - and procedure - level (Dx - level) analysis revealed 69.29% accuracy (95% CI: 67.01 - 71.49). Documentation quality was significantly associated with coding accuracy. Records meeting the quality criterion had 22.95 - fold higher odds of correct coding (Adjusted OR = 22.95, 95% CI: 10.58 - 49.77, p < 0.001), when controlling for clinical departments and the number of diagnoses. The qualitative findings revealed five key themes: (1) policy – to - practice gap, (2) workload - resource imbalance, (3) practical knowledge gap, (4) ineffective feedback system, and (5) digital technology integration. Joint Display integration of both phases yielded five meta - inferences: (1) MRA passing reflects format compliance rather than substantive quality; (2) problems are structural, not individual; (3) the foundation of success remains fragile due to eroding mentorship systems; (4) technology is a necessary but insufficient condition; and (5) the Continuous Quality Improvement (CQI) system still lacks systematic Root Cause Analysis (RCA). Recommendations include integrated quality improvement across three dimensions: (1) policy - establishing department - specific KPIs,
(2) personnel - structured mentorship systems and pre - practice preparation curricula, and
Z3) digital technology - AI Alert systems and Real-time Dashboards developed by a multidisciplinary team. Future research should evaluate the outcomes of implementing these guidelines across tertiary hospitals in diverse contexts, including the effectiveness of AI Alert systems, Real - time Dashboards, and the sustainability of mentorship systems.

Keywords: Medical record documentation quality; Diagnosis and procedure coding accuracy; Healthcare reimbursement claims; Mixed methods research